Tx in Pain Management Flashcards
NSAIDs examples ?
Acetylsalicylic Acid (Aspirin) Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin, Nuprin) Meloxicam (Mobic) Naproxen Sodium (Aleve, Anaprox) Diclofenac/misoprostol (Arthrotec, Cytotec)
Cyclooxygenase-2 (Cox-2) Inhibitors
examples ?
Celecoxib (Celebrex)
Antispasmodic’s
examples ?
Metaxalone (Skelaxin)
Cyclobenzaprine (Flexeril)
Disease-Modifying Antirheumatic Drugs ?
Methotrexate (Rheumatrex)
Leflunomide (Arava)
Hydroxychloroquine (Plaquenil)
Tumor Necrosis Factor (Tnf) Inhibitors ?
infliximab (Remicade)
etanercept (Embrel)
Adalimumab (Humira)
Steroids ?
Hydrocortisone (Solu-Cortef)
Prednisone (Deltasone)
Methylprednisolone (Solu-Medrol)
Drugs Used to Treat Gout ?
Indomethacin (Indocin)
Allopurinol (Zyloprim)
Colchicine (Generic)
Probenecid (Probalan)
Sulfinpyrazone (Anturane)
Acute Pain facts ?
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
Definition of pain ?
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
Acute pain ?
Generally considered nociceptive pain
Pain that follows the usual pain sensory pathways
Responses with elevation in blood pressure, increased pulse and diaphoresis
__________ pain is caused by stimulation of peripheral nerve fibers that respond only to stimuli
Nociceptive
How is pain classified ?
Classified according to the mode of noxious stimulation
Most common pain ?
Thermal (e.g. heat or cold)
Mechanical (e.g. crushing, tearing, shearing, etc.)
Chemical (e.g. iodine in a cut or chemicals)
Nociceptive pain may also be divided into ?
Visceral
“deep somatic” pain
“superficial somatic” pain
_______ structures are highly sensitive to stretch, ischemia and inflammation
Visceral
Visceral pain is ?
diffuse
difficult to locate
Visceral pain may be accompanied by ?
N / V
Visceral pain description ?
May be described as sickening, deep, squeezing, and dull
Deep somatic pain ?
stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles
Deep somatic pain description ?
dull, aching, poorly-localized pain
Deep somatic pain examples ?
Ankle sprain
Fractures
___________ pain is initiated by activation of nociceptors
Superficial
Superficial pain where is it and description ?
In the superficial tissue of skin
sharp, well-defined and clearly located
Superficial pain examples ?
Injuries that produce superficial somatic pain
minor wounds and minor (first degree) burns
Neuropathic pain causes ?
Caused by damage or disease affecting any parts of the nervous system
involved in bodily feelings somatosensory system
Peripheral neuropathic
description ?
burning, tingling, electrical, stabbing, or pins and needles
Peripheral neuropathic examples ?
Bumping the “funny bone” elicits acute peripheral neuropathic pain.
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
Psychogenic pain AKA ?
psychalgia
somatoform pain
Psychogenic pain is ?
pain caused, increased, or prolonged by mental, emotional, or behavioral factors
Psychogenic pain examples ?
Headache, back pain, and stomach pain are sometimes diagnosed as psychogenic
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
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
Seven Tenants for Conscientious Prescribing of Drugs for Pain ?
- Remove barriers that render pain management ineffective
- Never forget the consequences resulting from pain being poorly managed
- Properly assess pain before prescribing any drug
- Remember the goal of using medications for acute pain
- Remember to use different prescribing algorithms for mild, moderate and severe pain
- Use different algorithms when prescribing for chronic pain
- There is a role for adjuvant medications
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
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
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
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
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
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
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
Tenant 1 ?
Remove barriers that render pain management ineffective
Tenant 2 ?
Never forget the consequences resulting from pain being poorly managed
Tenant 3 ?
Properly assess pain before prescribing any drug
Tenant 4 ?
Remember the goal of using medications for acute pain
Tenant 5 ?
