Pain Flashcards
sub-i wards (120 cards)
1
Q
Define “pain” as per the International Association for the Study of Pain (IASP).
A
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
2
Q
List commonly used analgesic drug classes and individual drugs.
A
Morphine Hydromorphone Codeine Fentanyl Oxycodone Hydrocodone Methadone
3
Q
What are opiates’ mechanism of action?
- What secondary NT system do they act on?
- Which receptor mediates their dependence properties?
A
Bind mu, delta, and kappa receptors. Cause disinhibition of mesolimbic dopaminergic system (inhibits GABAergic neurons).
- Dependence-producing properties mediated thru mu receptors.
4
Q
What are some signs and sx of opiate OD?
A
- Unconsciousness
- Miosis
- Hypotension
- Bradycardia
- Respiratory depression
- Pulmonary edema
- Blue lips
- Unresponsive to stimuli
5
Q
What are some signs and sx of opiate WITHDRAWAL?
A
- Anxiety
- Dysphoria
- Craving
- Drug-seeking
- Sleep disturbances
- N/V/D
- Lacrimation
- Rhinorrhea
- Yawning
- Piloerection
- Chills
- Gooseflesh (‘cold turkey’)
- Mydriasis
- Cramps
- Fever
- Involuntary movements (“kicking the habit”).
6
Q
List some STRONG opiates.
A
- Meperidine
- Methadone
- Buprenorphine
- Oxymorphone
- Fentanyl
7
Q
List some MODERATE opiates.
A
- Oxycodone
- Hydrocodone
- Morphine
- Codeine
- Pentazocine (mild-mod)
8
Q
List 2 opiate reversal agents.
A
- Naloxone
- Naltrexone
9
Q
List the most common NSAIDs.
A
- Aspirin + salicylates
- Celecoxib
- Ibuprofen
- Naproxen
- Oxaproxin
- Indomethacin
- Diclofenac
- Ketorolac
10
Q
What is the MoA of traditional NSAIDs?
A
Nonselective (reversible) inhibition of COX-1 and COX-2
- Celecoxib is COX-2 inhibitor only
11
Q
Indications for NSAIDs?
A
- Fever
- Pain
- Inflammation
- RA
- OA
- Gout
12
Q
Adverse effects of NSAIDs?
A
- GI/stomach bleeding (5-10% fatality)
- Ulcers
- Acute renal failure (from ischemia)
- Bleeding
- Increased risk MI + CVA.
13
Q
When are NSAIDs contraindicated?
- Unique contraindications for ASA?
A
- GI ulcers
- Bleeding disorders
- Renal disorders (elderly)
- Previous hypersensitivity to ASA (airway compromise in sensitive asthmatics when pts given NSAIDs/ASA)
- Pregnancy
- Increased risk for CV dz (especially w/celecoxib).
- ASA: children w/febrile viral infections. ASA not typically given to children.
- Gout (inhibits uric acid secretions at low doses).
14
Q
Antidote to ASA OD?
A
Sodium bicarbonate.
- Found in Oil of Wintergreen.
15
Q
What is the MoA behind ASA’s anti-platelet function?
A
Blocks platelet’s TXA2 w/o blocking endothelial PGI2
16
Q
What is the name of the syndrome (and what is it?) that can develop if you give ASA to a child?
A
Reye’s syndrome: often fatal, liver degeneration, encephalitis.
17
Q
Why is celecoxib sometimes preferred over other NSAIDs?
- What is the downside, and why?
A
Fewer GI and bleeding toxicities than traditional NSAIDs (still has renal tox.)
- Otherwise not preferable due to increased CVD risk (^ coagulation by blocking endothelial PGI2, not blocking platelet’s TXA2)
18
Q
Which NSAID is mainly used as IV analgesic as a replacement for opioid analgesics?
A
Ketorolac
19
Q
What is acetaminophen’s MoA?
A
Potent COX-2 inhibitor in CNS, weak COX-1/2 inhibitor in periphery. Stimulates cannabinoid receptors.
20
Q
What are some indications for acetaminophen?
A
Fever, pain (NOT anti-platelet or anti-inflam.). Reduces fever/pain in children w/viral infections (avoid Reye’s), PUD, hemophilia, and pts w/ASA hypersensitivity
21
Q
What is behind the toxicity of acetaminophen?
