Pain Management Flashcards
Define Pain
Nociceptive: catergories
Neuropathic
Pain
- unpleasant sensory and/or emotional experience associated with actual or potential tissue damage
- subjective: difficutl to qualitfy and understand what pt. feels
- most common reason for medical attention
Nociceptive Pain
- somatic: from tissue, bone, skin, joint or connective tissue sharp, localized and throbbing pain
- visceral: from the organs themselves (internally); felt as referred or poorly localized pain thats deep and achy
Neuropathic Pain
- pain due to damange of teh nervous system
- felt like buring, sharp, electric-shock like pain that is shooting
- can be associted with paresthesias: pins and enedles
Definitions of alterations in pain sensitivity
hyperalgesia
allodynia
paresthesias
analgeisas
Hyperalgesias: an increased sensitivtiy to pain
- opioids can cause this, disease stattes and even just an exacerbated pain (rolled ankle, will hurt more to move)
Allodyina
- things which arent normally painful elict a painful response
- socks on feet = painful!
Paresthesias
- the pins and needles feeling
Analgesia
- pain relief
Pain Classifications
acute
chronic
breakthrough
Acute Pain
- pain which is brief
- lasting for the duration of an injury
- not a specific time frame, but like weeks
commonly acute pain is…..
- from an injury
- self limited
- gets better over time
- have autonomic symptoms
Chronic Pain
- pain which remains lasting longer than anticiapted
- usually > 3 months
commonly chronic pain is…
- sudden or gradually developing
- surrfering increases over time
- interventions help to make pain more bearable, not complete resolution
- can have anxiety/depression concurrently
Breakthrough
- pain flare which is on top of a chronic pain at baseline
step-wise guidelines for treatment of pain and medications
Pain is 3/10 = use what
Pain is 4-7/10 = use what
Pain is 7-10/10 = use what
Step 1: Pain is 3/10
- use Non-opiod pain relief = NSAID/acetaminophen + adjunt
Step 2: Pain is 4-7/10 (or remaisn after step 1)
- use opioid for mild to moderate pain
- + adjunct non-opioid
Step 3: Pain is 7-10/10 (or remains after Step 2)
- opioid for moderate to severe pain
- + non-opioid adjuct
Guidance on how to manage pain : Acute Pain Control
- acute (IR) v (ER) pain control and when to use
for Acute Pain
for Initial Stages: short acting agents = dose finders
- these are meds to fingure out what dose is alievating the pain
- can be given around the clock or just when needed
- key here = short acting on/off
for Intermittent
- giving these short acting meds (IR) around the clock; schedule to GET AHEAD of the pain
- not waiting for the pain wave, but given to prevent the wave
- start with IR formulation PRN => then if pain progresses chagne to around the clock dosing
Guidance on how to manage pain : Chronic Pain Control
ATC and breakthrough
Chronic Pain
Around the Clock Dosing: ATC
- these is when you decide if youre going to ATC dose IR or give long acting agents to control chronic pain
- ATC: helps you get ahead of the pain and prevent the wave
- start with short acting and convert to long
Breakthrough Pain
- use short acting agents to help
- can use long actin, but we use IR
key pearls (2) of all pain management dosing
- maximize the dose of first pain medication using before you add on another pain med
- consider adjuvant (OT,PT, etc.) whenever able
Acetaminophen
- use for what type of pain
- 2 MOA
- ADR
- max dose
Acetaminophen
- pain: nociceptive pain (muscle, skin, joints, connective tissue)
MOA
- anti-pyretic
- analgesic
- therefore: no anti-inflamm. properties
ADR
- well tolerated
- hepatotoxic: max dose is 4g/day under medical advice, 3g/day for everyone (keep pt. at 3g/day)
- watch combo drugs!
NSAIDS
names & key pearls about Naproxen, celcoxib and meloxicam
NSAIDS
- ibuprofen
- dicolfenac
- meloxicam : prefers COX II > COX I
- Naproxen: good for those with CVD (aleve)
- Celecoxib: watch if sulfa allergy; COXII inhibitor - good for GI issues, not good for CVD
NSAIDS
- type of pain used for
- MOA
- ADR
- elderly?
