Tx in Pain Management Flashcards

1
Q

NSAIDs examples ?

A
Acetylsalicylic Acid (Aspirin)
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin, Nuprin)
Meloxicam (Mobic)
Naproxen Sodium (Aleve, Anaprox)      Diclofenac/misoprostol (Arthrotec, Cytotec)
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2
Q

Cyclooxygenase-2 (Cox-2) Inhibitors

examples ?

A

Celecoxib (Celebrex)

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3
Q

Antispasmodic’s

examples ?

A

Metaxalone (Skelaxin)

Cyclobenzaprine (Flexeril)

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4
Q

Disease-Modifying Antirheumatic Drugs ?

A

Methotrexate (Rheumatrex)

Leflunomide (Arava)

Hydroxychloroquine (Plaquenil)

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5
Q

Tumor Necrosis Factor (Tnf) Inhibitors ?

A

infliximab (Remicade)

etanercept (Embrel)

Adalimumab (Humira)

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6
Q

Steroids ?

A

Hydrocortisone (Solu-Cortef)

Prednisone (Deltasone)

Methylprednisolone (Solu-Medrol)

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7
Q

Drugs Used to Treat Gout ?

A

Indomethacin (Indocin)

Allopurinol (Zyloprim)

Colchicine (Generic)

Probenecid (Probalan)

Sulfinpyrazone (Anturane)

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8
Q

Acute Pain facts ?

A

The most common reason for a patient to consult a physician’s assistance

More than 17 million people took six days in 1995 due to pain conditions

One of adults 65 years and older experience low back pain

3/5 of adults 65 and older say their pain lasted one year more

Arthritis, back pain, cancer and headaches are the major contributors of pain

68% of American adults experience some sort of back
pain in their lifetime

70% of cancer patients suffer from significant pain

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9
Q

Definition of pain ?

A

Bodily, mental or emotional suffering due to injury or illness

Pain or unpleasant sensory and emotional experience arising from actual or perceived tissue damage

Chronic pain lasts for more than three months while the key thing has an identifiable cause or cure end point

Both adults and children experience pain however children are less able to describe their pain

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10
Q

Acute pain ?

A

Generally considered nociceptive pain

Pain that follows the usual pain sensory pathways

Responses with elevation in blood pressure, increased pulse and diaphoresis

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11
Q

__________ pain is caused by stimulation of peripheral nerve fibers that respond only to stimuli

A

Nociceptive

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12
Q

How is pain classified ?

A

Classified according to the mode of noxious stimulation

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13
Q

Most common pain ?

A

Thermal (e.g. heat or cold)

Mechanical (e.g. crushing, tearing, shearing, etc.)

Chemical (e.g. iodine in a cut or chemicals)

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14
Q

Nociceptive pain may also be divided into ?

A

Visceral

“deep somatic” pain
“superficial somatic” pain

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15
Q

_______ structures are highly sensitive to stretch, ischemia and inflammation

A

Visceral

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16
Q

Visceral pain is ?

A

diffuse

difficult to locate

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17
Q

Visceral pain may be accompanied by ?

A

N / V

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18
Q

Visceral pain description ?

A

May be described as sickening, deep, squeezing, and dull

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19
Q

Deep somatic pain ?

A

stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles

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20
Q

Deep somatic pain description ?

A

dull, aching, poorly-localized pain

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21
Q

Deep somatic pain examples ?

A

Ankle sprain

Fractures

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22
Q

___________ pain is initiated by activation of nociceptors

A

Superficial

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23
Q

Superficial pain where is it and description ?

A

In the superficial tissue of skin

sharp, well-defined and clearly located

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24
Q

Superficial pain examples ?