A
Increased NAPQI, reduced glutathione –> hepatotoxicity.
22
Q
What is the antidote to acetaminophen OD?
A
N-acetyl cysteine.
- Effects enhanced by chronic alcohol (induces CYP2E1)
23
Q
Most common side effects of opiates?
- Others?
A
Most common:
- Constipation, somnolence/mental clouding
Others:
- Respiratory depression
- Sedation
- N/V
- Itching
- Urinary retention
24
Q
Meperidine: MoA?
A
Kappa opioid receptor agonist (also binds K+ channels, muscarinic receptors, and DA transporters)
25
Methadone: MoA?
Mu and delta opioid receptor agonist, NMDA (glutamate) agonist
26
MoA of naloxone + naltrexone?
Antagonizes mu, delta, and kappa opioid receptors
27
What's the difference between the functions of naloxone and naltrexone?
- Naloxone: for opioid OD (reversal)
| - Naltrexone: prevents relapse s/p opioid/alcohol detox
28
Which opiate can cause serotonin syndrome?
Meperidine
29
Recognize the indications for usage of patient-controlled analgesia (PCA). (5)
1. Post-operative pain
2. Severe acute pain
3. Acute exacerbations of chronic pain
4. Cancer pain
5. Patients unable to take oral medications
30
What are some contraindications for PCA? (2)
1. Poor understanding of the PCA
| 2. Poor health care support for PCA
31
What are some routes of adminstering PCA?
- IV PCA
- Epidural (PCEA)
- Other routes are intrathecal / transdermal (E-Trans) / surgical incisional (On-Q pumps) / intra-articular (On-Q pumps) etc.
32
Review some drugs commonly used in PCA:
1. Opioids: Morphine, Fentanyl and Hydromorphone
2. Local anesthetics: Bupivacaine and Ropivacaine.
3. Other drugs: Clonidine, Baclofen etc.
4. Various combinations of the above drugs to achieve synergistic effect and to minimize side effects.
33
*Name the 7 core components to consider when starting PCA.
1. Concentration
2. Total amount
3. Loading dose
4. Patient dose or Demand dose
5. Lockout interval
6. Basal rate
7. 1 or 4 hour limit
34
In PCA, what is meant by Concentration?
| - E.g. with morphine?
The amount of the drug per ml of the solution.
| - E.g. morphine concentration is 1 or 5 mg/mL.
35
In PCA, what is the "total amount" given with IV pumps? For epidural pumps?
- 30 mL for IV pumps
| - 250 mL for epidural pumps
36
In PCA, what is the Loading dose?
| - E.g. with morphine?
The dose given in frequent intervals to load the receptors and decrease severe pain.
- E.g., ‘morphine 2 mg q 5 minutes to a maximum of 20 mg’.
- Opioid tolerant patients will obviously need more.
- Individual titration is essential.
37
In PCA, what is the Patient dose / Demand dose?
| - E.g. with morphine?
The dose provided by the pump when the patient presses the ‘button’. This obviates the need to call the nurse each time.
- E.g., morphine 1 or 2 mg.
- Opioid tolerant patients and patients in severe pain with movement (dynamic pain or incidental pain) may need more
38
In PCA, what is the Lockout interval?
| - E.g. with morphine?
The time interval before the pump can provide the next dose (10 or 15 min common). It is a safety feature.
- E.g. 'morphine 2 mg every 10 minutes’ means that 10 minutes should pass before the pump can provide another dose of morphine.
- If the pain is not well controlled then the lockout interval may be decreased.
39
In PCA, what is the Basal rate?
- E.g. with morphine? (how would you write the units for the order?)
- In what types of pain is it useful?
- Why is monitoring essential?
The amount of drug given as a continuous infusion and is set per hour.
- E.g. ‘morphine 2 mg per hour’.
- Basal rate is useful in opioid tolerant patients, patients with severe rest pain and for nighttime analgesia.
- Obviously monitoring is essential to detect respiratory depression.
40
What does the Time limit mean for PCA?
- What is the time limit for epidural PCA?
- For IV PCA?
The limit means that the pump can provide only the amount set within the time frame. The amount includes both the basal rate and the demand doses. The limit may be set lower for patients with multiple co-morbid conditions and set higher for opioid tolerant patients. This is again a safety feature and needs to be titrated on an individual basis and frequent re-assessments.
