Pain Management Flashcards Preview

Primary Care 3 > Pain Management > Flashcards

Flashcards in Pain Management Deck (128)
1

Chronic Pain can be one of these two categories

Neuropathic or Nociceptive

2

Neuropathic pain

Seconday to a disease or a dysfunction of the nervous system. Either peripheral like PHN, Diabetic neuropathy or central like post stroke pain or MS.

3

Nocicpetive pain

Musculoskeletal (back, ankle) , Inflammatory (arthropathies, infection) or Mechanical/Compressive (kidney stone, tumor) Caveat -- multifactorial causes of chronic pain are not uncommon

4

Hyperalgesia

increased response to a stimulus that is normally painful

5

Hypoalgeisa

Diminished response to a normally painful stimulus

6

Analgesia

Absence of pain in response to stimulation that normally is painful

7

Hyperesthesia

Increased sensitivity to stimulation, excluding the special senses

8

Hypoesthesia

Diminished sensitivity to stimulation, excluding the special senses

9

Dysesthesia

An unpleasant abnormal sensation, whether spontaneous or evoked

10

Paresthesia

An abnormal sensation, whether spontaneous or evoked

11

Allodynia

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

12

Myelinated nociceptors

relatively fast- conducting A-delta fibers

13

Nociceptors

highly- specialized subset of primary sensory neurons that respond only to pain stimuli. Their signals sum to produce the nociceptive input, leading to the subjective sense of pain.

14

Sciatica pain

Pain typically found in posterior part of lower extremity and follows dermatomal pattern.

15

Digital Gangrene

Arterial ulcers are intensely painful and occur on the distal portions of the extremities. They may result in tissue necrosis.

16

Herpes Simplex Infection in HIV Infection

In patients with HIV disease, herpes simplex may appear as painful, nonhealing shallow ulcers.

17

Transduction

conversion of a noxious stimulus (thermal, mechanical, or chemical) into electrical activity in the peripheral terminals of nociceptor sensory fibers

18

Transmission

he passage of action potentials from the peripheral terminal along axons to the central terminal of nociceptors in the central nervous system

19

Conduction

is the synaptic transfer of input from one neuron to another

20

Modulation

alteration (eg, augmentation or suppression) of sensory input

21

Perception

the "decoding"/interpretation of afferent input in the brain that gives rise to the individual's specific sensory experience- the ouch experience

22

The International Association for the Study of Pain (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
Caveat Number #2: compatible with the International Classification of Diseases (ICD 9 and ICD 10) but provides for more detailed identification of various chronic pain syndromes and major acute pain syndromes

23

Axis I: Anatomic regions

Need Specifics to Accurately bill ex R10.1 pain localized to upper abdomen

24

Treatment options for chronic pain generally fall into six major categories

1. pharmacologic;
2. physical medicine;
3. behavioral medicine; 4. neuromodulation;
5. interventional, and 6. surgical approaches.

25

Opioids in chronic pain mgmt

Opioids should not be considered first- line or routine therapy for chronic pain. This does not mean that patients should be required to sequentially “fail” nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy - benefits should be weighed against the risk

26

Adaptive pain

Adaptive pain contributes to survival by protecting the organism from injury and/or promoting healing when injury has occurred.

27

Maladaptive pain

Chronic pain- aka – maladaptive - is pain as disease itself, and represents pathologic functioning of the nervous system.

28

Sympathetically Mediated Pain

pain arising from a peripheral nerve lesion and associated with autonomic chances (e.g. complex regional pain syndrome I and II)

29

Peripheral Neuropathic Pain

is due to damage to a peripheral nerve without autonomic change (e.g. post-herpetic neuralgia)

30

Central Pain

arises from abnormal CNS activity (e.g. phantom limb pain)

31

Nociceptive Pain

A nociceptor is a nerve fiber sensitive to a noxious stimulus or a stimulus that would become noxious if prolonged (e.g. operative incisions) Nociceptive pain is the perception of nociceptor input arising from tissue injury, inflammation or mechanical deformation.