Remember to use different prescribing algorithms for mild, moderate and severe pain
Tenant 6 ?
Use different algorithms when prescribing for chronic pain
Tenant 7 ?
There is a role for adjuvant medications
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
Morphine Sulphate examples ?
Avinza, Kadian, MS Contin, Oramorph SR, Roxanol
Morphine Sulphate DEA/FDA schedule ?
II
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 **
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
Morphine Sulphate indications ?
Moderate to Severe Pain
Morphine Sulphate routes ?
IV, PO, IM, epidural, rectal, PCA (patient controlled anesthesia) Pump - phantom pain
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
Morphine Sulphate Opioid equivalent chart ?
look it up
Oxycodine other names ?
Oxaydo
Oxecta
OxyContin
OxyFast
Roxicodone
Oxycodone/acetaminophen trade ?
Endocet
Percocet
Roxicet
Tylox
Oxycodone/aspirin trade ?
Percodan
Oxycodone/ibuprofen trade ?
Combunox
Oxycodone schedule ?
II
Oxycodone MOA?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
Oxycodone pharmacokinetics ?
Metabolized by Liver CYP450
Excretion in urine
Oxycodone route ?
PO
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
Oxycodone cautions ?
hypersens. to drug/class
respiratory depression,
severe asthma
severe hypercarbia ( hypoxia)
paralytic ileus
GI obstruction or stricture
circulatory shock
labor and delivery
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
Oxymorphone trade ?
Opana
Opana ER
Oxymorphone schedule ?
II
Oxymorphone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
Metabolized by Liver CYP450
Excretion in urine
Oxymorphone route ?
PO
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
Oxymorphone cautions ?
respiratory depression
apnea
respiratory arrest
hypotension, severe
paralytic ileus
ICP incr.
bradycardia
syncope
biliary spasm
seizures
anaphylaxis
dependency, abuse
Hydromorphone schedule ?
II
Hydromorphone trade ?
Dilaudid
**synthetic heroin **
Hydromorphone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
Metabolized by Liver CYP450
Excretion in urine
Hydromorphone route ?
IV
IM
PO
Rectal
PCA
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
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
Codeine trades and other names ?
Codeine Sulfate,
Codeine/acetaminophen,
Codeine/guaifenesin,
Codeine/butalbital/caffeine ( migraines )
Promethazine/codeine
phenergan
**great topic syrup for sore throats **
Codeine schedule ?
II
Codeine MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
Metabolized by Liver CYP450
Excretion in urine
Codeine route ?
IV, IM, PO, Rectal, PCA
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
Hydrocodone trade ?
Norco
hydrocodone/acetaminophen trade ?
Norco
Lortab
Lorcet
Vicodin-discontinued
hydrocodone/homatropine, hydrocodone/ibuprofen
Hydrocodone schedule ?
II
Hydrocodone MOA ?
binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
Metabolized by Liver
CYP450
Excretion in urine
Hydrocodone route ?
PO
Hydrocodone indications ?
Chronic pain
Hydrocodone BBW ?
Acetaminophen assoc. w/ acute liver failure
Most liver injury assoc. w/ acetaminophen doses >4000 mg per day and >1 acetaminophen-containing product
Tramadol trade ?
Ultram
Tramadol schedule ?
IV
new class
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
Tramadol route ?
PO
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 **
Synthetic Opioid Antagonist trade ?
Naloxone (Narcan)
nasal atomizer
Synthetic Opioid Antagonist MOA ?
antagonizes various opioid receptors (opioid antagonist)
Synthetic Opioid Antagonist route ?
IV
SC
Intranasal
**OD’s this is our GoTo
dawn program - education videos for high risk individuals **
Naloxone (Narcan) serious reactions ?
ventricular fibrillation
cardiac arrest
seizures
can occur with abrupt withdrawal
Naloxone (Narcan) common reactions ?
Tachycardia
hypotension
V / N
HTN
tremor
diaphoresis
withdrawal sxs.
pulmonary edema
