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PR3136 > Pain Management > Flashcards

Pain Management Flashcards

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1
Q

Definition of pain (3)

A
  • an unpleasant sensory & emotional experience associated with actual or potential tissue damage
  • a physiological & psychological response that vary from person to person & day to day
  • pain is anything the patient tells you
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2
Q

Classification of pain (2)

- duration

A
  1. Acute

2. Chronic

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3
Q

Acute pain (2)

A
  • associated with invasive procedures, trauma & disease

- resolves over days to weeks

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4
Q

Chronic pain (3)

A
  • persists past normal tissue healing
  • 4-6 weeks or 3 months
  • can be malignant or non-malignant (eg headache, migraine)
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5
Q

Types of pain (4)

- location

A
  1. Nociceptive pain
  2. Neuropathic pain
  3. Referred pain
  4. Ischemic pain
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6
Q
  1. Nociceptive pain & their receptors
A
  • arises due to tissue damage from noxious stimuli (chemical, thermal & mechanical)
  1. Visceral (organ)
    - often refer pain to a distant cutaneous site
    eg appendicitis, cholecystitis
    - stretch receptors
  2. Somatic (skin, muscles, bones)
    - localised pain
    - A-delta fibres & C-fibres
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7
Q
  1. Neuropathic pain (3)

& description

A
  1. Central
  2. Peripheral
  • no area of tenderness
  • no area of allydonia (decreased pain threshold)
  • resistance to opioids
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8
Q
  1. Referred pain (2)
A
  • pain located away from its point of origin

- occurs because signals from different part of the body travel along the same pathways

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9
Q
  1. Ischemic pain
A
  • loss of blood flow
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10
Q

Somatic pain sensation (nociceptive) (4)

A
  • aching
  • stabbing
  • throbbing
  • pressure
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11
Q

Visceral pain sensation (nociceptive) (4)

A
  • gnawing
  • cramping
  • aching
  • sharp pain
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12
Q

Neuropathic pain sensation (4)

A
  • burning
  • tingling
  • shooting
  • electric / shocking pain
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13
Q

How to do pain assessment (4+1)

A
  1. Believe the patient’s report of pain
  2. Use open-ended questions
  3. Take history of each pain
  4. Any psychological distress
(( SOCRATES ))
Site
Onset
Character
Radiation
Associations (any other symptoms)
Time course
Exacerbating / relieving factors
Severity
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14
Q

Steps to developing pain management treatment (6)

A
  1. Characterise & quantify pain
    - using scales
  2. Identify pain syndrome
    - acute or chronic
    - malignant or non-malignant
  3. Infer pathophysiology
    - nociceptive, neuropathic or mixed
  4. Evaluate physical & psychological comorbidities
  5. Assess degree & nature of disability
  6. Develop a therapeutic strategy
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15
Q

WHO Ladder (Pharmacological treatment for pain)

  • mild
  • moderate
  • severe
A

Mild pain : non-opioids +/- adjuvants
eg paracetamol, NSAIDs
- avoid aspirin due to irreversible anti-platelet effects

Moderate pain : weak opioids +/- adjuvants
eg tramadol, codeine

Severe pain : strong opioids +/- adjuvants 
eg morphine (q4h), fentanyl, oxycodone (q6), methadone
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16
Q

WHO treatment guides for cancer pain (5)

A
  1. Oral dosage form preferred
  2. Regular dosing
  3. Detailed dosing instructions
  4. Initiate dose according to patient’s pain intensity/scale
  5. Titrate to adequate pain relief & tolerable side effects
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17
Q

Titration of analgesics

A

Mild pain : even slower titration
Moderate pain : slow titration
Severe pain : rapid titration

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18
Q

Dosing of Paracetamol / Acetaminophen

A

Dose (normal) : 0.5-1g every 6-8h (max 4g/24h)

Dose (hepatic impairment) : 1g every 12h (max 2g/24h)

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19
Q

Advantages of Paracetamol / Acetaminophen (3)

A
  • low incidence of ADR
  • PO/PR available
  • multi-preparations & combinations
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20
Q

Disadvantages of Paracetamol / Acetaminophen (3)