32

Somatic Pain

arises from injury to body tissues, well localized, variable in description and experience

33

Visceral Pain

arises from the viscera mediated by stretch receptor, poorly localized, deep, dull and cramping.

34

Examples of Nocioceptive pain

Examples: trauma, burns, infections, arthritis, ischemia and tissue distortion

35

Examples of neuropathic pain

diabetic neuralgia, trigeminal neuralgia, thalamic pain syndrome

36

Nociceptive Somatic pain described as

“ache”, “throb”, “sharp” May worsens with movement

37

Nociceptive Visceral described as

“colickly”, “vague”, “diffuse” May worsen with meals

38

Neuropathic described as

“burning”, “sharp”, “tingling” May worsen with touch

39

Chronic neck pain

Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution. No trigger points, poor ROM in involved muscle

40

Fibromyalgia

Diffuse muscular pain, stiffness, fatigue, sleep disturbance, Diffuse muscle tenderness, >11 trigger points

41

Chronic back pain

Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution, NO trigger points, poor ROM in involved muscle

42

Myofascial back pain syndrome

Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution, TRIGGER points in area of pain, usually no muscle atrophy, poor ROM in involved muscle

43

When to use opiods

Opioids are generally recommended to reduce the level of moderate to severe pain, Opioids should be considered if reasonable, conservative therapy has failed

44

Nonopiod analgesics

acetaminophen and nonsteroidal anti- inflammatory drugs (nonselective agents and selective COX-2 inhibitors).

45

Adjuvants

specific medications for neuropathic pain (antidepressants, anticonvulsants, miscellaneous agents), specific medications for cancer-related pain (bisphosphonates, radioisotopes, steroids), and medications for bowel spasms

46

fibromyalgia cardinal symptom

Chronic widespread pain

47

Documentation with opiod treatment

Documentation is critical and should include the initial evaluation, substance abuse history, psychosocial issues, pain/pain relief, side effects, functional outcomes, and continuing monitoring- with each visit. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse- WITH EACH VISIT- Now Being Done Monthly.

48

When to refer

• Previous failure with opioids or other analgesics • Significant psychosocial issues
• Conviction of a drug-related crime
• Current use of illicit drugs
• Regular contact with drug high-risk groups
• History of substance abuse
• Be careful- you cannot quickly abandon the patient

49

Bio/Physical Approaches

• pharmacologic and/or nonpharmacologic therapies
• physical rehabilitation
• physical/ occupational therapy
• homeexercise program

50

Psychological Intervention

• mood disturbances • coping skills
• sleep disturbance

51

Social Issues

• family/social relations
• work issues

52

Psychologicalintervention

integralpartoftheroutinemanagement→improvespatients’coping skills and their ability to relax and sleep without interruption

53

Alternatives to Opioid Therapy

• adjuvant analgesics
• nonpharmacologic modalities
• CAM (e.g. Acupuncture/massage)
• Anticonvulsants
• Tricyclic antidepressants
• Topical medications

54

Interventional treatments

• Neuralblockade
• Stimulatory techniques (spinal cord stimulation; peripheral nerve stimulation)

55

Nonpharmacological therapies

• Biofeedback
• Relaxation therapy
• Cognitive/behavioralstrategies • Acupuncture

56

Antispasmodics

can be useful in treating this aspect of the patient's symptoms, but their action may be more the result of sedation rather than muscle relaxation.

57

Benefits of high-dose opioids for chronic pain

these are not established

58

ER/LA opioids

methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. reserved for “management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers

59

limiting days of opioids

Because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days (contextual evidence review), limiting days of opioids prescribed also should minimize the need to taper opioids. Each day of unnecessary opioid use increases likelihood of physical dependence without adding benefit

60

Initiating Opioid Therapy

• Consider cost, tolerability, ease of administration, compliance
• Develop and document an Exit Strategy
• Should regularly reassess all patients receiving long-term opioid therapy, including patients who are new to the clinician but on long- term opioid therapy, at least every 3 months.

