Ortho Pain management Flashcards
General Tx of acute pain in orthopedics
General Tx of chronic pain
Acute:
- mixture of narcotics and non-narcotic medication
- splinting/bracing/immobilization
Chronic pain:
- establish ground rules, MC dealt w/ through chronic pain providers.
- pain contracts
- ancillary services (behavioral health, biofeedback, PT, OT)
Narcotics are usually given in combo with what other medication?
What are the MC narcotics?
Narcotics are usually given in combo with APAP (acetaminophen)
MC Narcotics:
- Codeine
- Hydrocodone
- Oxycodone
- Tramadol
- Hydromorphone
- Meperidine
- Fentanyl
What medications are in each of the DEA schedules:
- Schedule I
- Schedule II
- Schedule III
- Schedule IV
- Schedule V
Schedule 1:
- illegal/restricted to research.
- high potential for abuse
- ex: hallucinogens, marijuana, peyote, heroin
Schedule 2:
- requires a Rx
- no refills or verbal orders
- codeine
- hydrocodone
- hydromorphone
- morphine
- cocaine
- fentanyl
- methadone
- meperidine
Class 3:
- requires Rx
- Max 5 refills/6mo
- verbal orders allowed
- Stimulants: benzphetamine, clortemine
- Depressants: ketamine, pentobarbital, secobarbital, sulfomethane
Class 4:
- requires Rx
- low abuse potential
- Max 5 refills/6mo
- examples: alprazolam, barbital, clonazepam, lorazepam, midazolam, phenobarbital, diazepam, tramadol
Class 5:
- low abuse potential
- Rx or may be OTC
- Ex: Robitussin AC (antitussive), Lyrica (anticonvulsant), lomotil(antidiarrheal), potiga(anticonvulsant)
Codeine/APAP
- aka?
- DEA Schedule?
- MOA
Hydrocodone:
- aka
- DEA Schedule?
- MOA
Oxycodone:
- combo preparations?
- aka
- DEA schedule
- MOA
Codeine/Apap:
- Aka: Tylenol #3
- DEA Schedule: III
- opioid agonists
Hydrocodone:
- aka: Lorcet, vicodin, norco, lortab
- DEA schedule: II
- opioid agonists
Oxycodone:
- Combo: Percocet = oxycodone/APAP
- aka: OxyContin, MS-contin, oral morphine sulfate
- DEA schedule: II
- MOA: opioid agonist
Tramadol:
- aka
- combo preparation?
- MOA
- DEA schedule?
Hydromorphone
- aka
- MOA
- DEA Schedule?
Meperidine
- aka
- risks
- DEA schedule
- SE
Fentanyl
- aka
- indications
- DEA schedule
Tramadol:
- aka: ultram
- Combo: Tramadol + Ultracet
- MOA: unknown, binds to opioid receptors and inhibits NE/Seritonin reuptake.
- DEA Schedule: IV
Hydromorphone:
- aka: dilaudid
- MOA: opioid agonists
- DEA schedule: II
Meperidine:
- aka: Demerol
- Risk: seizure risk over time and dose
- DEA schedule: II
- SE: often causes nausea and vomiting …… give with phenergan
Fentanyl
- aka: duragesic
- indications: for opioid tolerant pts only.
- DEA Schedule : II
NSAIDS:
- Acetic Acid
- -drug names
- -MOA
- Propionic acids
- -drug names
- -MOA
- -SE
- COX 2 inhibitors:
- -drug names
- -indications in orthopedics
- -CI in who?
Acetic Acid:
- Drugs: diclofenac, etodolac, indomethacin, ketorolac
- MOA: inhibit cyclooxygenase, reducing prostaglandin and thromboxane synthesis
Proprionic Acids:
- drugs: naproxen, ibuprofen
- MOA: “cox 1 and cox 2 inhibitor. Mess with prostaglandins”..yeah, thats right off the slide.
- SE: “GI issues, kidney issues”.. yeah that too.
COX 2:
- Drugs: Celebrex
- Indications: ortho surgeons use as an adjunct with narcotics following total joint surgery
- CI in those with sulfa allergy
Steroids:
-list the PO and injectable steroids.
