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Flashcards in pain management Deck (49):
1

pain def 1

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

2

*pain def 2*

A revised definition identifies pain as "a somatic perception containing: (1) a bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, and (3) a feeling of unpleasantness or other negative emotion based on this experienced threat” 

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hyperalgesia

Increased response to a stimulus that normally is painful

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hypoalgesia

 Diminished response to a normally painful stimulus

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hyperesthesia

Increased sensitivity to stimulation, excluding the special senses

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hypesthesia

Diminished sensitivity to stimulation, excluding the special senses

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dysesthesia

An unpleasant abnormal sensation, whether spontaneous or evoked

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paresthesia

An abnormal sensation, whether spontaneous or evoked

9

allodynia

Pain resulting from a stimulus (such as light touch) that does not normally elicit pain

10

addiction

misuse of a substance for purposes other than one for which it was prescribed and despite negative consequences in health, employment, or legal/social spheres, demand for specific medications and doses, anger and irritability, poor cooperation, disturbed interpersonal reactions

11

pseudo-addiction

exhibiting behaviors associated with addiction but only because their pain is inadequately treated
*undercontrolled*
figuring out difference is tough!*
-assess validity of pain
-multidisc. approach
-get a good hx
-tx pain

12

avoid profiling in drug addiction

"white women" are the face of modern pill addiction

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Neuropathic pain

abnormal neural activity secondary to disease, injury, or dysfunction of the nervous system

14

Sympathetically mediated pain (SMP) arises from ???
assoc. w/ ???
known as...
most common cause ??

a peripheral nerve lesion
associated with autonomic changes (complex regional pain syndrome I and II, formerly known as reflex sympathetic dystrophy and causalgia)
*Diabetic neuropathy most common!*

15

Peripheral neuropathic pain

damage to a peripheral nerve without autonomic change (postherpetic neuralgia, neuroma formation)

16

Central pain arises from ???
examples:

abnormal central nervous system (CNS) activity

phantom limb pain, pain from spinal cord injuries, and post-stroke pain
-hard to tx, tx CNS issue

17

pain toxonomy axes (IASP)

Axis I: Anatomic regions
Axis II: Organ systems
Axis III: Temporal characteristics, pattern of occurrence
Axis IV: Intensity, time since onset of pain
Axis V: Etiology

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chronic pain dx

Chronic complaints of pain
Symptoms frequently exceed signs
Minimal relief with standard treatment
History of having seen many clinicians
Frequent use of several nonspecific medications

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visceral pain is very hard to ?

localize

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fibromyalgia dx

Usually women aged 20-50
-Chronic widespread musculoskeletal pain syndrome with multiple tender points
-Fatigue, headaches, numbness
-Inflammation absent*, lab studies normal
-easily written off!
-look like have MDD

21

afferent pain tract

STT: spinothalamic tract

22

benzos for chronic pain

diazepam (valium)
lorazepam (ativan)
midazolam (versed)
clonazepam (klonopin)

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opioid withdrawal stage I

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opioid withdrawal stage II

8-24 hrs
insomnia, restlessness, anxiety, yawning, stomach cramps, lacrimation, rhinorrhea, diaphoresis, mydriasis

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opioid withdrawal stage III

up to 3 days
vomiting, diarrhea, fever, chills, musc. spasms, tremor, tachycardia, piloerection, HTN, seizures (neonates)

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muscle relaxants for chronic pain

cyclobenzaprine
carisoprodol (soma)
baclofen (lioresal)
methocarbamol (robaxin)
*loopiness-take before bed, used with ice packs

27

barriers

Physicians have poor training
Fears of legality:
FDA, DEA, controlled substance
*document!*
Fears of abuse:
-Tolerance vs Dependence vs Addiction vs Pseudo-addiction
-IPMP website, can see pts prescribed opioids to

28

pain1 slide 17: KNOW!!***

WHO analgesic ladder

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mild pain

non-opioid: acetaminophen (paracetomol)(liv. tox, not v. strong), ASA, NSAID (GI, CV, renal SE)
+/-adjuvant

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mild-mod pain

opioid (codeine-not so much, tramadol*partial agonist)
+/- non-opioid
+/- adjuvant

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mod-sev pain

opioid (morphine, fentanyl, dilaudid etc)
+/-non-opioid
+/-adjuvant

32

nociceptive pain: joints

patches, topical lidocaine

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non-imflamm pain

tylenol

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for chronic pain

adjuvants

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neuropathic pain tx: 1st line agents

gabapentin
SNRIS
TCAs

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neuropathic pain tx: 2nd line

opioids (tramadol)
antiepileptics

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neuropathic pain tx: 3rd line

NMDA antagonists
combo
tizanidine
baclofen

38

neuropathic pain tx: 4th line

consider botulinum toxin injection or
intrathecal ziconotide

39

spinal stimulator

for chronic lower lumbar pain, block pain
not first line tx, meds first

40

opioid manangement

document everything
-avoid refills
-printed out, NOT electronic prescription

41

benzos good for..
but...

central, spasm, neuropathic pain, also tx anxiety rel. to pain
tough to manage, can make pt "high"
-Brown does not give often

42

tapering protocal

DEA have sp. protocol for opioids, give less and less with added behavioral therapy

43

palliative care focus

Focus on symptoms, quality of life, and goals of care

44

palliative care management

Pain
Dyspnea
Nausea,vomiting
Constipation
Agitation
Emotional distress (depression, anxiety, relationships)
Existential distress (spiritual distress)

45

opioid SEs

constipation- may need meds (docusate, colace, etc)
methalnaltrexone reverses constipation

46

OMM

medium effect on chronic low back pain

47

case 1: motorbike accident, 100 mph, road rash, stabilized

Need pain scale
Probably in v. severe pain, potentially in shock (mental)
Opioids are a good choice: don’t want to give so much stop breathing, or affect neural reflexes and cannot monitor
-give morphine, "start low and go slow"(better for when you want to give a lot and worried about neuro) could use dilaudid, longer dosage schedule, not ideal
-do everything when get to ER: head CT, CXR (ptx, broken clavicle etc.)
-paramedics may call ahead to drs and give meds/prep for others/procedures
-needle thoracotomy (fastest- relieves pressure, chest tube)

48

case 2: sharp stomach pain around lunch time, right of bb-radiates to right side
no rebound tenderness
no pmhx

-abdominal CT: appendicitis (take out), diverticulitis
-visceral pain, not well localized
-morphine, potentially stronger- dilaudid, fentanyl patch
-control pain, prep for surgery

49

case 3: unresponsive old man, low RR, HTN, dying, end-stage lung ca

-family wanted comfort measures only (not IV)
-palliative care, end of life care (not just, however-diff than hospice)
-fentanyl patch: long-acting