Pain

Question 1

Acute Pain

Answer 1

Diminishes as healing occurs; responds well to analgesics

Question 2

Chronic Pain

Answer 2

Lasts longer than three months, nerves may have become oversensitive and react to even a slight stimulus

Question 3

Neuropathic Pain

Answer 3

C/B damage to PNS or CNS; not well-controlled by opioids alone, needs adjuvent therapy

Question 4

Characteristics of neuropathic pain

Answer 4

Numbing, shooting, stabbing, sharp, electric shock-like, burning. Example- diabetic nueropathy

Question 5

Tolerance

Answer 5

Body adapts so exposure to a drug changes that result in a decrease in one or more of the drugs effects

Question 6

Physical Dependance

Answer 6

Symptoms c/b abrupt cessation, rapid dose reduction, decreased blood level, and/or administration of an antagonist

Question 7

Addiction

Answer 7

Primary, chronic, nuerobiologic disease w/genetic, psychosocial and environmental factors

Question 8

Incident Pain

Answer 8

Transient increase in pain that is caused by a specific activity or event that precipitates pain. Examples- dressing changes, movement, position changes, and procedures such as catheterization

Question 9

Breakthrough Pain

Answer 9

Transient, moderate to severe pain that occurs in patients whose baseline persistent pain is otherwise mild to moderate and fairly well controlled. 3-5 min, can last up to 30 min. Can happen several times a day

Question 10

OLD CART

Answer 10

Onset, location, duration, characteristics, aggravating factors, relieving factors, treatment

Question 11

Non-Opiods

Answer 11

Mild to moderate pain. NSAIDS decrease production of pain-sensitizing chemicals. Dont produce tolerance or dependence. Have an analgesic ceiling. Used with opioids to lower opioid dose.

Question 12

ASA (non-opioid)

Answer 12

Use limited due to side effects

Question 13

Tylenol (non-opioid)

Answer 13

Does not cause bleeding, but can be toxic to the liver

Question 14

NSAIDS

Answer 14

Can cause bleeding, renal toxicity, CHF in elderly, some interactions with anticoagulants, oral hypoglycemics, antihypertensives, diuretics

Question 15

How do opioids work?

Answer 15

Modify the perception of pain

Question 16

Opioids: Agonists

Answer 16

morphine, oxycodone, hydrocodone, codeine, methadone, hydromorphone.
Often combined with non-opioid analgesics limiting the total daily dose that can be given. Potent, have no analgesic ceiling, can be given through several routes

Question 17

Opioids: Agonist-antagonist

Answer 17

Nubain, Talwin, Stadol
Produce less resp depression but cause more dysphoria and agitation, have an analgesic ceiling, can lead to withdrawal, not used much

Question 18

Avoid giving these drugs:

Answer 18

Darvon and Demerol- produce a toxic metabolite causing seizures

Question 19

Opioids

Answer 19

Use for moderate to severe pain, use for breakthrough pain. Only need one b/c they are all similar pharmacologically. Can give by any route, oral route is preferred unless pain is severe or need dose titration. .

Question 20

Opioids: Codeine

Answer 20

Weak opioid, requires an enzyme to break it down to work, not good for severe pain

Question 21

Opioids: Hydrocodone

Answer 21

Always combined with Tylenol or Ibuprofen, so does is limited

Question 22

Opioids: Oxycodone

Answer 22

Single or combined, long acting is OxyContin

Question 23

Opioids: Morphine

Answer 23

Gold standard, roxanol, avinza and MS Contin are long-acting

Question 24

Opioids: Hydromorphone (Dilaudid)

Answer 24

8* more potent than morphine, only short acting

Question 25

Opioids: Fentanyl

Answer 25

72 hour patch (Duragesic), oral lozenge (Actiq), not for opioid-naive. Very short acting

Question 26

Opioids: Methadone

Answer 26

Works on 2 receptors, long half-life (23-36 hrs), sedation, bad for elderly

Question 27

Opioids: Tramadol (Ultram)

Answer 27

Atypical opioid, can cause seizures

Question 28

Opioids common side effects

Answer 28

Constipation, n/v, sedation, respiratory depression, itching (pruritus)

Question 29

Opioids less common side effects

Answer 29

Urinary retention (more common with epidural) dizziness, confusion, hallucinations, opioid-induced hyperalgesia (OIH)

Question 30

Adjuvants

Answer 30

Can be used alone or in combination

Question 31

Adjuvents: Corticosteroids

Answer 31

(prednisone, dexamethasone) Best for cancer pain, spinal cord compression, inflammatory join pain. Many side effects. Dont give with NSAIDS