61

Moderate to Severe pain

Morphine, Fentanyl, oxycodone, hydromorphone

62

Mild to Moderate

Codeine, Tramadol, hydrocodone, propoxyphene

63

Mild pain

nonopiod, Tylenol, Asa, Nsaids, Corticosteroids Tricyclic antidepressants Anticonvulsants Topical Preparations

64

Factors That Influence Analgesic Selection

• Type of pain
• Severity
• Duration
• Patient-specific factors:::
• age
• pain and analgesic history
• concomitant diseases, organ function
• psychosocial issues

65

Create an Exit Strategy

Upon initiating opioid therapy, agree with patient on criteria for failure of the trial. Common failure criteria include: • lack of significant pain reduction
• lack of improvement in function • persistent side effects
• persistent noncompliance

66

The "Four A's of Pain"

Analgesia
Activities of daily living Adverse effects
Aberrant drug-taking behaviors
Important to remember two other “A’s”
Assessment
Action (treatment plan)

67

Prescribe naloxone when factors that increase risk for opioid overdose, such as:

• History of overdose
• history of substance use disorder, higher opioid dosages

68

Review the patient’s history of controlled substance prescriptions

the state prescription drug monitoring program

69

Urine drug testing

--before starting opioid therapy --consider urine drug testing at least annually to assess --Recommend 3 negative test per 12 months for prescribed medications as well as other controlled prescription drugs and illicit drugs

70

Nausea and vomiting s/e

Switch opioids; anti-emetics

71

Sedation s/e

Lower dose (if possible); add co-analgesics;
add stimulants

72

Constipation s/e

Treat prophylactically with stool softeners, bowel stimulants; non-pharmacological measures; switch opioids

73

Itching s/e

Switch opioids; antihistamines

74

Endocrine dysfunction/reduced libido s/e

Endocrine monitoring; testosterone replacement; endocrine consultation

75

Edema and sweating s/e

switch opioids

76

Dizziness s/e

Antivertiginous agents (eg, scopolamine)

77

Confusion s/e

Titrate dose; switch opioids

78

Opioid treatment may lead to the development of

• pharmacological tolerance
• opioid-induced pain through similar cellular mechanisms Both may contribute to the clinical manifestation of apparent opioid tolerance with a demand of opioid dose escalation. Opioid dose escalation may feed back into the cellular mechanisms of pharmacological tolerance

79

Opioid-induced pain sensitivity

further escalating the opioid demand

80

Continue Opioid Therapy

An option if there is • effective pain relief
• improvement in ADLs
• improvement in psychosocial functioning • management of side effects

81

Relevant regulations of the CDC include

• federal (DEA)
• state policies
• Your scope of practice
• Your prescribing habits
• Your collaborative agreement

82

Exit Strategy

Start on Day one. Documentation of lack of pain reduction and/or lack of functional improvement
• criteria for tapering emphasized in the initial patient agreement • This is Huge: Distinguish between abandoning opioid therapy, abandoning pain management, and abandoning patient • Taper off opioid therapy, with or without specialty assistance

83

preferred treatment for chronic pain

Nonpharmacologic therapy and nonopioid
pharmacologic therapy

84

Clinicians should consider opioid therapy only if

expected benefits for both pain and function are
anticipated to outweigh risks to the patient.

85

If opioids are used you need to combine them with what?

nonpharmacologic therapy and nonopioid
pharmacologic therapy, as appropriate.

86

Before starting opioid therapy for chronic pain,
clinicians should establish

treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.

87

Clinicians should continue opioid therapy only if there is

clinically meaningful improvement in pain and function that outweighs risks to patient safety.

88

Before starting and periodically during opioid therapy, clinicians should discuss with patients

known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

89

When starting opioid therapy for chronic pain, clinicians should prescribe

immediate-release opioids instead of
extended-release/long-acting (ER/LA) opioids.

90

When opioids are started, clinicians should prescribe

the lowest effective dosage.

91

Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to

≥50 morphine milligram equivalents (MME)/day

92

We should avoid increasing dosage to

≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.

