FINAL-Chronic Pain

Question 1

Chronic Pain definition…

Answer 1

Persistent pain recurring for greater than 3 months or 1 month after resolution of an acute tissue injury or non-healing lesion

Question 2

Acute vs Chronic Pain tx goals…

Answer 2

Acute-CESSATION of pain

Chronic-Decrease pain and increase QOL

Question 3

Cycle of Pain

Answer 3

Pain-Avoidance Behavior-Decreased Mobility-Altered functional status-Diminished self-efficacy-Social Limitations-Pain Augmented

Question 4

Meds to use for Neuropathic Pain

Answer 4

Gabapentin (Neurontin)
G. enacarbil (Horizant)
Pregabalin (Lyrica)
Gralise
Carbamazepine (Tegretol)
Topiramate
Lamotrigine

Question 5

Use for Horizant

Answer 5

Gabapentin Enacarbil

• PHN
• RLS

Question 6

Use for Pregabalin

Answer 6

Lyrica

• Good for SEDATION
• Peripheral Edema

Question 7

Use for Gralise

Answer 7

PHN

Question 8

DOC for Carbamazepine

Answer 8

Trigeminal Neuralgia

Question 9

Carbamazepine Brand

Answer 9

Tegretol

Question 10

Membrane Stabilizing Anticonvulsants

Answer 10

Topiramate

Lamotrigine

Question 11

Antidepressants preferred for pain

Answer 11

TCAs
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Desipramine (Norpramin)
Imipramine (Tofranil)

Question 12

Amitriptyline

Answer 12

Elavil

Question 13

Nortriptiyline

Answer 13

Pamelor

Question 14

Desipramine

Answer 14

Norpramine

Question 15

Imipramine

Answer 15

Tofranil

Question 16

Side Effects of TCAs

Answer 16

Dry mouth
Somnolence
Sedation
Constipation
Cardiac

Question 17

SNRIs important to chronic pain tx…

Answer 17

Duloxetine (Cymbalta)
Venlafaxine(Effexor)
Milnacipran (Savella)

Question 18

Duloxetine indication for

Answer 18

CYMBALTA

FDA INDICATED FOR

• Fibromyalgia
• Low Back Pain
• Diabetic Neuropathy

Question 19

Milnacipran Indication

Answer 19

SAVELLA

FDA approved for FIBROMYALGIA

Question 20

SSRIs are not proven effective for pain tx, but are used in pts with

Answer 20

Depression

Question 21

Benzos

Answer 21

Shown in one study to provide some efficacy for neuralgic pain

Question 22

NMDA Receptor Agonists

Answer 22

Dextromethorphan
Memantine
Methadone
Amantidine

Question 23

NMDA receptor agonists should be used….

Answer 23

Neuropathic pain

PHN, Diabetic neuropathy, Phantom limb pain, Peripheral nerve injury, CRPS etc

Question 24

NSAIDs should be used for….

Answer 24

Patients with back pain

Question 25

Skeletal Muscle Relaxants are recommended for...

Answer 25

Short term use for acute low back pain, but you will see them used for muliple chronic pain conditions

Question 26

Skeletal muscle relaxants used for Spasticity (MS, Cerebral palsy, Post stroke syndrome, TBI, Spinal cord injury)

Answer 26

Tizanidine | Baclofen

Question 27

Skeletal Muscle Relaxants

Answer 27

``` Carisoprodol Cyclobenzaprine Methocarbamol Metaxolone Baclofen Orphenadrine Tizanidine(Alpha 2 agonist) Dantrolene ```

Question 28

CI for chronic opioid therapy

Answer 28

Decompensated psychiatric illness, psychotic dx, or mania History of drug or alcohol abuse

Question 29

Weak to Mod Opioids

Answer 29

Codeine and Tramadol

Question 30

Morphine

Answer 30

``` MS Contin, Kadian Gold Standard ER not for naive RENAL ADJUST CNS depression, Resp depression, Hypotension ``` Abuse deterrent ER formulas: Embeda(+naloxone) Arymo ER MorphaBond ER

Question 31

Hydrocodone

Answer 31

``` Pro-drug converted to hydropmorphone Hepatic caution Usually in combo with acetaminophen ER TOO E XPENSIVE CNS Depression, hepatotoxicity(acet.) ```

Question 32

ER Hydrocodone

Answer 32

Zohydro ER | Hysingla ER

Question 33

Oxycodone

Answer 33

NO IV** renal/hepatic CNS depression, resp despression, hypotension

Question 34

Oxymorphone

Answer 34

Opana | PO ONLY IR & ER

Question 35

Buprenorphine

Answer 35

Transdermal-BUTRANS Indicated for the management of pain sever enough to require daily, around-the clock, long term opioid treatment and for which alternative treatment options are inadequate Q WEEKLY Combo with Naloxone for treatment of opioid dependence

Question 36

Transdermal Fentanyl Info and CI

Answer 36

NOT FOR NAIVE Hep/Renal CI: respiratory disease DDI with Erythromycin and Clarithromycin

Question 37

Opioid Tolerant Patients

Answer 37

Taking daily for a week or longer 60mg of oral morphine, 30mg oxycodone, or at least 8mg of oral hydromorphone or and equianalgesic dose of another opioid

Question 38

Methadone

Answer 38

Considered ideal candidate for chronic pain -highly inexpensive -High efficay -Extended duration of action Lot of BBW *QT PROLONGATION*-->ECG at baseline AND 30 DAYS AFTER STARTING** PK non-linear to morphine SE & NE

Question 39

Fentanyl Transmucosal

Answer 39

``` Actiq (lozenge) Fentora (buccal tab) Onsolis (buccal film) Abstral (SL tablet) Subsys (SL spray) Lazanda (nasal spray) ``` FOR CHRONIC INTRACTABLE PAIN

Question 40

Breakthrough dose should be

Answer 40

5-15% of toatl daily dose | dose q2-6 hours

Question 41

Ketamine

Answer 41

NMDA usually used for sedation USed for Maladaptive pain syndromes (CRPS) adjunct in acute pain, chronic unclear

Question 42

Diabetic Neuropathy FDA approved tx

Answer 42

Duloxetine (CYMBALTA) Pregabalin (LYRICA) There are others but these are FDA indicated

Question 43

Post Herpetic Neuralgia

Answer 43

Lidocaine patch FDA indicated: G. Enacarbil (HORIZANT) Gralise Oioids, there are a lot of other options

Question 44

Trigeminal Neuralgia Tx

Answer 44

CARBAMAZEPINE (tegretol)