- Epidural: 1 hr
- IV: 4 hrs
41
When should Basal rate PCA not be used?
Basal rate should NOT be initially used in opiate naïve patients.
42
What does TKO stand for, and why do nurses sometimes ask for it during PCA?
"To keep open"
| - So that small volumes of drug don’t get caught up in the tubing.
43
During PCA, if pt gets snowed during increased dosing, you’ve reached and surpassed the _________________.
Mean effective analgesic concentration (MEAC)
44
In PCA, if pain inadequately controlled, what should you adjust first?
Adjust demand dose before adjusting basal rate
45
*In PCA, how long should you leave the Basal rate before adjusting it?
8-24 hours (at least 8 hrs!)
46
Opioids should be combined with NSAIDs, pain adjuvants and modalities whenever possible. Rapid tapering of the opioids (__% less every day) is essential once the pain condition improves.
25%
47
Most opiate side effects improve with time except ______________.
Constipation
| - Needs aggressive bowel program as soon as possible.
48
During PCA, what are some side effects of local anesthetics?
- Hypotension
- Motor weakness
- Numbness
- Urinary retention
49
During PCA, what pump issues may arise?
- Pump malfunction
- Catheter dislodgment
- Disconnections
- Kinking
- Infection
50
Who can press a patient's PCA button?
Patients, family, staff should all be informed that only the patient should press the PCA button.
51
How would you manage the transition of a patient on PCA back to oral pain therapy?
The PCA is used for as long as it is practical and tolerated. At the time of transition to other routes of use (most commonly oral medications) patients should be re-assessed and needs for analgesics reviewed. The last 12- or 24- hour requirements are noted and equiv.-analgesic conversions made for the alternate drugs and alternate routes. In general oral form of morphine is 3 times higher than the IV form. 2/3rds of the total dose is given in a sustained release form for basal analgesia and 1/3rds as rescue medication for breakthrough pain. For example if the last 24-hour dose was 15 mg of morphine i.v, then oral morphine requirements would be 45 mg. Morphine ER (extended release) 15 mg po bid and Morphine IR (immediate release) 15 mg po prn q 4 hourly would be appropriate. If the patient needs too frequent rescue doses then the dose of the sustained release form should be increased. Rest pain is better controlled with sustained release forms and incidental pain is better controlled with immediate release forms. Rapid tapering of the opioids is essential once the pain condition improves.
52
What is the maximum dose of acetaminophen (Tylenol) allowed per day?
- What if they have liver dz?
3-4g
| - If liver disease, can take 1/2 nl dose
53
*What is the PO:IV morphine conversion?
3:1
54
List the duration of action for the following drugs:
1. Morphine
2. Hydromorphone
3. Codeine
4. Fentanyl
5. Oxycodone
6. Hydrocodone
7. Methadone
1. Morphine: 3-4 hours
2. Hydromorphone: 3-4 hours
3. Codeine: 3-4 hours
4. Fentanyl: 72 hours
5. Oxycodone: 3-4 hours
6. Hydrocodone: 4-6 hours
7. Methadone: 4-6 hours
55
Which is more potent, hydromorphone or morphine?
Hydromorphone (4-5x as potent as morphine)
56
How often is the fentanyl patch changed?
q72 hours
57
Which is more potent, oxycodone or morphine?
Oxycodone (slightly more potent than morphine)
58
Which is more potent, hydrocodone or morphine?
Morphine: hydrocodone = 1:1
59
Onset time for:
- PO?
- IV?
- PO: 30 min
| - IV: 10 min
60
Time at peak effect for:
- PO?
- IV?
- PO: 1.5-2 hrs
| - IV: 30-45 min
61
How long for effect to wear off:
- PO?
- IV?
- PO: 4 hrs
| - IV: 2-3 hrs
62
If giving an opiate medication, when can you start titrating up the dose (generally)?
- If pain still severe, by what % can you titrate up?
- If pain mild-mod, by what % can you titrate up?
At peak effect time
- If still severe, can increase 50-100%
- If mild-mod, can increase 35-50%
(recall, in PCA, you would increase the demand dose by this amount)
63
If a patient was in constant pain, theoretically, how often could you re-dose normal-duration PO opiates?
q4 hours (i.e. time until effect wears off. Poor long-term plan)
64
If a patient in constant pain, and you prescribe long-acting opiates, how long until you need to re-dose?
q12 hours
65
List some opiates available in long-acting form.