A
  • lack anti-inflammatory properties
  • hepatotoxicity with large doses (avoid >4g/24h)
  • risk of overdose as many combination preparations contains paracetamol
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21
Q

NSAIDs (3)

A
  • use any NSAIDs effective for the patient, otherwise use ibuprofen
  • failure to improve even after trial of 2 NSAIDs require another approach to analgesia (weak opioids)
  • COX-2 selective NSAIDs have lower GI side effects & anti-platelet activities
    eg diclofenac, celecoxib, etoricoxib
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22
Q

NSAIDs precautions (7)

A
  1. Elderly >65y/o
  2. Bleeding disorder
  3. Anti-coagulants
  4. GI disease (ulcer, bleeding, perforation)
  5. Cardiovascular disease
  6. Asthma & bronchospasm
  7. Renal/hepatic disease
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23
Q

Types of Adjuvants (5)

A
  1. Gabapentin, pregabalin, antidepressants, anti-epileptics & topical lidocaine
  2. Corticosteroids
  3. Muscle relaxants
  4. Hyoscine
  5. NSAIDs & bisphosphonates
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24
Q

Classifications of opioids by pain intensity (2,1,5)

A

Weak opioids (2)

  • codeine
  • tramadol
Moderate opioids (1)
- tapentadol (between tramadol & morphine)

Strong opioids (5)