A

Injuries that produce superficial somatic pain

minor wounds and minor (first degree) burns

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25
Neuropathic pain causes ?
Caused by damage or disease affecting any parts of the nervous system involved in bodily feelings somatosensory system
26
Peripheral neuropathic | description ?
burning, tingling, electrical, stabbing, or pins and needles
27
Peripheral neuropathic examples ?
Bumping the "funny bone" elicits acute peripheral neuropathic pain.
28
Phantom pain ?
Pain felt in a part of the body that has been lost From which the brain no longer receives signals. It is a type of neuropathic pain. Phantom limb pain is a common experience of amputees
29
Psychogenic pain AKA ?
psychalgia somatoform pain
30
Psychogenic pain is ?
pain caused, increased, or prolonged by mental, emotional, or behavioral factors
31
Psychogenic pain examples ?
Headache, back pain, and stomach pain are sometimes diagnosed as psychogenic
32
Psychogenic Pain considerations ?
often stigmatized by both medical professionals and the general public Tend to think that pain from a psychological source is not "real" Specialists consider that it is no less actual or hurtful than pain from any other source
33
Chronic Pain facts ?
35% of American population has some degree of chronic pain 50 million Americans partially or totally disabled due to chronic pain Chronic Pain considered to be a symptom rather than diagnosis for several years “Chronic Pain Syndrome” ICD-10 code G89.4
34
Seven Tenants for Conscientious Prescribing of Drugs for Pain ?
1. Remove barriers that render pain management ineffective 2. Never forget the consequences resulting from pain being poorly managed 3. Properly assess pain before prescribing any drug 4. Remember the goal of using medications for acute pain 5. Remember to use different prescribing algorithms for mild, moderate and severe pain 6. Use different algorithms when prescribing for chronic pain 7. There is a role for adjuvant medications
35
Tenant #1 ?
Remove barriers that render pain management ineffective There are barriers to effective treatment of pain on the part of both the patient and clinician The stigma of the pain medicines being too strong or harmful Share concerns about drugs being addictive Concerns about regulatory agencies like DEA
36
Tenant #2 ?
Impaired function and poor quality life Depression Polypharmacy through treatment of other manifestations of pain: Agitation, confusion, sleep disturbance, false, cognitive dysfunction, decreased socialization, anorexia **Never forget the consequences resulting from pain being poorly managed**
37
Tenant #3 ?
A detailed history and physical is imperative “Controlled Substance Act” -federal law and are scheduled depending upon its medical use and potential for abuse and safety Pain needs to be identified by its source and type A complete diagnostic evaluation Use a standardized pain scale Discuss with the patient realistic goals of pain control **Properly assess pain before prescribing any drug**
38
Tenant #4 ?
A primary goal of acute pain management is to restore function as soon as possible and prevent the redevelopment of a chronic pain syndrome Use different combinations of medicines with decreasing potential for addiction and harm This applies to acute pain and chronic pain **Remember the goal of using medications for acute pain**
39
Tenant #5 ?
Use a variety of medications that starts with mild pain and progress using different endpoints and assessments Start with NSAID’s or creams Ben-Gay For moderate pain use medications like tramadol or Tylenol with codeine or hydrocodone For severe pain use higher dose opioids like morphine and Dilauded **Remember to use different prescribing algorithms for mild to moderate and severe pain**
40
Tenant #6 ?
Pain described as lasting longer than three months Often includes a significant neuropathic component and usually requires the use of medications to manage chronic pain Hyperstimulation of NMDA receptors and ultimately decrease the effectiveness of opioids upon the mu receptors Down regulation of the mu receptors or excessive pre-and post synaptic substance P. **Use different algorithms when prescribing for chronic pain** - these are tough patients to manage
