Therapeutic Pain Management Flashcards
Exam 2
How much neuronal loss occurs in people with chronic pain?
5-11% neuronal loss, this is equivalent to 10-20 years of aging
What is pain?
The sensation of harmful stimulation
What is suffering?
The emotional component of subjective distress
Who has a lower pain threshold?
Younger/Older?
Men/Women?
Energized/Tired?
Older
Men
Fatigued
Which neurotransmitter is associated with pain and depression?
Seratonin
Explain acute pain.
Acute pain lasts from seconds - 3 months and is easily localized. Acute pain is the result of a specific injury, and subsides when the condition resolves. Acute pain can be recurrent with episodes being separated by periods of time that are pain-free.
Examples include recurrent corneal erosions, corneal uclers, corneal abrasions, etc
Explain chronic pain.
Chronic pain lasts more than 3-6 months and is not easily localized or defined. Chronic pain can be the result of a known medical condition and traditional analgesics are less effective and require higher doses. Chronic pain can be treated but is unlikely to be cured.
What is neurotrophic pain?
Chronic pain associated with nerve damage
What is dysesthesia?
Abnormal sensations such as burning, tingling, and/or pins/needles
What is allodynia?
Pain associated with non-painful stimuli
What is the first thing you should ask about a patient’s pain?
Subjective rating 1-10
What is FOLDAR?
Pain management acronym F: Frequency O: Onset L: Location D: Duration A: Association R: Relief
What are the three types of topical ophthalmic medications used to treat pain? Give a couple of examples of each.
Cycloplegics:
Homatropine (Gold Standard for synechia)
Cyclopentolate
NSAIDS:
Voltaren
Corticosteroids: (Only for pain from inflammation) Prednisolone Acetate (Pred Forte)
How do cycloplegics manage pain?
Relax ciliary body
Block AcH receptors
What are the three types of oral medications used to treat pain? Give an example of each.
OTC non-narcotic analgesics:
Aspirin
Acetaminophen
Ibuprofen
Prescription Non-Narcotic analgesics:
Indomethacin
Prescription Narcotic Analgesics (Controlled substances) :
Codeine
Hydrocodone
Tramadol
What are the three mechanisms for non-narcotic analgesics?
- Central Acting: Interrupt pain signal in the CNS
- Peripheral Acting: Prevent the discharge of pain the pain receptor.
- Anesthetic agent: Interrupt pain signal from reaching the CNS.
What are the benefits of non-narcotic analgesics?
- Ceiling effect, so no increase in effect with an increase in dosage
- No tolerance of dependence develop
- Not addictive
What are the different OTC non-narcotic analgesics?
Aspirin
Acetaminophen (APAP)
Ibuprofen
Naproxen
What is the MOA of aspirin?
Irreversible inactivation of COX-1 and COX-2, inhibiting prostaglandin synthesis
What are the clinical indications of aspirin?
Analgesic (mild to moderate)
Anti-pyretic (fever)
Antiinflammatory (with high dosage)
Anticoagulant/cardio-protective effects**
What are the adverse effects of aspirin?
GI upset/irritation
Prolonged bleeding time
**When taken daily for 12+ months, 59% increase in the incidence of wet AMD
What are the contraindications of aspirin use for pain?
Stomach ulcers/GI bleeding
Asthma
Excessive alcohol use
Pregnancy (Avoid in 3rd trimester)
What pregnancy category is aspirin?
Category D, fetal harm can occur, so don’t use in the third trimester of pregnancy
What is the MOA of acetaminophen?
Unknown, but may inhibit central prostaglandin synthesis (COX-2) Acetaminophen has NO anti-inflammatory properties
What are the indications for acetaminophen?
Mild to moderate pain
anti-pyretic
Synergistic with narcotics
What are the adverse effects of acetaminophen?
Acute liver failure (leading cause in the US)
Serious and potentially fatal skin reactions (SJS)
What are the contraindications for acetaminophen?
