Week 8 Notes Flashcards
What is the definition of pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
What are the categories of pain?
- Acute Pain
- Chronic Pain
What characterizes acute pain?
Results from disease, inflammation or injury to tissues; generally comes on suddenly and may be accompanied by anxiety or emotional distress.
What characterizes chronic pain?
Widely believed to represent disease itself and can be made much worse by environmental and psychological factors; persists over a long period of time and is resistant to most medical treatments.
What is one of the most prevalent public health epidemics related to pain management?
Death involving prescription drug abuse.
What were the statistics for drug overdose deaths in the U.S. in 2021?
- Total Drug Overdoses: 106,699
- Overdoses involving Opioids: 80,411 (75.4%)
What are the four areas addressed by the CDC Clinical Practice Guidelines for Prescribing Opioids for Pain?
- Whether or Not to Initiate Opioids for Pain
- Selecting Opioids and Determining Dosages
- Deciding Duration of Initial Opioid Prescription and Determining Follow-Up
- Assessing Risk and Addressing Potential Harms of Opioid Use
What framework does the CDC guidelines use for prescribing opioids for pain?
Grading of Recommendations, Assessment, Development, and Evaluation (GRADES) Framework.
What are the first-line recommendations for opioid therapy in chronic non-cancer pain according to updated guidelines?
- NSAIDs
- Anticonvulsants
- Acetaminophen
- Muscle relaxants
Non-pharmacological recommendations: exercise programs, physical therapy, acupuncture, massage, TENS, chiropractic treatment, and biofeedback therapy
Fill in the blank: The first-line opioid choices for mild pain include _______.
[tramadol, codeine, hydrocodone]
Mild to moderate pain: hydrocodone or oxycodone
Fill in the blank: For severe pain, the first-line opioid choices are _______.
[hydrocodone, oxycodone, morphine]
What are the fundamental tenets of responsible opioid prescribing?
- Patient Evaluation & Selection
- Periodic Review and Monitoring
- Treatment Plans
What factors contribute to undertreated pain versus over-prescribing?
- Lack of knowledge among prescribers about current pain management guidelines
- Lack of knowledge among prescribers about addiction, dependence and misuse
What is the purpose of the Opioid Risk Tool?
A self-report screening tool designed for adult patients in primary care settings to assess risk for opioid abuse among individuals with chronic pain.
What does SOAPP Version 1.0-14Q do?
A tool for clinicians designed to determine how much monitoring a patient on long-term opioid therapy might need.
What is included in a comprehensive assessment of a patient for opioid prescribing?
- Pain Condition
- General Medical History
- Previous Treatments
- Psychosocial History and Evaluation
- Substance Use History and Addiction Screening
- Sleep Patterns
- Functional Assessment
True or False: Chronic pain is generally considered to be less resistant to medical treatments than acute pain.
False
What are non-pharmacological recommendations for pain management?
- Exercise programs
- Physical therapy
- Acupuncture
- Massage
- TENS
- Chiropractic treatment
- Biofeedback therapy
What is the role of Prescription Drug Monitoring Programs?
To monitor prescriptions and prevent misuse/abuse.
What is the significance of establishing treatment goals in opioid prescribing?
It guides responsible prescribing and patient outcomes.
What is the purpose of a Pain Management Agreement?
To outline expectations and responsibilities between the clinician and the patient.
What are the six points in guidance for responsible opioid prescribing?
- Comprehensive Assessment of patient
- Prescription drug monitoring programs
- Risk stratification
- Urine drug testing
- Establishing treatment goals
- Informed decision making
What are the three different groups of opioids?
Natural, semisynthetic, synthetic
What is the primary action of opioid analgesics?
Provide analgesia without loss of consciousness
Name two natural opioids.
- Morphine
- Codeine
What are semisynthetic derivatives of opioids?
- Oxycodone
- Hydromorphone
- Oxymorphone
What are the two groups of synthetic compounds?
- Phenylpiperidines
- Pseudopiperidines
Name two compounds in the phenylpiperidine group.
- Meperidine
- Fentanyl
Which compound belongs to the pseudopiperidine group?
Methadone
How many basic opioid receptors are there?
Three
Which opioid receptor is responsible for most of the action of opioids?
Mu receptor
What is the function of the mu 1 receptor?
Responsible for central interpretation of pain
What effects are associated with the mu 2 receptor?
- Respiratory depression
- Spinal analgesia
- Physical dependence
- Euphoria
What is the effect of kappa receptors?
Modest analgesia with little to no respiratory depression or dependence
What is the effect of delta receptor agonists?
Poor analgesia with little addictive potential
What is the major pharmacokinetic effect of opioids when taken orally?
Significant first-pass effect
How are opioids distributed in the body?
Various extents of plasma protein binding with highest concentrations in tissues
What happens to morphine metabolites in patients with compromised renal function?
