Chronic pain PPT by McDizzle Flashcards
Josh Guide to mind fucking anyone and everyone on issues of chronic pain!!!!!!!! skeet skeet bitches.!!!!!!!!!!!!!!!! (84 cards)
1
Q
What is pain?
A
an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage or both
2
Q
what is Chronic Pain?
A
persistent or recurrent pain, lasting beyond the usual course of acute illness or injury, or more than 6 months, and adversely affecting the patients well-being
3
Q
What are the effects of unreleived pain
A
Delayed healing altered immunity Increased stress anxiety or depression general physical and psychological decline Economical adversity
4
Q
in a study >50% of pts had to change MDs due to lack of pain control? why is this?
A
- unwilling to treat pain
- did not take the pt’s pain seriously
- inadequate knowledge about pain treatment
5
Q
What contributes to the lack of pain control throughout the world?
A
- inadequate education
- poor understanding of pain syndromes
- lack of diagnostic tools
- attitudes regarding pain
- reimbursement barriers
- inadequate treatment guidelines
- poor understanding of drugs used
- reluctance to use certain pharm agents
- lack of knowledge of complementary therapies
- drug side effects
6
Q
Common barriers to treatment of Chronic Pain:
Provider related?
A
- limited knowledge of pain patho and assessment skills
- biases against opioid therapy and overestimation of risk
- fear of regulatory scrutiny/action
7
Q
Common barriers to treatment of Chronic Pain:
Patient related?
A
- exaggerated fear of addiction, tolerance, SE
- reluctance to report pain: stoicsm, desire to please “MD”
- concerns about “meaning” of pain
8
Q
Common barriers to treatment of Chronic Pain:
system related
A
- low priority given to pain and symptom control
- limits on # of RXs and refills per month
- reimbursement policies
9
Q
Common barriers to treatment of Chronic Pain:
economic and racial?
A
- language and culture differences
- perceptions and misconceptions
- lack of assertiveness in seeking treatment
- unavailability of meds
10
Q
Pathophysiology of pain:
Types of pain?
A
- nociceptive
- neuropathic
- idiopathic
11
Q
Pathophysiology of pain:
patho of chronic pain???
A
-the nervous system REMODELS continuously in response to repeated pain signals —> nerves become hypERsensitive to pain & resistant to antinociceptive system
12
Q
Pathophysiology of pain:
what happens if chronic pain is untreated?
A
pain signals will continue even after injury resolves
13
Q
Pathophysiology of pain:
Chronic pain signals become embedded in the ___ _____ ______
A
CNS
14
Q
Which type of pain is pain sensing signals are initiated in response to a stimulus they elict pain relieving responses
A
Acute pin
15
Q
Which type of pain sends pain signals that are generated for no reason and may be intensified; pain relieving mechanisms may be defective or deactivated
A
Chronic Pain
16
Q
nociceptive pain pain results from what?
A
ongoing activation of primary afferent neurons responding to noxious stimuli
17
Q
nociceptive pain is consistant with what?
A
degree of tissue injury
18
Q
nociceptive pain is described as what?
A
aching
squeezing
stabbing
throbbing
19
Q
nociceptive pain 2 subtypes
A
Somatic (r/t activation of somatic afferent neurons)
Visceral (r/t activation of Visceral afferent neurons)
20
Q
Somatic pain:
characteristics
A
well localized Continuous or intermittent aching dull gnawing nagging sharp
21
Q
Somatic pain
examples
A
Bone fracture
arthritis
Bone metastasis
22
Q
Visceral Pain:
Characteristics
A
poorly localized referred to distant sites Sharp gnawing vague deep pressure may become worse with movement/inhale
23
Q
Visceral Pain:
examples
A
gallbladder
pancreatitis
Cancer
24
Q
What type of pain is initiated by primary lesion in the nervous system; beleived to be sustained by aberrant somatosensory processing in the peripheral and CNS
A
Neuropathic pain
25
Neuropathic pain:
| characteristics
```
burning
shooting
electrical quality
aching
throbbing
sharp
Constant or intermittant
```
26
Neuropathic pain is independent of obvious ongoing _____ activation
nociceptive
27
Neuropathic pain
| examples
post herpatic neuralgia
| diabetic neuropathy
28
2 subtypes of Neuropathic pain
Presumed "central generator"
| Presumed "peripheral generator"
29
Idiopathic pain what is it?