  • morphine
  • fentanyl
  • methadone
  • oxycodone
  • pethidine (not used)
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25
Codeine metabolism (2)
- CYP2D6 metabolism to active morphine metabolite - hence CYP2D6 inhibitors/hepatic insufficiency decrease efficacy of codeine - use tramadol
26
Dosing of codeine
Normal dose - 15-60mg up to 6 times daily - max 400mg/day Renal impairment - CrCl 10-50mL (75%) - CrCl <10mL/min (50%) Hepatic impairment - necessary if hepatic insufficiency - use tramadol
27
Tramadol (5)
- onset 1h - duration 9h - also SSRI (good for neuropathic pain) - CYP2D6 metabolism to active metabolites BUT extensively glucuronidation, demethylation & sulfation Hence preferred > codeine if hepatic disease - high doses lowers seizure threshold
28
Dosing of tramadol
Normal dose - 50-100mg every 4-6h (max 400mg/24h) Renal impairment - CrCl <30mL/min (50-100mg every 12h) (max 200mg/day) - do not use ER if CrCl <30mL/min Hepatic impairment - Cirrhosis (25-50mg every 12h) - do not use ER if severe hepatic dysfunction
29
Dosing of morphine
Normal dose - if previously on weak opioid : 10mg every 4h OR MR 20-30mg every 12h - if opioid-naive : 5mg every 4h - if elderly & frail & renal impairment : 5mg every 4h Renal impairment - CrCl 10-30mL/min (75%) - CrCl <10mL/min (50%) Hepatic impairment - mild (unchanged) - severe (excessive sedation)
30
Fentanyl (2)
- 100x more potent than morphine Hence dose is in mcg NOT mg - CYP3A4 metabolism
31
Dosing of fentanyl
Normal dose - 50-100mcg/kg - MICROgrams No dose adjustments for renal/hepatic impairment - monitor
32
Indications for fentanyl (4)
1. Intolerable side effects from morphine 2. Renal failure 3. Dysphagia 4. "tablet phobia" or poor oral compliance - cos transdermal patch
33
Methadone (3) - metabolism - MOA
- hepatic metabolism by CYP3A4 - complex dosing hence only for experienced physicians - MOA : 1. Opioid receptor antagonists 2. NMDA antagonists 3. Serotonin re-uptake inhibitor
34
Dosing of methadone (renal & hepatic)
Renal impairment - CrCl <10mL/min (50-75%) Hepatic impairment - avoid in severe hepatic disease
35
Oxycodone metabolism (2)
- CYP2D6 (inhibitors decrease oxycodone efficacy) | - CYP3A4
36
Dosing of oxycodone
Normal dose - immediate release (5mg every 6h) - controlled release (10mg every 12h for opioid naive) No dose adjustment for renal impairment Hepatic impairment - reduce dose if severe hepatic disease
37
Tapentadol (2)
- only for acute pain | - between tramadol & morphine
38
Pethidine (1)
- for acute pain only, not for chronic pain due to fast onset & short acting
39
Can use pethidine for palliative care? | Why do we avoid pethidine in palliative care? (4)
No 1. Quick onset but short duration of action - increased risk of dependence 2. Norpethidine is a toxic metabolite 3. Norpethidine decreases seizure threshold 4. More emetogenic than morphine
40
PO Morphine : IM/IV Morphine
3 : 1
41
PO Codeine : PO Morphine PO Tramadol : PO Morphine
PO Codeine : PO Morphine = 10 : 1 PO Tramadol : PO Morphine = 5 : 1 OR 10 : 1
42
PO Oxycodone : PO Morphine
1:2
43
Morphine : Fentanyl patch
30mg/24h : 12mcg/h
44
Morphine : Methadone
- complicated conversion | - stepwise over 3 days
45
New breakthrough dose
1/6 of new total daily dose
46
Stimuli for : - A-delta fibres - C-fibres
A-delta fibres - mechanical & thermal stimuli C fibres - mechanical, thermal & chemical stimuli
47
Steps of Nociception (4)
1. Transduction 2. Transmission 3. Modulation - in spinal cord 4. Perception
48
Tools to assess pain scale if : - <3y/o - unable to communicate pain
FLACC ``` Face Legs Activity Cry Consolability ```
49
What kind of pain to use - gabapentin - pregabalin - antidepressants - anti-epileptics - topical lidocaine for what kind of pain? (1)
Neuropathic pain
50
What kind of pain to use Corticosteroids? (4)
- neuropathic pain - bone pain - raised intracranial pressure (reduce edema) - liver capsule stretch pain
51
What kind of pain to use muscle relaxants? (2)
eg baclofen, benzodiazepines - cramps - muscle spasms
52
What kind of pain to use Hyoscine? (1)
- intestinal colic
53
What kind of pain to use NSAIDs & bisphosphonates? (1)
- bone pain
54
First line opioid for severe pain
Morphine
55
CYP2D6 inhibitors (3)
- chlorpromazine - fluoxetine / paroxetine - quinidine & quinine
56
Tramadol DDI (4)
Increase risk of seizures - SSRI - TCA - neuroleptic drugs - naloxone
57
Fentanyl patch (3)
- transdermal patch duration 48-72h - after patch removal, still got drug depot in body - reserve for patients (cannot morphine, renal failure, dysphagia or poor oral compliance)
58
CYP2D6 inhibitors decrease efficacy of __ (2)
1. Codeine | 2. Oxycodone
59
Situations to consider 25-50% dose reduction when converting between opioids (3)
- elderly & frail - conversion to methadone - organ dysfunction (renal & hepatic impairment)
60
Situations to NOT consider 25-50% dose reduction when converting between opioids (2)
- severe pain (up titration of dose) | - conversion to fentanyl patch (maintain dose)
61
When to up titrate total daily maintenance dose
>4 breakthrough doses in a day
62
Treatment for opioid overdose if : - Respiratory rate >= 8bpm - Arousable - Not cyanosed (2)
- wait & see only, do not use naloxone | - reduce or omit next dose of morphine
63
Treatment for opioid overdose if : - Respiratory rate < 8bpm - barely arousable/unconscious - cyanosed (1)
- IV 20mcg Naloxone (=0.5mL) every 2min until patient RR is satisfactory
64
ADR of opioids (common) (3)
1. N/V 2. Somnolence & mental clouding 3. Constipation - req chronic use of laxatives 1-2 weeks tolerance development for 1&2
65
ADR of opioids (less common) (5)
1. Myoclonus / seizures - clonazepam 2. Respiratory depression 3. Postural hypotension 4. Rash / itch - due to histamine release - antihistamine 5. Urinary retention
66
Management of opioids ADR (3)
1. Change to another opioids 2. Symptomatic treatment 3. Dose reduction + adjuvants
67
Monitoring outcomes for opioid therapy (4)
1. Pain relief 2. Side effects 3. Recovery of function/activity 4. Drug-related behaviours - addiction - but risk of addiction in cancer pain & acute pain unlikely
68
PO Morphine : PO Codeine : PO Tramadol : PO Oxycodone
2 : 20 : 10/20 : 1

PR3136 (19 decks)

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