- Morphine
- Oxycodone
- Hydrocodone
- Hydromorphone
- Fentanyl transdermal
66
Define dependence.
If you stop drug abruptly, patients will go through withdrawal (doesn't mean someone is addicted)
67
Define tolerance.
Need a larger dose for the same effect.
68
Define addiction.
Psychosocial-behavioral medical problem where patients are preoccupied by drugs, using them inappropriately, getting them surreptitiously, using them for reasons beyond pain management, etc.
69
Define pseudoaddiction.
A condition resembling drug addiction but caused by under-prescription of drugs to treat pain in the patient, causing them to seek more.
- Behavioral, not because the patient is addicted, but because we aren't listening to them and meeting their needs (e.g. SCD pt)
70
There are many misconceptions about pain in elderly. Review some.
- Pain is not necessarily a part of aging
- Older individuals do not experience pain in a less intense way than younger people
- Elderly may express pain as confusion, social withdrawal, or apathy in an otherwise alert and social older adult
- Other confounding problems for elders: they may expect pain (placebo); they don't wanna bother staff to get help with pain; they're afraid of side effects of pain meds; they can't afford the meds; trouble communicating the pain.
71
What is the most accurate and reliable evidence for the existence of pain in the elderly?
- What if there are communication or cognitive deficits?
The patient’s self-report is the most accurate and reliable evidence of the existence of pain and its intensity, and this holds true for pts of all ages, regardless of communication or cognitive deficits.
72
What are some pain assessment techniques in older individuals?
- Self-report of pain
- Comprehensive pain assessment (H+P, CC, psychological and functional assessment)
- Rating scales: Numeric, Verbal Descriptor, Pictorial (e.g. Wong-Baker Faces), Visual analogue scale (e.g. 10cm line), Pain Questionnaire, Pain Interview
73
What are some pain assessment techniques in younger individuals? (3)
Three main methods are currently used to measure pain intensity: self report, behavioral, and physiological measures
- Behavioral measures consist of assessment of crying, facial expressions, body postures, and movements. They are more frequently used with neonates, infants, and younger children where communication is difficult
- Physiological measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmer sweating, and sometimes neuro-endocrine responses
74
Review some pain scales in younger individuals.
(older kids as you descend list)
- Premature Infant Pain Profile (PIPP)
- Neonatal Facial Coding System (NFCS)
- Neonatal Infant Pain scale (NIPS)
- Maximally discriminate facial movement coding system (MAX)
- Chidren's Hospital of Eastern Ontario Pain Scale (CHEOPS)
- The Faces Legs Activity Cry Consolability Scale (FLACC)
- Observational Pain Scale
- Toddler-Preschooler Postoperative Pain Scale (TPPPS)
- Child Facial Coding System (CFCS)
- COMFORT Scale
- Faces Pain Scale
- The Observational Scale of behavioral Distress (OSBD)
- Poker Chip Tool
- Oucher Scale
- Visual Analogue Scale (VAS)
- Pediatric Pain Questionnaire
- Adolescent Pediatric Pain Tool (APPT)
- McGill Pain Questionnaire
75
What is key to addressing pain in the elderly, besides the assessments?
The process begins with each member of the health care team becoming “pain vigilant,” being constantly alert to cues that suggest the older adult may be experiencing pain, and adapting assessment approaches to meet the needs of each individual.
76
When a patient undergoing dose titration who cannot achieve a favorable balance between analgesia and side effects is determined be poorly responsive to a specific opioid, there are several approaches to consider:
- Improving the symptomatic management of the dose-limiting side effect
- Changing to an alternative opioid (opioid rotation)
- Adding another therapy (a nonopioid analgesic, an adjuvant analgesic, or a nonpharmacological tx) that may improve analgesia even as the opioid dose is lowered.
77
*List agents used to prevent opioid-induced constipation (class of drug & their names)
- Contact cathartic (eg, senna, two tablets at bedtime), with or without a stool softener (eg, docusate 100 mg orally twice daily),
- or daily administration of an osmotic laxative (eg, PEG 17g [one heaping tablespoon]) or lactulose (30 mL), except if lactose intolerant.