PO Muscle Relaxants:
- goal of therapy
- MOA
- indications
PO Steroids: medrol-dose pack, prednosone
Injectable: triamcinalone-kenalog. celestone-betamethasone, depo-medrol-methylprednisolone
Muscle Relaxants:
-Goal: the aim of centrally acting skeletal muscle relaxants is to produce a decrease in muscle tone and involuntary movement without loss of voluntary motor function or consciousness.
- MOA: alters the balance of synaptic excitation and inhibition of the motor neuron receives
- *These are CNS depressants
- indications:
- -relief of acute painful musculoskeletal conditions of local origin.
- -as an adjunct to rest and PT
- -relief of acute painful musculoskeletal conditions which include muscle spasm secondary to trauma, radiculopathy, musculoskeletal strain or sprain, herniated intervertebral disc, and muscle spasm of osteoarthritis
Muscle Relaxants:
- Caution in who?
- long term effects
- Not recommended for use in who?
- SE
- duration of use
- what are the muscle relaxant drug names?
Muscle Relaxants:
- Caution with renal and hepatic insufficiency.
- Long term effects:
- -leukopenia, thrombocytopenia, hemolytic anemia, bleeding agranulocytosis
-Not recommended for use in pregnancy, children
SE:
-drowsiness, HA, dizziness, and blurred vision, dry mouth
Duration of use:
-initial tx 10-14days
Drug names:
- norgesic *
- carisoprodol (soma) *
- Cyclobebenzaprine (flexeril) *
- Diazepam (valium)*
- Methocarbamol (Robaxin)*
- metaxalone (Skelaxin)
- Tizanidine (Zanaflex)
- Baclofen (Lioresal)
Norgesic:
-what is this?
Carisoprodol:
- aka
- what is this?
- duration of use?
- adverse effects
Norgesic:
- combination muscle relaxant/analgesics
- asa/caffeine/orphenadrine
Carisoprodol:
- aka: soma
- what: one of the products of metabolism, meprobamate, is an active as an ANXIOLYTIC. In animals it depresses the transmission of polysynaptic neurons in the spinal cord.
-duration of use: should not be used longer than 10-14days
adverse effects:
- drowsiness, dizziness
- N/V
- vertigo/ataxia
- Epigastric distress
- HA/ insomnia
- Tachycardia
- Facial flushing
- postural hypotension
Carisoprodol
- CI
- precautions
CI:
-Porphyria: inherited porphobilinogen deaminase mutation….. abd & urinary sx, peripheral neuropathy, systemic and central nervous system involvement
Precautions:
-seizures
Cyclobebenzaprine
- aka
- structurally similar to which other drug class?
- MOA
- duration of use
- SE
- CI
Aka: flexeril
Structurally similar to TCA
MOA:
-relieves skeletal muscle spasm of local origin without interfering with muscle function
Duration:
-dont use longer than 10-14days
SE:
-anticholinergic effects
Cyclobebenzaprine:
- CI
- Adverse effects
CI:
- w/ concurrent use of MAOIs
- acute phase of MI
- arrhythmias
- heart block
Adverse Effects:
- drowsiness
- dry mouth
- fatigue
- HA
Diazepam:
- aka
- MOA
aka: Valium
MOA:
- used as a centrally acting skeletal muscle relaxant
- depresses muscle excitability indirectly by potentiating the effects of synaptic inhibition medication by GABA.
- this is the only benzo approved for tx of muscle spasm or MSK disorders
Methocarbamol:
- aka
- T/F this has markedly less CNS depression than all of the other muscle relaxantS?
- MOA
- duration of use
aka: Robaxin
True, it has markedly less CNS depression than all the other muscle relaxants
MOA:
-unknown in humans, has no direct action on the contractile mechanism of striated muscle, the motor end plate, or the nerve.
What drug classes are used to treat ortho pain?
What modalities are used for conservative therapy?
ORtho pain:
- NSAIDS
- MUscle relaxants
- Narcotics
- Steroids
- TCA
- GABA (gabapentin, valproic acid/depakote/valproate)
- OTC (i.e glucosamine)
Conservative Therapy:
- Ice/heat
- pt handouts on stretches/exercises
- PT/OT
- Chiropractor
- Behavioral Health for chronic pain
- Biofeedback/hypnosis/anti-inflamm diet
- Splinting/bracing/immobilization