Can cause prolonged analgesia
What is the primary pharmacodynamic action of opioids?
Enhance activity in descending aminergic pathways or antinociceptive pathways
What physiological effect leads to analgesia in the CNS?
Closing N-type voltage-operated calcium channels and opening calcium-dependent potassium channels
What are the two components of pain?
- Affective
- Sensory
What is euphoria in the context of opioid use?
A sensation of pleasant feeling
What side effect can occur with opioid use related to sleep?
Sedation
What causes respiratory depression in opioid use?
Inhibition of the brain stem respiratory center
Which opioid is best at producing cough suppression?
Codeine
What are common GI side effects of opioids?
- Constipation
- Decreased GI motility
What effect do opioids have on renal function?
Depressed renal function due to decreased renal blood flow
What is a notable effect of opioids on thermoregulation?
Alter equilibrium point of hypothalamic heat regulatory mechanisms
What are the signs of opioid toxicity?
- Coma
- Pinpoint pupils
- Depressed respiration
What are common withdrawal symptoms from opioids?
- Rhinorrhea
- Lacrimation
- Piloerection
- Nausea and vomiting
- Diarrhea
- Chills
- Hyperventilation
- Tachycardia
- Body aches
- Frequent yawning
What are the three types of opioid receptors?
Mu (µ), Delta (∆), Kappa (K)
Mu is the major analgesic receptor, Delta is associated with spinal analgesia, and Kappa is linked with high potency analgesics.
What is the prototypical opioid agonist?
Morphine
Morphine is a pure alkaloid isolated in 1803 and named after Morpheus, the Greek god of dreams.
What are the common side effects of opioid analgesics?
Euphoria, respiratory depression, physical dependence
These side effects are significant concerns when using opioid analgesics.
How are opioid analgesics regulated?
Under the Controlled Substances Act and policed by the DEA
This regulation is due to the potential for abuse and dependence.
What is the typical onset of action for opioid analgesics?
2 – 60 minutes
The onset varies depending on the method of administration.
What is the half-life of most opioid analgesics?
Generally up to 6 hours
This can vary based on the specific drug and individual metabolism.
What are the two types of NSAIDs?
Non-selective COX inhibitors, COX-2 inhibitors
These classifications are based on their mechanism of action.
What are some examples of NSAIDs?
Ibuprofen, Naproxen, Aspirin, Toradol, Mobic
These drugs exert analgesic, antipyretic, and anti-inflammatory effects.
What is the maximum daily dose of acetaminophen?
2 grams
This limit is set to prevent liver toxicity.
What is the mechanism of action of Allopurinol?
Prevents formation of uric acid by inhibiting xanthine oxidase
Allopurinol is used in the treatment of gout and hyperuricemia.
What type of drug is Methotrexate?
Disease-Modifying AntiRheumatic Drug (DMARD)
It acts as a folic acid antagonist inhibiting DNA synthesis and cell reproduction.
What is the role of Colchicine in gout treatment?
Decreases inflammation by decreasing movement of leukocytes into tissues containing urate crystals
Colchicine does not have analgesic or antipyretic effects.
Fill in the blank: Opioid analgesics include full agonists, partial agonists, and _______.
antagonists
This classification is important for understanding their pharmacological effects.
True or False: Tramadol is a non-opioid drug.
False
Tramadol is centrally-acting and binds to µ receptors.
What are the adverse effects of NSAIDs?
CNS, GI, Respiratory
These effects can vary based on the specific NSAID and patient factors.
What is the function of mixed agonist-antagonists?
Activate one type of opioid receptor while blocking another type
They produce fewer side effects than true opioids.
What is the primary use of Acetaminophen?
Treatment of mild pain and fever
It lacks anti-inflammatory properties.
What is the central principle regarding the use of controlled substances?
Balance between preventing abuse and ensuring medical availability.
What dual imperative does the federal government have regarding controlled substances?
Prevent abuse, trafficking, and diversion while ensuring medical availability for individuals in pain.
What is the purpose of the Controlled Substances Act of 1970?
To regulate the manufacture, importation, possession, use, and distribution of certain substances.
Which agency is responsible for interpreting and enforcing the Controlled Substances Act?
The Drug Enforcement Agency (DEA).
What are the schedules of controlled substances based on?
Potential for abuse and accepted medical use.
What is an example of a Schedule I medication?
Cocaine or heroin.
What medical use does cocaine have despite being a Schedule I substance?
Used for nasal packing in emergency rooms for intractable epistaxis.
What is an example of a Schedule V medication?
Pseudoephedrine.
Why must opioids be available for medical use?
To relieve pain and suffering.
What does the label ‘controlled substance’ indicate about a medication’s medical value?
It does not change their medical value.
What must not interfere with medical practice and patient care?
Efforts to prevent abuse.
Who must comply with federal and state regulations for prescribing scheduled controlled substances?
