Pain Management

Question 1

What are the types of pain

Answer 1

Nociceptive pain
Inflammatory pain
Neuropathic pain
Functional pain

Question 2

What is Nociceptive pain

Answer 2

Pain in response to noxious stimulus

- can be somatic or visceral

Question 3

What is Inflammatory pain

Answer 3

when tissue damage occurs despite the nociceptive defense system..inflammatory pain ensues.

Question 4

What is Neuropathic pain

Answer 4

Neuropathic pain results from damage to or dysfunction of the peripheral or central nervous system rather than stimulation of pain receptors.

• TRAMADOL

Question 5

What is Functional Pain

Answer 5

Pain due to abnormal processing or function of the central nervous system in response to normal stimuli

Question 6

which types of pain can be involved in Acute pain

Answer 6

Acute pain is usually nociceptive but can also be neuropathic.

Question 7

which types of pain can be involved in Chronic Pain

Answer 7

may be:
nociceptive 
inflammatory
neuropathic  
or functional

Question 8

Chronic malignant pain is associated with kind of diseases?

Answer 8

Associated with progressive disease like cancer of AIDs

Question 9

Chronic Non-malignant pain is not associated with?

Answer 9

Pain not associated with a life threatening disease and lasting longer than 6 months beyond the healing period.

Question 10

What medication should be given for mild to moderate pain

Answer 10

Acetamiophen and NSAIDs are effective for mild to moderate pain.
- Non-opioids do not cause physical dependence or tolerance.

Question 11

What is the first line choice for lower back pain and osteoarthritis and is often selected as intial therapy for mild to moderate pain?

Answer 11

Acetaminophen

Question 12

opioids for mild-moderate pain:

Answer 12

codeine
hydrocodone
oxycodon
Meperidin 
Tramadol (neuropathic pain)

Question 13

Opioids for mild to severe pain:

Answer 13

Morphine
Hydromorphone
Oxymorphone
Levorphanol
Fentanyl
Sufentanil
Methadone

Question 14

Breakthrough pain
how is it alleviated?
what are the formulation for the analgesic?

Answer 14

Transitory severe acute pain that occura on a background of chronic pain that is adequately controlled by an opioid regimen
- targeted with a transmucosal Fentanyl formulation

6 formulation are available in the US:

• Oral transumucosal lozenge
• Immediate-release transmucosal tablet
• Effervescent buccal tablet
• Bucaal solubke film
• Nasal spray
• sublingual spray

Question 15

Mixed agonist-antagonists all have what kind of effect?

are they a good for patients with severe pain?

Answer 15

Mixed agonist-antagonist:
- Pentazocine
- butorphanol
- Nalbuphine
and buprenorphine

all have Ceiling effect
Bad choice

Question 16

Normeperidine (metabolite) AE:

Answer 16

t1/2=15-20hrs 
"No MSD"
Dysphoria
Myoclonus 
Seizures

Question 17

Mixed agonist-antagonists adverse effects:
Pentazocine
nalbuphine
butorphanol

Answer 17

psychotomimetic adverse effects ( k agonists)

Question 18

Most common opioid adverse effects:

Answer 18

Pruritis
Constipation
Nausea/Vomiting
Sedation

Question 19

opioid induced Pruritis managed by

Answer 19

hydroxyzine or

diphenhydramine

Question 20

opioid inuduced nausea and vomiting managed by

Answer 20

hydroxyzine
metoclopramide
prochlorperazine

Question 21

Persisitent opioid SEDATION that limits activity should be managed by?