Question 32

Adjuvents: Antidepressants

Answer 32

(TCA's- Elavil, SNRI's-Cymbalta) Increases serotonin & norepinephrine, promotes sleep, dont give if hx of seizures or cardiac disease, bad for older adults (long half life), many side effects, SNRI's have less side effecs, but cost more

Question 33

Adjuvents: Antiseizure drugs

Answer 33

(Lamictal, Neurontin, Lyrica) Affect peripheral nerves and CNS

Question 34

Adjuvents: GABA receptor agonists

Answer 34

(Baclofen) inhibits pain trandmission, used for muscle spasms, best used intrathecally

Question 35

Adjuvents: Alpha Adrenergic Agonists

Answer 35

(clonidine, zanaflex) used for chronic headaches, nueropathic pain

Question 36

Adjuvents: Local analgesics

Answer 36

Interrupts transmission of pain signals to the brain, works for types of nueropathic pain

Question 37

Med Administration: Breakthrough or Incident Pain

Answer 37

Use fast acting meds

Question 38

Med Administration: Titration

Answer 38

Adjusting does based on adequacy of analgesic effect verse side effects

Question 39

Med Administration: Equinanalgesic dosing

Answer 39

Carefully monitor and adjust for each individual patient

Question 40

Administration Routs: Oral

Answer 40

Route of choice if GI system is good. Opioids require a larger dose than IV or Im due to first pass effect. Slower onset, peak in 1-2 hours, dont crush, break, chew sustained-release drugs

Question 41

Administration Routes: Sublingual/buccal

Answer 41

Bypasses the first pass effect, doesnt always work well,Fentanyl can be given as a "lollipop"

Question 42

Administrarion Routes: Intranasal

Answer 42

Stadol, Sumatriptan; used for headache and migraines

Question 43

Administration Routes: Rectal

Answer 43

Often overlooked, Good if pt has n/v, NPO, at home. Lasts 4-6 hours, can't use if bleeding risk

Question 44

Administration Routes: Transdermal

Answer 44

Fentanyl Patch. Slow to reach full effect when first applied. Can cause death from overdose (s/s- slow RR, confusion, dizziness) Can absorb med too quickly if febrile

Question 45

Administration Routes: Creams/Lotions

Answer 45

Trolamine salicylate for joint/muscle pain; capsaicin; EMLA. Little systemic absorption, can cause skin reactions

Question 46

Administration Routes: Parenteral (SC, IM, IV)

Answer 46

IM is not recomended due to pain, unreliable absorption, abscesses with frequent use SC is rarely used due to slow response, but can be used if no IV access IV is best for immediate analgesia and rapid titratin (fastest onset but shorter duration, peaks in 5-15 min, not good for constant pain)

Question 47

Administration Routes: Intraspinal

Answer 47

Epidural or Intrathecal. Intermittent bolus or intrathecal. Tip of catheter placed as close to nerve as possible. Highly potent and requires much smaller doses.

Question 48

Administration Routes: Intraspinal Cx and s/e

Answer 48

S/E- itching, nausea, urinary retention. | Cx- Catheter displacement, accidental infusion of nuerotoxic agents, infection

Question 49

Adminstration Routes: Patient Controlled Analgesia

Answer 49

IV delivery system or epidural catheter. PT decides when dose is needed, can have continuous basal rate, be careful w/opioid naive patients, monitor sedation level and resp rate, important to do good pt teaching. *Give before pain is severe, assure them they can't "overdose," start oral drugs as PCA is being tapered, only the pt can push the button

Question 50

Nerve Block

Answer 50

regional analgesia, used during and after surgery, sometimes used for chronic pain syndromes

Question 51

Nueroblative Techniques

Answer 51

Used for severe pain unresponsive to other tx, destroys the nerves by surgical resection or thermocoagulation

Question 52

Nueroaugmentation

Answer 52

Electrical stimulation of the brain and spinal cord, used for chronic back pain from nerve damage, also CRPS, spinal cord injury

Question 53

Non-Drug Therapies

Answer 53

Massage, exercise, TENS (primarily for acute pain), acupuncture, heat, cold, distraction, hypnosis, relaxation strategies

Question 54

Gerontologic Considerations W/drug therapy

Answer 54

High prevalence of cognitive, sensory-perceptual, and motor problems making it harder to assess. Metabolize drugs more slowly. NSAIDS cause serious GI bleeding in elderly. Cognitive impairment/ataxia can be worsened w/analgesics

Question 55

Substance Abusers

Answer 55

Still use opioids but not opioid agonist-anatagonists. Avoid psychoactive drugs. Many need higher doses or increased frequency of administration. Need a multidisciplinary approach.