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Spring 2022 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What is acute pain?

A

Nociceptive pain associated with specific somatosensory stimuli with an identifiable peripheral injury or lesion
<12 weeks duration

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2
Q

When does acute pain transition to chronic pain classification?

A

12 weeks

Shift from peripheral damage and tissue inflammation to more central sensitization and CNS mechanisms

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3
Q

Risks for transitioning from acute to chronic pain

A

Hx of chronic pain elsewhere
Stress
Comorbidities

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4
Q

What are the characteristics of centralized chronic pain?

A

Multifocal

Almost always associated with symptoms of energy, sleep, memory, mood disturbance

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5
Q

Define neuropathic pain origin

A

Pain caused by lesion or disease of the somatosensory nervous system

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6
Q

Define nociceptive pain

A

Pain that arises from actual or threatened damage to non-neural tissue and results d/t activation of nociceptors

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7
Q

Neuropathic Pain

Duration/Timing

A

Spontaneous, continuous, paroxysmal, evoked

Allodynia

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8
Q

Allodynia

A

Sensitive to touch

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9
Q

Neuropathic Pain

Descriptors/Qualities

A

Burning, electrical shock-like, dysesthesia, brush allodynia

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10
Q

Dysesthesia

A

Abnormal sensation

Pain-like quality: burning, tingling, prickling, aching

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11
Q

Identifying sources of neuropathic pain

A

PE

Evaluate for thermal and mechanical sensory deficits

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12
Q

Diagnostic testing for neuropathic pain

A

EMG
Quantitative sensory testing,
Brain/spinal cord imaging Nerve or skin biopsy

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13
Q

What is the DN4 Questionnaire?

A

Estimates probability of neuropathic pain
-Characteristics, associated symptoms, PE findings for hypoesthesia to touch and pinprick and ability to increase or illicit pain by brushing

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14
Q

History components for pain

A

Onset, location, duration, timing, characteristics, alleviating/aggravating factors, associated symptoms, impact on QOL

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15
Q

Psychosocial considerations for pain assessment/chronic pain

A

Psych hx, medical hx, r/f SUD

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16
Q

Biological Pain Factors

A

Etiology, dx, age, injury, neuro, genetic, hormones, obesity

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17
Q

Psychological Pain Factors

A

Mood, stress, coping, trauma, childhood

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18
Q

Social Pain Factors

A

Culture, economic, social support, spirituality, ethnicity, education, bio/stigma

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19
Q

Management of Refractory Neuropathic Pain

A

Interventional: Spinal cord stimulator, spinal medications, blocks, surgical

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20
Q

Management of Mild Pain

A

Non-opioids +/- adjuvant

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21
Q

Management of Moderate Pain

A

Weak opioid + non-opioid +/- adjuvant

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22
Q

Management of Severe Pain

A

Strong opioid + non-opioid +/- adjuvant

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23
Q

What are the 5 As of Pain Management?

A

Analgesia - pain relief
Activities - optimize ADLs, psychosocial functioning
Adverse effects - minimize AEs
Aberrant drug taking - Avoid d/t addiction-related outcomes
Affect - Relationship between pain and mood

Always document in clinical note

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24
Q

Non-opioid pain management medications

A

APAP, NSAIDs, anticonvulsants, antidepressants, musculoskeletal agents, anti-anxiety agents

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25
Q

First line therapy for chronic neuropathic pain

A

Anticonvulsants - pregabalin, carbamazepine, oxcarbazepine, gabapentin

SNRIs - duloxetine, venlafaxine

TCAs - Nortriptyline, amitriptyline

Topical analgesics - lidocaine, capsaicin

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26
Q

First line pharmacological management of neuropathic pain with strong evidence

A

Gabapentin 400 to 1200 mg TID
Gabapentin 600 to 1800 mg BID
Pregabalin 150 to 300 mg BID

SNRIs:
Duloxetine (Cymbalta) 60 to 120 mg daily
Venlafaxine (Effexor) ER 150 to 225 mg daily
TCAs (Nortriptyline/amitripyline) 25 to 150 mg daily or 12.5 to 75 mg BID

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27
Q

Second line pharmacological management of neuropathic pain with weak evidence

A

Capsaicin 8% patches
One to four patches to painful area for 30-60 min q3m

Lidocaine patches
One to three patches to pain region daily 12h on/12h off

Tramadol 200-400 mg in three divided doses; if ER in 2 divided doses

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28
Q

Third line pharmacological management of neuropathic pain with weak evidence

A

Botulinum toxin A
50-200 units SQ q3m

Strong Opioids

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29
Q

Pharmacologic agents for neuropathic pain with inconclusive recommendations

A 
Combination therapy
Capsaicin cream
Carbamazepine
Clonidine topical
Lacosamide 
Lamotrigine
NMDA antagonists
Oxcarbazepine
SSRIs
Tapentadol
Topiramate
Zonisamide
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30
Q

Pharmacologic agents for neuropathic pain with weak recommendations against use

A

Cannabinoids

Valproate

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31
Q

Pharmacologic agents for neuropathic pain with strong recommendations against use

A

Levetiracetam

Mexiletine (Anti-arrhythmic)

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32
Q

Management of non-neuropathic, non-cancer pain

A

First line - APAP, NSAIDs

Alternatives: 
Antispasmodics - tizanidine (Zanaflex), baclofen 
Topical preparations 
Multimodal approaches
SNRIs
TCAs
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33
Q

Opioids

Routes of Administration

A

oral, buccal, SL spray, IV, IM, intrathecal, suppository, transdermal, lozenges

34
Q

When may the efficacy of opioids wane?