Liver toxicity/damage
Alcoholism (1-2 drinks per day)
Hypersensitivity to acetaminophen
What is the new limited dosage of acetaminophen?
What is the new limit of acetaminophen that can be in combo drugs?
3250 mg in 24 hours for adults and children over 12.
Combo drugs can have no more than 325mg per dose.
What pregnancy category is acetaminophen?
Category B, the safest analgesic for pregnant women
What is the MOA of ibuprofen/naproxen?
The mechanism is unknown but thought to be a COX-2 inhibitor preventing prostaglandin synthesis.
What are the indications for ibuprofen/naproxen?
Mile-moderate pain
Anti-inflammatory
Anti-pyretic
Some rheumatologic conditions
What are some adverse effects of ibuprofen/naproxen?
GI upset/GI bleeding, you should always take naproxen with food/water/antacids
Renal failure
Increased risk of cardiovascular thrombotic events
Nystagmus/diplopia with moderate/severe overdose
What are the contraindications of ibuprofen/naproxen?
Hypersensitivity to aspirin/NSAIDs (anaphylaxis)
Ulcers
Renal insufficiency
CAPG (Coronary Artery Bypass Graft) pain management peri-surgery
What pregnancy category is naproxen/ibuprofen?
C, don’t use in the third trimester
What dosages is acetaminophen available in?
325mg
500mg extra strength
What is the recommended dosage for acetaminophen? What is the max dose of acetaminophen?
Recommended Dose: 650mg q4 hours
Max Dose: 3250mg q24hr
What dosages is aspirin available in?
81 and 325mg tablets
What is the recommended dosage of aspirin?
650-975 mg q4-6 hours
Which OTC non-narcotic analgesic should not be used in kids with a fever or with flu-like symptoms in an effort to avoid causing Reye’s syndrome?
Aspirin
Reyes causes brain and liver damage
What dosages is ibuprofen available in?
100mg in children and 200mg in adults
What is the recommended dose of ibuprofen?
What is the max dose of ibuprofen?
Recommended dose: 200-400mg q4-6 hours
Max Dose: 1200mg q24 hours
Do not use longer than 10 days
What dosages is naproxen available in?
220mg
What is the recommended dosage of naproxen?
What is the max dose of naproxen?
Recommended dosage: 220mg q8-12 hours with 2 pills as a loading dose
Max Dose: 2 tabs (440mg) in 12 hours or 3 tabs (660mg) in 24 hours
Do not use longer than 10 days
Which OTC non-narcotic analgesics should not be used longer than 10 days? Why?
Naproxen or Ibuprofen (NSAIDs), prolonged NSAID use causes corneal melts
Which prescription non-narcotic is used in a combination treatment with oral pred to treat of scleritis?
Indomethacin
What dosages is indomethacin available in?
25, 50, 75mg capsules
What is the recommended dosage for indomethacin for scleritis?
25-50mg TID
What is the black box warning for indomethacin?
Not for acute pain, can cause renal failure
How long can you take ketorolac for?
5 days only
What are the different kinds of prescription narcotic analgesics? Define them.
Opiate: Natural substance from opium (Codeine and morphine)
Opioid: Substances that do not occur naturally, can be synthetic or semi-synthetic. Synthetics are manufactured chemically, semi-synthetics are a hybrid chemical alteration of natural opioids.
Synthetic opioid: fentanyl and methadone
Semi-synthetic opioid: Hydrocodone and oxycodone
Narcotic:
Agents that produce insensibility.
What is the MOA of prescription narcotic agents?
bind u receptors decreasing pain AND suffering
What are some general precautions that should be considered when prescribing prescription narcotic analgesics?
- They do NOT have a ceiling effect meaning an increase in dosage increases the effect.
- Tolerances can develop requiring more of the drug for a similar effect
What are the different prescription narcotic analgesics? What schedule is each drug?
Codeine (II)
Hydrocodone (II)
Tramadol (IV)
What is codeine usually combined with? What is the reason for combining codeine with these agents?