78
To prevent constipation in opioid use, in addition to prophylactic docusate senna or laxitives, patients should be encouraged to:
All patients should be encouraged to increase fluid intake, mobility, and dietary fiber (unless severely debilitated with limited oral fluid intake, or bowel obstruction is suspected).
(In addition, comfort and privacy for defecation must be ensured)
79
Can probiotics play a role in opioid-induiced chronic constipation tx?
Regular ingestion of probiotics can improve chronic constipation; given the safety of these therapies, a trial in patients with OIC is reasonable.
80
What are some techniques to reduce/prevent the sedation and/or mental clouding commonly caused by opiates? (4)
- Reduce/stop concomitant CNS depressants
- If analgesia satisfactory, opioid dose reduction.
- If analgesia unsatisfactory, opioid rotation or start/increase coanalgesics (achieve an opioid-sparing effect.
- Alt. strategy: start psychostimulant (e.g. methylphenidate, modafinil)
81
Medication tx for nausea in opiate use?
Metoclopramide or prochlorperazine
| - In refractory cases, switch to an atypical antipsychotic, such as olanzapine or risperidone
82
Myoclonus is a spasm of certain muscle groups that is typically associated with high doses of opioids. Options for tx?
Benzos
83
What should be used in cases of serious opioid-induced respiratory depression?
Naloxone ("pens" and inhalers are available for family of opiate user)
84
Management of opiate-induced pruritis?
Antihistamines
| - Also paroxetine or opioid rotation
85
As many as 1 in __ people receiving prescription opioids long term in a primary care setting struggles with addiction
4
86
What are the preferred tx's for chronic pain?
Nonpharmacologic and nonopioid pharmacologic tx preferred
87
*When should opiate therapy be considered for CHRONIC pain?
Consider opioid therapy only if expected benefits for pain AND function outweigh risks
- Continue opioids only if there is meaningful improvement in pain and function that outweigh risks to patient safety
88
What should be established with every pt prior to starting opiate therapy for chronic pain?
Realistic goals for pain AND function
89
What is the PEG assessment scale?
| - What % is considered a clinically meaningful improvement?
PEG assessment scale
• Pain average (0‐10)
• Interference with Enjoyment of life (0‐10)
• Interference with General activity (0‐10)
30% = Clinically meaningful improvement
90
Before starting chronic opioid therapy, what are the risks that the patient should be informed of?
* Overdose
* Constipation, sedation, dry mouth, weight gain, memory deficits, loss of appetite, fatigue, nausea/vomiting, pruritus, dizziness, urinary retention
* Opioid endocrinopathy (adrenal insufficiency, infertility)
* Addiction
91
When starting opiate tx, are immediate release or extended/long-acting release (ER/LA) preferred?
Immediate release
92
What should you be doing if total opioid dose > 50 mg of morphine equivalent daily? (2)
What additional actions should you take if total opioid dose > 90 mg of morphine equivalent daily? (3)
> 50 mg morphine/equivalent daily
• Reassess pain, function, tx
• Consider offering naloxone
> 90 mg morphine/equivalent daily
• Discuss other pain therapies
• Work with patient to taper opioid down or off
• Consider consulting pain specialist
93
Describe how opiates should be prescribed for ACUTE pain.
| - Quantity?
* Lowest effective dose
* Immediate release formulation
* Quantity no greater than the expected duration of pain severe enough to require opiates
94
In prescribing opiates for ACUTE pain, __ days or less often sufficient, more than __ days is rarely needed.
3, 7
95
Evaluate patient within __-__ weeks of starting opioid for chronic pain or after escalating dose
• Then every __ months
Evaluate patient within 1-4 weeks of starting opioid for chronic pain or after escalating dose
• Then every 3 months
- Evaluate benefits, harms, lowering and tapering doses, discontinuing, other therapies
96
What are some r/f's for increased harm while on opioid therapy? (5)
* Moderate to severe OSA
* Pregnancy
* Renal insufficiency
* Liver insufficiency
* Age >65
97
Which patients should be considered candidates for naloxone Rx? (4)
* Hx of overdose
* Hx of substance abuse disorder
* Taking other CNS depressants
* On doses >50mg morphine equivalent/day
98
If you lookup a pt on the Prescription Drug Monitoring Database (PDMD) and find prescriptions from multiple sources, high doses, or dangerous combinations, what should you do?