A

After 3 months

35
Q

Side effects of opioid medications

A

Constipation, sedation, lethargy, nausea, vomiting, irritability, pruritus, respiratory depression

36
Q

What is opioid induced hyperalgesia (OIH)?

A

Enhanced pain sensitization with prolonged opioid therapy
Pain is generalized, diffuse, ill-defined despite increasing dosages

Management options: wean opioid, opioid rotation, NMDA antagonist (ketamine)

37
Q

Opioid therapy evaluation for risk of harm and misuse should include what two documents?

A

Opioid agreement

Informed consent

38
Q

What are the frequency of reassessment intervals when initiating and continuing opioid therapy?

A

Reassess in 4 weeks then q3m

39
Q

Current recommendation for MDD of opioids per morphine equivalency?

A

Less than 90 mg of morphine mg equivalent per day

40
Q

Opioids interactions with hypothalmic-pituitary-adrenal and gonadal tracts

A

Decreased sex hormones/fertility
Decreased cortisol
Decreased growth hormone

41
Q

Signs and symptoms of opioid induced endocrinopathies

Hypothalamic-pituitatry-gonadal

A

Female: amenorrhea, dysmenorrhea, menstrual cycle disturbance

Male: ED, decreased libido, decreased sperm, loss of muscle mass

Fatigue, weakness, osteoporosis, depression, anxiety, anemia

42
Q

Signs and symptoms of opioid induced endocrinopathies

Hypothalamic-pituitatry-adrenal

A

Hypotension, n/v, hypoglycemia

43
Q

Signs and symptoms of opioid induced endocrinopathies

Pituitary

A

Decreased growth hormone, s/s unknown

44
Q

Components of opioid use informed consent

A

Discuss risk/benefit, potential for common opioid-related AEs, risk of chronic therapy, respiratory depression/death, risks of long-term or high-dose therapy

45
Q

Objectives of obtaining an opioid agreement

A

Improve adherence with safe use of controlled substances and reducing aberrant behaviors
Obtain informed consent
Outline prescribing policy/procedure
Mitigate provider’s legal risk

46
Q

Recommendations for monitoring opioid therapy

A

Document pain intensity and level of functioning
Assess and document progress towards therapeutic goals
Presence of AEs
Adherence to therapy

Evaluate q3m minimum

47
Q

Alcohol use and opioids

A

No safe level of use

Increases r/f morbidity and mortality

48
Q

Naloxone (Narcan)

A

?

49
Q

Buprenorphine Uses

A

OUD, pain management

50
Q

Buprenorphine

Class and mechanism of action

A

Opioid partial agonist of mu receptors

51
Q

Restorative therapies for pain

A

PT, OT, physiotherapy, exercise, TENS, traction, cold/heart, therapeutic u/s, bracing

52
Q

Interventional Procedures for Pain Management Examples

A

Trigger point injections, joint injections, peripheral nerve injections

Nerve block, epidural, radio-frequency (RF) ablation, autologous stem cell therapy, cryoneuroablation, neuromodulation

Spinal cord sitmulation, intrathecal pump, vertebral augmentation, percutaneous discectomy

53
Q

Behavioral health approaches to managing pain

A

Behavioral therapy, CBT, acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), emotional awareness and expression therapy (EAET), self-regulatory and psychophysiological approaches

54
Q

Barriers to behavioral health interventions for pain management

A

Clinical barriers: Accessibility, knowledge gaps, provider attitudes

System barriers: cost and reimbursement

Patient barriers: stigma, attitude

55
Q

OUD DSM-5 Criteria

A
  • Larger amounts over longer periods
  • Persistent desire to use, unsuccessful efforts to cut down
  • Time spent obtaining/recovering
  • Craving, strong desire
  • Use interfering with major role obligations
  • Continued use despite negative consequences
  • Giving up social, occupational, or recreational activities to use
  • Physically hazardous situations
  • Continued use despite psych/physical problem caused by or exacerbated by use
  • Tolerance
  • Withdrawal
56
Q

OUD DSM-5 Criteria for Classification

A

Mild: 2-3 s/s
Mod: 4-5 s/s
Severe: 6+ s/s

57
Q

OUD Risk Assessment Components

A

Biopsychosocial Approach

  • Patient hx
  • PE
  • Dx screening tools
  • Consult PDMP
58
Q

PDMP Monitoring

A

State program to check for fill dates, refill patterns, prescribers, length of medication supply, meds in other states