exist in the absence of an identifiable physical or psychological pathology that could account for the pain
30
Idiopathic pain is uncommon in what types of pt's
pt's with progressive illness
31
What is psychogenic pain?
pain that shows positive evidence of predominant psychological contribution and may be labeled with a specific phychiatric diagnosis
32
Pain assessment UPQRST
```
U-use the pt's self report
P-palliative (provocative)
Q- quality
R- Radiation
S- Severity
T-Temporal
```
33
UPQRST +2
| what is the +2
2 additional questions!
- what have you tried to relieve your pain
- how is the pain affecting your life
34
How can you assess pain in the cognitively impaired?
```
Ask simple questions yes/no
assess risk factors for pain
Observe for non-verbal signs of pain
Investigate behavior/routine changes
assess function and pain
attempt an analgesic trial
```
35
The WHO has a ladder that states to start treating the patient based off where their pain is level is at what are the 3 levels
mild
moderate
severe
36
What is pain management for mild pain?
opioids
37
What is pain management for Moderate pain
opioids + something else
38
What is pain management for severe pain (basic don;t name meds yet)
opioids + something else + something else
39
What is pharmacological management for mild pain
Acetaminaphen
NSAIDs
COX-2 inhibitors
LA injections
40
What is pharmacological management for moderate pain?
Step 1 plus step 2
( Acetaminaphen, NSAIDs, COX-2 inhibitors, LA injections)
add intermitant doses of opioids
41
What is pharmacological management for severe pain?
Step 1 plus step 2 plus step 3
( Acetaminaphen, NSAIDs, COX-2 inhibitors, LA injections, and intermitant doses of opioids)
add regional block, sustained release opioids
42
Acetaminophen
| dose maximum
4000 mg/day
43
Acetaminophen adverse reactions are dose dependent but more susceptible in what patents?
alcoholics
44
```
Acetaminophen facts
Anit-flammatory effects?
adverse effects vs other non-opioids?
effects on platelet fxn?
Adverse effect?
```
minimal
fewer
none
hepatotoxicity (increased with liver disease ETOH)
45
NSAIDs
| exert effects at the ______ and _____ levelsls
peripheral and central
46
NSAIDs exhibit _______, ________, and _______ effects
antipyretic
analgesic
antiflammatory
47
NSAIDs do or do not produce physical or psychological dependence?
do not
48
NSAIDs are usefull for acute and chronic pain due to a variety of causes including what?
trauma
surgery
arthritis
CA
49
NSAIDs ceiling dose must be monitored to avoid toxicity with a maximum dose of _______mg/day
3200
50
combining NSAIDs increases the potential adverse effects! what are the adverse effects of NSAIDs
hepatic dysfunction
bleeding
Gastric ulceration
renal failure
51
what are some drug classes used for adjuvant analgesics for neuropathic pain
```
Anticonvuslants
antidepressents
Corticosteroids
Alpha-2 adrenergic agonist
NMDA receptor agonist
Topicals
```
52
Adjuvant analgesics: anticonculsants
| what are some examples
```
gabapentin
carbamazepine
phenytoin
valproate
clonazepam
```
53
```
Adjuvant analgesics: antidepressants
what class is best shown to work from evidence
```
tricyclics
54
Adjuvant analgesics: antidepressants
| what classes are better tolerated than tricyclics?