Answer 21

Methylphenidate

modafinil

Question 22

if opioid use compromises respiration use:

Answer 22

Naloxone

Question 23

Analgesic adjunctive agents (Coanalgesics)

Answer 23

Antidepressants
Anticonvulsants
Glucocorticoids

Question 24

Tricyclic Antidepressants

Answer 24

tertiary amines: (TAI is a Turd)
Amitriptyline
Imipramine

Secondary amines: fewer side effects. Desired in elderly.
Desipramine
Nortriptyline

Question 25

Tricyclic antidepressants: AE

Answer 25

``` constipation dry mouth blurred vision cognitive changes tachycardia urinary hesitation ``` ``` rare AE: Sexual dysfunction orthostatic hypotension weight gain sedation ```

Question 26

Tricyclic antidepressants should be administered cautiously in patients with:

Answer 26

Angle-closure glaucoma (due to blurry vision) BPH Urinary retention (because of urinary hesitation) Constipation CV disease (due to tachycardia) impaired Liver function

Question 27

TCA: Amitriptyline, Imipramine, Desipramine, Nortriptyline | should be avoided in patients with:

Answer 27

``` Second or third degree heart block Arrhythmias Prolonged QT Interval Severe Liver disease Recent acute MI ```

Question 28

Serotonin and Norepinephrine Reuptake inhibitors (SNRIs)

Answer 28

Venflaxaxine and Duleoxetine: - SNRIs selectively inhibit reuptake of serotonin and norepinephrine. - SNRIs lack the antihistamine; a-adrenergic blocking and anticholinergic effects of TCAs (Amitriptyline, Imipramine, Desipramine, Nortriptyline).

Question 29

What kind of pain are Venflafaxine and Duloxetine effective for:

Answer 29

Neuropathic pain

Question 30

SNRIs AE: which are better tolerated between SNRIs (Venlfafaxine and Duloxetine) and TCAs (Amitriptyline, Imipramine, Desipramine, Nortriptyline)?

Answer 30

Nausea sexualdysfunction somnolence SNRIs are better tolerated than TCAs.

Question 31

Anticonvulsants

Answer 31

Gabepentin and Pregabalin | Carbamazepine

Question 32

Gabepentin and Pregabalin MOA? AE?

Answer 32

Block voltage gated calcium channels leading to reduction of the influx of calcium into neurons decreasing release of glutamate norepinephrine and substance P. AE: dizziness solmnolence peripheral edema

Question 33

DOC for trigeminal Neuralgia | MOA?

Answer 33

Carbamazepine - Voltage-gated sodium channels in sensory neurons play a crucial role in neuropathic pain - Carbamazepine blocks voltage gated sodium channels.

Question 34

Carbamazapine AE:

Answer 34

``` Drowsiness dizziness nausea vomiting Carbamazepine-induced leukopenia is not uncommon Aplastic anemia is a rare side effet ```

Question 35

Glucocorticoids | DOC

Answer 35

commonly used in advanced illness - useful for acute nerve compression; increased intracranial pressure; Bone pain; viseral pain; anorexia; nausea and depressed mood - Dexamethasone is the DOC - Prednisone and methylprednisolone can also be used.

Question 36

Glucocorticoids indications

Answer 36

Improve appetite; nausea; malaise and overal quality of life.

Question 37

Hydroxyzine adds to what kind of effect?

Answer 37

May add to the analgesic effect of opioids

Question 38

Clonidine can be administered in what forms?

Answer 38

Available as oral or transdermal patch formulations. May improve pain and hyperalgesia in sympathetically maintained pain.

Question 39

Lidocaine Patch or capsaicin patch

Answer 39

are approved for postherpetic neuralgia

Question 40

Caffeine can enhance analgesic effect of

Answer 40

Acetaminophen and NSAIDs.

Question 41

OPOID management of adverse effects: Pruritus Due to histamine release from mast cells Can be managed

Answer 41

with hydroxyzine or diphenhydramine.

Question 42

OPOID management of adverse effects: | Nausea/vomiting managed by?

Answer 42

It can be treated with hydroxyzine, metoclopramide or prochlorperazine.

Question 43

ANTIDEPRESSANTS AND ANTICONVULSANTS

Answer 43

Mainstay of treatment for several neuropathic pain syndromes

Question 44

ANTIDEPRESSANTS MOA of serotonin and norepinephrine?

Answer 44

- Serotonin and norepinephrine mediate descending inhibition of ascending pain pathways in the brain and spinal cord - Antidepressants that enhance both serotonergic and noradrenergic transmission display significant analgesic effects • Tricyclic antidepressants (TCAs) •Serotonin and norepinephrine reuptake inhibitors (SNRIs).