Codeine + Aspirin: Will add anti-inflammatory benefits
Codeine + Acetaminophen: Synergystic effect for good pain control (act on separate parts of CNS)
What is hydrocodone a derivative of? Is hydrocodone more or less potent than codeine? By how much?
Hydrocodone is a derivative of codeine and is six times more potent. Hydrocodone is therefore used for moderate to severe pain compared to codeine which is used for moderate pain.
Is codeine or hydrocodone more addictive?
Hydrocodone
Why might you prescribe hydrocodone over codeine for somebody if they present with moderate pain?
Hydrocodone can be prescribed for someone with a codeine allergy
What are 3 adverse effects of opioid analgesics?
Nausea/Vomiting
Headache
Blur
What are 5 contraindications of opioid analgesics?
Kidney/Liver disease Head injury Pregnant History of alcohol use Respiratory disease (COPD/Apnea)
What are the components of Tylenol #3 and Tylenol #4? What schedule is Tylenol #3/#4?
Acetaminophen and codeine
Schedule III
What is the formulation of Tylenol #3?
300mg APAP; 30mg codeine Tablets
What is the formulation of Tylenol #4?
300mg APAP; 60mg codeine tablets
What is the recommended dosage of Tylenol #3/#4?
15-60mg codeine q4-6 hours
What is the max dosage of Tylenol #3/#4?
360mg of codeine per day
What is the age limit for Tylenol #3? Tylenol #4?
Tylenol #3: >7 years
Tylenol #4: > 13 years
What pregnancy category is Tylenol #3/#4?
C
What are the possible combinations of aspirin and codeine?
30mg codeine and 325mg aspirin
60mg codeine and 325mg aspirin
What is the recommended dosage of aspirin/codeine combinations?
1-2 tablets q4-6 hours
What is the max dosage of aspirin/codeine combinations?
360mg codeine per day
What is the pregnancy category of aspirin/codeine combinations?
D (ASA)
What schedule is aspirin/codeine combinations?
Schedule III
What are the formulations of Acetaminophen/Hydrocodone combinations?
300mg APAP; 5mg hydrocodone (Vicodin)
300mg APAP: 7.5mg hydrocodone (Vicodin ES)
300mg APAP; 10mg hydrocodone (Vicodin HP)
325mg APAP; 5, 7.5, 10mg hyrdocodone (Norco (tablets))
300mg APAP; 10mg hydrocodone (Lortab (solution))
What is the recommended dosage of acetaminophen/hydrocodone combinations? (Vicodin)
1 tab q4-6 hours
What is the max dosage of acetaminophen/hydrocodone combinations? (Vicodin)
Hydrocodone: 60mg/day
APAP: 650mg q4-6 hours, 3250mg total
What is the age limit for acetaminophen/hydrocodone combinations?
> 16 years (Vicodin/Vicodin ES/Vicodin HP)
>2 years (Norco/Lortab)
What are the formulations of Ibuprofen/Hydrocodone combinations?
200mg ibuprofen; 7.5mg hydrocodone
What is the recommended dosage of ibuprofen/hydrocodone?
1 tablet q4-6 hours
What is the max dosage of ibuprofen/hydrocodone?
5 tablets
What is the age limit for ibuprofen/hydrocodone combinations?
> 16 years
What is the recommended dosage of acetaminophen/hydrocodone (Norco/Lortab)
2.5-10mg q4-6 hours
If a patient is experiencing MILD pain, what should you consider for treatment?
Topical medications should be considered,
cycloplegics are great for mild pain
Artificial tears
steroids
If a patient is experiencing MODERATE pain, what should you consider for treatment?
Non-opioid analgesics (5-7/10 on a subjective scale)
Acetaminophen and ibuprofen
If a patient is experiencing SEVERE pain, what should you consider for treatment?
Prescription narcotic analgesics
Tylenol #3, Vicodin, Tramadol
How is tramadol different from other opioids?
Also is an antidepressant
Optometrists should never prescribe more than a __ day supply of opioids.
3 day