SSRI and atypicals
55
Adjuvant analgesics: antidepressants
| they are proven efficient for all types of neuropathic pain, but often preferred for what?
continuous dysesthesias
56
Adjuvant analgesics: antidepressants
| dose for pain management?
less than antidepresssent use
57
Adjuvant analgesics: anticonvulsants dose for pain?
similar to anticonvulsant dose
58
Adjuvant analgesics: Corticosteroids
| they have been shown to improve what?
```
pain
appetite
nausea
malaise
quality of life in Ca pt's
```
59
Adjuvant analgesics: Corticosteroids
| In CA pt's it is indicated for refractory neuropathic pain and also?
```
bone pain
bowel obstruction
capsular bone
lymphedema
headache
```
60
Adjuvant analgesics: Corticosteroids
| in non-cancer pts it;s use is limited to what?
inflammatory conditions
61
Adjuvant analgesics: Corticosteroids
| what are the 2 usual drugs used?
dexamethasone
| prednisione
62
Name 6 short acting opiods
```
Hydrocodone/APAP
Hydromorphone
Morphine
Oxycodone w or w/o APAP
oral transmucosal fentanyl
tramadol
```
63
name 4 long acting opioids
transdermal fentanyl
methadone
extended release morphine
Oxycodone CR
64
Advantages of long-acting opiods
fewer peaks and troughs (sustained pain releif)
dosed less often (improved adherence)
potentially improved satisfactions
65
Elements to consider for drug selection
```
severity of pain
previous exposure
availability
pt preference
renal and liver fxn
cost
```
66
how do you dose to optimize effects of medications
fixed schedule around the clock vs as needed dosing, rescue doses
67
recomendations for by-the-clock (fixed schedule) dosing
- dose with long acting opiod plus an "asneeded" short acting opioid (usually 5-15% of total daily dose) q 2-3h PRN
- baseline dose increases 25-100% or equal to rescue dose use
- increase rescue dose as baseline dose increases
68
equivalent doses put dose into SC/IV/IM dose!
| 30 mg morphine PO
10 mg
69
equivalent doses put dose into SC/IV/IM dose!
| 4-8mg Hydromorphone
1.5 mg
70
equivalent doses put dose into SC/IV/IM dose!
| 20 mg oxycodone
none
71
equivalent doses put dose into SC/IV/IM dose!
| 20 mg methadone
10 mg
72
If a pt is receiving a 24hr done of 180mg PO. what is teh equivalent 24hr dose of PO hydromorphone
Morphine 30mg PO = morphine 180mg PO
-------------------- ----------------------
hydromophone 7.5mg x
X= 45 mg PO (6-8mg PO q4)
73
what is the key to successful opiod therapy
titration
74
what is the ceiling dose for pure agonist opioids?
none
75
Opioid unexpected SE
```
resp depression
depression
Apnea
Resp arrest
Circ depression
Hypotension
Shock
Constipation
```
76
What are expected SE of opiods
```
N/V
Somnolence
Dizziness
Pruritis
Headache
Dry mouth
Sweating
```
77
what are non pharm ways to manage pain
```
Lifestyle changes (weight loss)
Rehab therapy
Psychosocial therapies
Interventional tech (TENS, Injections, surgery)
Complementry therapies (massage)
```
78
How do you measure opioid outcomes?
```
the 4 A's
Analgesia
ADLs
Adverse effects
Aberrant drug taking (addiction)
```
79
what is an abstinence syndrome induced by administration of an antagonist or by dose reduction
physical dependence
80
What is the diminished drug effect from drug exposure
tolerance
81
2 tyoes of tolerance
associative and pharmacological
82
what is a disease with pharmacological, genetic, and psychosocial elements, has elements of loss of control, compulsive use, use despite harm
Addiction
83
what is aberrant drug-related behaviors driven by uncontrolled pain
pseudoaddiction
84
What pts (3) are at low risk for addiction
acute pain
Ca pain
pt's w/o backgrounds of abuse