59
Q

Components of the Opioid Risk Tool (ORT)

A

Fam Hx of SUD
ETOH 1pt
Illegal drugs 2pt
Rx 4pt

Personal Hx of SUD
ETOH 3pt
Illegal drugs 4pt
Rx 5pt

Ages between 16-45yr 1pt

Hx of preadolescent abuse 3pt

Psych disorder
ADD, OCD, bipolar, schizo 2pt
depression, anxiety 1pt

Low risk 0-3
Mod 4-7
High 7+

60
Q

Urine toxicology for opioid treatment

A

Random

Assess for adherence/abuse

61
Q

How is low back pain classified?

A

Symptom duration, potential
cause, presence or absence of radicular pain symptoms, and corresponding
anatomical or radiographic abnormalities

62
Q

Duration of back pain

Acute/Subacute/Chronic

A

Acute - 4 weeks
Subacute - 4-12 weeks
Chronic - >12 weeks

63
Q

Treatment recommendations for acute or subacute back pain

A

Non-pharmacologic methods are essential - heat, massage, acupuncture, spinal manipulation

Pharmacological methods: NSAIDs, muscle relaxants

64
Q

Non-pharmacologic treatment recommendations for chronic back pain
First-line

A

Rehab, acupuncture, mindfulness-based stress reduction (MBSR), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, spinal manipulation, CBT, operant therapy, low-level laser therapy

65
Q

Pharmacologic treatment recommendations for chronic back pain

A

First-line: NSAIDs

Second-line: Duloxetine (Cymbalta), tramadol

66
Q

First line treatment for OA of hands

A

Exercise, self-efficacy and self-management programs, CMC orthoses, NSAIDs,

67
Q

First-line treatment of OA of knees

A

Exercise, self-efficacy and self-management programs, NSAIDs, topical NSAIDs, IA steroids, weight loss, tai chi, cane, knee brace

68
Q

First-line treatment of OA of hips

A

Exercise, self-efficacy and self-management programs, NSAIDs IA steroids, weight loss, tai chi, cane

69
Q

Pharmacologic Treatments for OA

A

NSAIDs, intraarticular glucocorticoids, APAP, duloxetine, tramadol, topical capsaicin

70
Q

Myofascial Pain Syndrome

Definition

A

Presence of trigger points within muscles or fascia

Trigger point characteristics:

  • tender/hyperirritable
  • Taut
  • Palpable bands
  • Mediated twitch response
71
Q

Myofascial Pain Syndrome

Risk Factors

A 
Etiology unknown: overuse, disuse
Ergonomic factors: posture, overuse
Structural factors: OA, scoliosis
Systemic factors: hypothyroid, vitamin d deficiency, iron deficiency 
Oral parafunctional behaviors, TMJ
Insomnia
Hx of Ca
Psychological factors
72
Q

Myofascial Pain Syndrom

Diagnosis

A

Trigger Points Manual

Needs 5 major criteria and 3 minor criteria

Major: localized spontaneous pain, altered sensations in the expected referred area for a given trigger point, taut palpable band, localized tenderness at precise point, reduced ROM

Minor: reproduction of spontaneously perceived pain and altered sensations by pressure of trigger point, elicitation of a local twitch response of muscle fibers by transverse snapping palpation or by needle insertion into trigger point, pain relieved by muscle stretching or injection of trigger point

73
Q

Referred pain patterns of the upper trapezius muscle in MPS

A

Neck behind ear, loops above ear to behind eye, TMJ/lower jaw

74
Q

Referred pain patterns of the strernocleidomastoid muscle in MPS

A

Trigger points along muscle

Upper occiput pain, radiated around eye, top of head, chin, under jaw, cheeks

Clavicular division: Ear, Forehead

75
Q

Myofascial Pain Syndrome treatment

A

Rehabilitate muscles: stretching, posture, strengthening, CV. fitness

Topical anesthetic, injection
Botulinum Toxin A

Acupuncture, kinesiotaping, TENS, infrared ray, shockwave, laser

76
Q

COVID-19 and Chronic Pain

A

Those with covid history especially in setting of inflammatory conditions

Caregivers, burnout

77
Q

Examples of 50 Morphine Milligram Equivalents (MME)/day

A

50 mg of hydrocodone
33 mg of oxycodone
12 mg of methadone

78
Q

Examples of 90 MME/day

A

90 mg of hydrocodone
60 mg of oxycodone
20 mg of methadone

79
Q

Conversion factors for opioids to MME

A 
Codeine 0.15
Fentanyl transdermal 2.4
Hydrocodone 1
Hydromorphone 4
Methadone ***Varies by scale ranges
Morphine 1 
Oxycodone 1.5
Oxymorphone 3
80
Q

At which dose of MME/day should extra precautions be taken to minimize risk for AEs of opioid use

A

50 MME/day

Spring 2022 (14 decks)

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