- councel
NSAIDS
- use for nociceptive pain
- analgesic
- anti inflammaotry
ADR
- GI irritation and ulceration
- RENAL IMPAIRMENT: do not use NSAIDS in the elderly; they have bad kidneys
- HTN pt. : increased sodium retetion, can make it worse
- caution use in CHF, HTN, PUD and GERD
- increased risk of bleeding: caution in those with concominant anticoag. use (if on a DOAC or heparin, cannot use
councel
- take with food!!
Elderly
- do not use NSAIDS
- renal impairment : excretion issue
- Drug-Drug interactions
- Toxicities: CV, renal and GI
Ketoralac
when is it used for pain
contraindications
how often can it be used
Ketoralac: an IV formulation of NSAID
Indication for Use
- severe severe pain: considered to be equipotenet to a weak opioid
COntraindications
- PUD
- history of GI bleed
- renal disease
- prophlyaxis before surgery cannpt be used = bleeding risk
Use
- can only be given for 5 days or LESS & given 90 days apart
- cannot be used chronically = too high of a GI bleed risk
Opioids: REceptors Types and Concurrent actions
- abuse potential by receptor
Mu
Delta
Kappa
Receptors = mu, delta and kappa
Mu receptor: most common
the one that created analgesic properties = pain relief!
Side effects =
- respiratory depression
- bradycardia
- euphoria
- pruritis
- mitosis (constricted)
- nausea/vomiting
- inhibits gut motility (constipation)
HIGH abuse potential & Physical Dependnce
Delta Receptor
- low abuse potential
- analgesic properties
Kappa Receptor
- low abuse potential
- analgesic properties
side effects
- sedation
- psychomotor effects (delirum/dementia)
- dysphorisa
- diuresis
Opioids: what degree of pain is this indicated
oral formualtion & avalible dosing (IR v ER) & when used
Opioids: for moderate to severe pain
- class II highest abust potential drug
- patient specific responses to the doses and analgesic effects!
- for short term and chronic pain
Oral Formulation
Immediate Release (IR): Short Acting
- start with IR meds first to see how it controls the pain
- can be used for breakthrough ain
- can cause more sedation as it peaks
Extended Release (ER): Long Acting
- good for maitnence of pain management
- used after the dosage of IR has been stabilized
- this is consider standard/maitnence dosing
- less peaks: more steady release
Opioids
IV dosing pearls
Transdermal dosing pearls
Opioids
IV Dosing
- provides most rapid effect
- flexibile dosing
Transdermal (fetynal and bubrinorphine come as patches)
- not recommende for those with unstable pain = only used with those who are consistent, chronic pain
- always ensure these pt. are on a controlled regimen before transitioning to a patch : never really starting with a patch (NEVER strating with fetynal)
other administeration
- transbuccal
- intranasal
Morphine
onset of action & type of pain relief
metabolites
side effects
Morphine: usually the first opioid started when starting to use them
Onset of Action = quick (used for acute pain)
30 mins, 90 if ER, IV = minutes
Metabolites
- the metabolites will build up if renally impaired, need to watch your dosing
- M6G metabolite: is MORE POTENT than the parent drug; the reason for the respiratory depression side effect
- also has M3G but less clinically important
Side Effects
Histamine Release: pt. get itchy on this, hypotension and bronchospams
Respiratory Depression: at initial dose & every increased, increase risk (and the M6G metabolite)
Nausea/Vomiting
constipation: give them a stimulant laxitive
reduced Testoterone levels
Urinary retention
Codeine (Tylenol #3)
pain relief efficacy & indications
metabolites
side effects
Codeine: doesn’t work well for pain relief
- weak analgesic
- can be used for cough suppression
Metabolites
- metabolized to morphine!! via 2D6
- watch D-D interactions & slow/fast metabolizers
- nausea: lower dosing has higher risk of nasuea & more than other opioids