93

Long-term opioid use often begins with treatment of

acute pain

94

When opioids are used for acute pain, clinicians should prescribe

the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

95

Clinicians should evaluate benefits and harms of continued therapy with patients every

3 months or more frequently (many places do this monthly)

96

If benefits do not outweigh harms of continued opioid therapy, clinicians should

optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

97

Before starting and periodically during continuation of opioid therapy, clinicians should

evaluate risk factors for opioid-related harms.

98

Clinicians should incorporate into the management plan strategies to mitigate risk, including

considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

99

Clinicians should review the patient’s history of controlled substance prescriptions using

state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.

100

Clinicians should review PDMP data when

starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

101

When prescribing opioids for chronic pain, clinicians should use urine drug testing

before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

102

Clinicians should avoid prescribing opioid pain medication and

benzos

103

Clinicians should offer or arrange evidence-based treatment for patients with opioid use disorder

usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies

104

Can improve pain in diabetic
neuropathy and post-herpetic neuralgia

Lyrica and Neurontin

105

FDA approved adjuvant therapy for fibromyalgia

Lyrica and Tricyclic and SNRI antidepressants

106

Effective analgesia for neuropathic pain conditions

tricyclic antidepressants and SNRIs (Cymbalta) often at lower dosages and with a shorter time to onset of effect than for treatment of depression

107

Situations in which opioids will be discontinued or doses tapered

if treatment goals are not met, opioids are no longer needed, or adverse events put the patient at risk

108

Scale to track patient oucomes

PEG - Pain assessment, Enjoyment of life, interfere with General activity

109

Clinically meaningful improvement has been defined as a

30% improvement in scores for both pain and function

110

assessment of functional improvement

assess functional goals like walking around the block

111

If they do not receive benefit in both pain and function

taper of stop the opiod and use nonpharm and nonopiod forms of pain management (NSAIDS, SNRI, pt/ot, etc)

112

common effects of opioids,

constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when stopping opioids.

113

ER/LA opioids

methadone, transdermal fentanyl,extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine -- higher risk of overdose

114

ER/LA opioids be reserved for

management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers

115

opioid-tolerant patients

patients who have received certain dosages of opioids (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week. ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate-release opioids daily for at least 1 week

116

Methadone risk

Prolonged respiratory despression, QT prolonged

117

transdermal fentanyl risk

absorption properties differ widely from patient to patient

118

higher opioid dosages areassociated with increased risks for

motor vehicle injury, opioiduse disorder, and overdose

119

although there is not a single dosage threshold below which overdose risk is eliminated, holding dosages < This Dose of MME/day would likely reduce risk among a large proportion of patients who would experience fatal overdose at higher prescribed dosages

50 MME/Day, increasing dosages to 50 or more MME/day increases overdose risk without necessarily adding benefits for pain control or function and that clinicians should carefully reassess evidence of individual benefits and risks when considering increasing opioid dosages to ≥50 MME/day. If > 50 need increased follow up monitoring and narcan education

120

opioid dosages should not be increased to ≥ this dose MME/day without careful justification based on diagnosis and on individualized assessment of benefits and risks

90 MME/day

121

Wait how long before increasing a dosage

5 half lives or usually one week - especially with methadone

122

Consult pain mgmt if

do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements

123

early warning signs of serious adverse events, signs of opioid use disorder

difficulty controlling use, work or family problems related to opioid use

124

exposed to greater risk of opioid use disorder or overdose

patients with depression or other mental health conditions, a history of substance use disorder, a histor of overdose, taking ≥50 MME/day, or taking other central nervous system depressants with opioids

125

Tapering opiods

10-50% of original dose over 2-3 weeks. If taking for years it may need to be done by 10 percent per month.

126

signs of opioid withdrawal

drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection -- need to taper slow enough to avoid these symptoms

127

factors that increase risk for harm

history of overdose, history of substance use disorder, higher dosages of opioids (≥50 MME/day), and concurrent use of benzodiazepines with opioids

128

If clinicians suspect their patient might be sharing or selling opioids and not taking them, clinicians should

consider urine drug testing to assist in determining whether opioids can be discontinued without causing withdrawal. A negative drug test for prescribed opioids might indicate the patient is not taking prescribed opioids,