41
Tenant #7 ?
Medications that may be used for the management of pain but whose primary indication is not for analgesia May include tricyclic antidepressants, and it involves, corticosteroids, anesthetics, muscle relaxants and antiarrhythmic’s (lidocaine) **There is a role for adjuvant medications** Review these concepts on pages 456, 457 and 458
42
Tenant 1 ?
Remove barriers that render pain management ineffective
43
Tenant 2 ?
Never forget the consequences resulting from pain being poorly managed
44
Tenant 3 ?
Properly assess pain before prescribing any drug
45
Tenant 4 ?
Remember the goal of using medications for acute pain
46
Tenant 5 ?
Remember to use different prescribing algorithms for mild, moderate and severe pain
47
Tenant 6 ?
Use different algorithms when prescribing for chronic pain
48
Tenant 7 ?
There is a role for adjuvant medications
49
Pure Opioid Agonists examples ?
Morphine ( Roxanol) Oxycodone (Oxycontin) caused the lawsuit that funded Oxymorphone (Opana) Hydromorphone (Dilaudid) Codeine Hydrocodone (Norco, Lortab) Tramadol (Ultram) (Non-Opioid) non-narcotic mimics mu receptors good pain medicine w/o CNS depression effects
50
Morphine Sulphate examples ?
Avinza, Kadian, MS Contin, Oramorph SR, Roxanol
51
Morphine Sulphate DEA/FDA schedule ?
II
52
Morphine Sulphate MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist) Metabolized by Liver CYP450 Excretion in urine **i kidney disease remember higher serum levels so watch dosing **
53
Morphine Sulphate black box warning ?
Addiction, Abuse, and Misuse Schedule II controlled substance w/ risk of addiction, abuse, and misuse May lead to overdose and death Assess opioid abuse or addiction risk prior to prescribing opioid abuse risk if personal or family substance abuse or mental illness hx regularly monitor all pts for misuse, abuse, and addiction
54
Morphine Sulphate indications ?
Moderate to Severe Pain
55
Morphine Sulphate routes ?
IV, PO, IM, epidural, rectal, PCA (patient controlled anesthesia) Pump - phantom pain
56
Morphine Sulphate cautions ?
respiratory depression apnea respiratory arrest circulatory depression hypotension severe shock paralytic ileus ICP incr. Seizures biliary spasm Bradycardia anaphylaxis dependency abuse Many Drug-Drug Interactions
57
Morphine Sulphate Opioid equivalent chart ?
look it up
58
Oxycodine other names ?
Oxaydo Oxecta OxyContin OxyFast Roxicodone
59
Oxycodone/acetaminophen trade ?
Endocet Percocet Roxicet Tylox
60
Oxycodone/aspirin trade ?
Percodan
61
Oxycodone/ibuprofen trade ?
Combunox
62
Oxycodone schedule ?
II
63
Oxycodone MOA?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
64
Oxycodone pharmacokinetics ?
Metabolized by Liver CYP450 Excretion in urine
65
Oxycodone route ?
PO
66
Oxycodone BBW ?
Addiction, Abuse, and Misuse Schedule II controlled substance w/ risk of addiction, abuse, and misuse May lead to overdose and death Assess opioid abuse or addiction risk prior to prescribing opioid abuse risk if personal or family substance abuse or mental illness hx regularly monitor all pts for misuse, abuse, and addiction
67
Oxycodone cautions ?
hypersens. to drug/class respiratory depression, severe asthma severe hypercarbia ( hypoxia) paralytic ileus GI obstruction or stricture circulatory shock labor and delivery
68
Oxycodone caution in and if ?
avoid abrupt withdrawal (prolonged or long-term use) coma or impaired consciousness caution in elderly or debilitated pts caution if renal impairment caution if hepatic impairment caution if pulmonary impairment caution if CNS depression
69
Oxymorphone trade ?
Opana Opana ER
70
Oxymorphone schedule ?
II
71
Oxymorphone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist) Metabolized by Liver CYP450 Excretion in urine
72
Oxymorphone route ?
PO
73
Oxymorphone BBW ?
Addiction, Abuse, and Misuse Schedule II controlled substance w/ risk of addiction, abuse, and misuse May lead to overdose and death Assess opioid abuse or addiction risk prior to prescribing opioid abuse risk if personal or family substance abuse or mental illness hx regularly monitor all pts for misuse, abuse, and addiction