Health care providers.
Where are federal regulations for controlled substances contained?
The Controlled Substances Act.
Where can state regulations for prescribing controlled substances be found?
The health care provider’s licensing board and governing board.
Which board governs nurse practitioners regarding controlled substances?
The nursing board in each state.
Which board governs physicians regarding controlled substances?
The medical board.
What applies when federal laws differ from state laws regarding controlled substances?
The more stringent rule applies.
What is gout?
The most common form of inflammatory arthritis affecting about 9.2 million adults in the United States
What causes gout?
An alteration in purine metabolism leading to elevated uric acid levels in the blood
What are the goals of therapy for gout?
Manage pain from acute attacks, lower uric acid levels long-term, and lifestyle management
What organization developed the latest clinical practice guidelines for gout management?
American College of Rheumatology
When were the latest guidelines for gout management developed?
2022
What methodology is used in the guidelines for gout management?
GRADE methodology (grading of recommendations, assessment, development, and evaluations)
What are xanthine oxidase inhibitors?
A group of medications that includes allopurinol and febuxostat used in urate-lowering therapy
How do xanthine oxidase inhibitors work?
By inhibiting the enzyme responsible for the conversion of hypoxanthine and xanthine to uric acid
What is the first-line agent for treating gout?
Allopurinol
What side effect is commonly associated with xanthine oxidase inhibitors?
Hepatotoxicity
What is a potential risk when initiating therapy with allopurinol or febuxostat?
Patients may experience a gout flare
What skin reaction can allopurinol cause?
Life-threatening skin rash similar to Stevens-Johnson syndrome
What is probenecid?
A uricosuric drug that inhibits renal tubular reabsorption of urate
How is pegloticase administered?
Parenterally (injection)
What are common side effects of probenecid?
Nausea, vomiting, diarrhea, and GI side effects
In which patients should probenecid be avoided?
Patients with peptic ulcer disease
What is the drug of choice among uricosuric drugs?
Probenecid
What class of medications can be used to manage acute gout flares?
Colchicine, NSAIDs, and glucocorticoids
What is the preferred dosing regimen for colchicine in acute gout flares?
1.2 mg at first sign of flare, followed by 0.6 mg one hour later
What are interleukin-1B inhibitors used for?
Management of gout flares in patients who do not respond to standard treatments
What are emerging therapies for gout focused on?
Long-term urate-lowering therapies and selective gut anaerobic purine degrading bacteria
What is a common side effect of biologics, including interleukin-1B inhibitors?
Increased risk of infection
What are corticosteroids commonly referred to as?
Glucocorticoids or steroids
Where are corticosteroids produced in the body?
Adrenal cortex
What is the primary role of corticosteroids in the body?
Maintaining homeostasis
What can result from inadequate or excessive corticosteroid secretion?
Disease
What are the three groups of endogenous corticosteroids?
- Glucocorticoids
- Mineralocorticoids
- Adrenal sex hormones
How many different steroid hormones are categorized into these groups?
About 30
What is one mechanism by which corticosteroids decrease inflammation?
Inhibiting arachidonic acid metabolism
What are some cytokines inhibited by corticosteroids?
- Interleukin-1
- Tumor necrosis factor
What are the symptoms of withdrawal syndrome from exogenous corticosteroids?
- Malaise
- Myalgia
- Nausea
- Headache
- Low-grade fever
- Hypotension
What is the prototype for exogenous corticosteroids?
Hydrocortisone
What does hydrocortisone equal in terms of anti-inflammatory effect?
Cortisol
What is the general principle for short-term corticosteroid therapy?
Use for self-limiting conditions
When should long-term corticosteroid use be reserved?
Life-threatening conditions or severe disabling symptoms
What is the defined duration of short-term corticosteroid use?
Less than one week
What is the typical tapering schedule for short-term corticosteroid use?
Large dose divided in 48 to 72 hours and then tapered
Why is it important to avoid abrupt withdrawal of corticosteroids?
To prevent acute adrenal cortical insufficiency
What is a common regimen for treating asthma exacerbation with corticosteroids?
Five-day prednisone burst
What is preferred when treating with corticosteroids, local or systemic therapy?
Local therapy when possible
What should patients be advised regarding the timing of prednisone administration?
Take in the morning with food
What is a potential adverse effect of prednisone related to diabetes?
Increased blood sugar levels
What are contraindications for prescribing prednisone?
- Allergy
- Infection
What is a common glucocorticoid used for allergic conditions?
Methylprednisolone
What is the high-powered glucocorticoid often used for cerebral edema?
Dexamethasone
What role have glucocorticoids played in the treatment of COVID-19?
Used in moderately to severely ill patients
What are some studies showing mixed results regarding glucocorticoids in COVID-19?
Efficacy in preventing mechanical ventilation or increasing mortality