• Address concerns
• Do not dismiss patients from practice
- Use opportunity to provide potentially lifesaving information and interventions
99
When should UDS be used for those starting opiates for CHRONIC pain?
Before starting and at least annually
100
When should you avoid prescribing benzos to those on opiates?
Whenever possible
101
What tx's can be sought for those with opiate-use d/o?
Buprenorphine or methadone
| + behavioral therapies
102
*List some non-pharmacologic measures to treat pain.
- Distraction
- Breathing exercises
- Prayer and meditation
- Music, videos
- Pet therapy
- Spiritual readings
- Biofeedback
- Massage
- Heat/cold
- TENS (Transcutaneous electrical nerve stimulation)
- PT modalities
- Hypnosis
- CBT's
103
Methadone comes in a __mg tablet.
10mg tablet
104
Peak effect of fentanyl patch seen at __-__ hrs.
8-12 hrs
105
What are some brand names of hydrocodone?
- Vicodin
- Vicodin ES
- Lortab
- Lortab w/APAP
- Norco
- Norco w/APAP
106
List the different brand names of morphine based on how they act.
- Extended release: 15,30,60,90 and100mg.
- MS Contin: BID dosing (so give 1/2 dose normal morphine)
- Kadian and Avinza are once daily dosing.
- Short acting forms are Roxanol and MS-IR.
107
In PCA, studies show that the optimal starting demand dose is __mg IV Morphine.
1mg
| use 0.5mg demand dose in elderly
108
In PCA, a nurse-initiated "bolus dose" is typically what amount?
2x the demand dose (e.g. 2 or 4 mg)
109
Give some e.g.'s of when you'd give a nurse-initiated bolus dose.
- Physical therapy
- Dressing changes
- Radiology tests
110
What are the 2 most common adverse effects of PCA?
Nausea
| Respiratory depression
111
**How would you calculate an initial basal rate in PCA?
1. Convert PO opiate to that of PCA and then calculate 24-hour dose.
2. Divide by 24 to get hourly basal rate
- Remember not to order if opiate-niave
112
**How would you calculate the demand dose (AKA patient or incremental dose) in PCA?
Use 50-100% of the previously calculated hourly basal rate.
| e.g. if basal rate is 2mg/hr, demand dose is 1mg or 2mg
113
**How would you calculate the loading dose in PCA?
Double the demand dose (AKA patient or incremental dose)
114
In PCA, how often can you increase the demand dose?
q30-60 min
115
In switching b/w opiates, what % should you prescribe of the old opiate when converted to the new opiate?
50-67% of the old form (tolerance does not completely transfer)
116
***In PCA, how do you convert to oral therapy? (include basal rate and that for breakthrough pain)
1. Convert to opiate of choice and then calculate 24-hour dose
2. Divide 24 hour dose by 2
3. Prescribe half of 24-hour dose BID (extended release tabs)
4. Prescribe 10-15% of 24-hour dose for breakthrough pain (immediate release tabs)
(for our website, says give 2/3 of 24 hour dose as extended release, 1/3 as immediate release)
117
How is meperidine metabolized?
- Why does this matter?
- What is the T1/2?
Renally excreted--careful in renal insufficiency
- Therefore risk of CNS excitability which could lead to seizures is markedly higher. The half-life of normeperidine is 8 hours or more, therefore he could develop this problem during or after dosing and use of this med.
118
Discuss why meperidine may be difficult for use in chronic pain?
Meperidine is an atropine derivative, it often causes tachycardia, therefore it could be difficult to tell if his tachycardia is pain related, or in response to dehydration, or fever.
119
Meperidine should not be used more than ___ hours or at doses greater than ___mg/24 hours.
48 hrs
| 600 mg / 24 hrs
120
Review some alternative meds to meperidine:
1. Fentanyl (100mcg = 10 mg MSO4).
2. Hydromorphone (1.5 mg = 10 mg MSO4).
3. Nondrug therapies: distraction, guided imagery, music, heat, cold, massage, meditation, prayer, etc.
4. Epidural steroid injection for acute herniated disc.
5. Adjuvant therapies for chronic pain: amitriptyline, neurontin, clonidine, NSAIDs.
6. Surgical consultation.
7. Psychological evaluation of depression and anxiety, determine if coping mechanisms effective, and treatment of same.