74
Oxymorphone cautions ?
respiratory depression apnea respiratory arrest hypotension, severe paralytic ileus ICP incr. bradycardia syncope biliary spasm seizures anaphylaxis dependency, abuse
75
Hydromorphone schedule ?
II
76
Hydromorphone trade ?
Dilaudid **synthetic heroin **
77
Hydromorphone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist) Metabolized by Liver CYP450 Excretion in urine
78
Hydromorphone route ?
IV IM PO Rectal PCA
79
Hydromorphone BBW ?
Abuse Potential Respiratory Depression Schedule II controlled substance w/ risk of addiction, abuse, and misuse May lead to overdose and death Assess opioid abuse or addiction risk prior to prescribing opioid abuse risk if personal or family substance abuse or mental illness hx regularly monitor all pts for misuse, abuse, and addiction
80
Hydromorphone cautions ?
hypersens. to sulfites hypersens. to drug Hypercarbia GI obstruction paralytic ileus labor and delivery caution in elderly caution if pregnancy 3rd trimester caution if alcohol use caution if delirium tremens caution if ICP incr. caution if seizure disorder caution if hypothyroidism caution if adrenal insufficiency opioid non-tolerant pts (high potency dosage form) respiratory depression, severe asthma acute or severe avoid abrupt withdrawal (prolonged or long-term use) caution if renal / hepatic impairment caution if pulmonary impairment caution if CNS depression / depressant use caution if toxic psychosis
81
Codeine trades and other names ?
Codeine Sulfate, Codeine/acetaminophen, Codeine/guaifenesin, Codeine/butalbital/caffeine ( migraines ) Promethazine/codeine phenergan **great topic syrup for sore throats **
82
Codeine schedule ?
II
83
Codeine MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist) Metabolized by Liver CYP450 Excretion in urine
84
Codeine route ?
IV, IM, PO, Rectal, PCA
85
Codeine BBW ?
Abuse Potential Respiratory Depression Schedule II controlled substance w/ risk of addiction, abuse, and misuse May lead to overdose and death Assess opioid abuse or addiction risk prior to prescribing opioid abuse risk if personal or family substance abuse or mental illness hx regularly monitor all pts for misuse, abuse, and addiction
86
Hydrocodone trade ?
Norco
87
hydrocodone/acetaminophen trade ?
Norco Lortab Lorcet Vicodin-discontinued hydrocodone/homatropine, hydrocodone/ibuprofen
88
Hydrocodone schedule ?
II
89
Hydrocodone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist) Metabolized by Liver CYP450 Excretion in urine
90
Hydrocodone route ?
PO
91
Hydrocodone indications ?
Chronic pain
92
Hydrocodone BBW ?
Acetaminophen assoc. w/ acute liver failure Most liver injury assoc. w/ acetaminophen doses >4000 mg per day and >1 acetaminophen-containing product
93
Tramadol trade ?
Ultram
94
Tramadol schedule ?
IV new class
95
Tramadol MOA ?
Exact mechanism of action unknown Binds to mu opioid receptors and weakly inhibits norepinephrine/serotonin reuptake, producing analgesia (central opioid agonist) Metabolized by Liver CYP450 Excretion in urine
96
Tramadol route ?
PO
97
Tramadol cautions ?
seizures serotonin syndrome suicidal ideation dependency, abuse hypersensitivity / anaphylactoid rxn Stevens-Johnson syndrome toxic epidermal necrolysis hypotension, orthostatic respiratory depression withdrawal sx if abrupt D/C (prolonged or long-term use) BEERS!! Altered mental status **if they are prone to suicide or depression this is not a good medicine for them **
98
Synthetic Opioid Antagonist trade ?
Naloxone (Narcan) nasal atomizer
99
Synthetic Opioid Antagonist MOA ?
antagonizes various opioid receptors (opioid antagonist)
100
Synthetic Opioid Antagonist route ?
IV SC Intranasal **OD’s this is our GoTo dawn program - education videos for high risk individuals **
101
Naloxone (Narcan) serious reactions ?
ventricular fibrillation cardiac arrest seizures **can occur with abrupt withdrawal**
102
Naloxone (Narcan) common reactions ?
Tachycardia hypotension V / N HTN tremor diaphoresis withdrawal sxs. pulmonary edema