Pain Management (KEY POINTS)

Question 1

Describe somatic pain

Answer 1

Arises from skin, bone, joint, muscle, or CT

Throbbing, well localized

Question 2

Describe visceral pain

Answer 2

Arises from internal organs s/a intestine or pancreas

Localized or referred pain

Question 3

What are the free nerve endings (nociceptors) stimulated by?

Answer 3

Mechanical, thermal, & chemical impulses

Question 4

What fibers = large diameter? What do they evoke?

Answer 4

Myelinated Aδ fibers

Sharp, well-localized pain

Question 5

What fibers = small diameter? What do they evoke?

Answer 5

Unmyelinated C fibers

Dull, aching, poorly localized pain

Question 6

How is pain modulated by the body?

Answer 6

Endogenous opiate system

Blockage of N-methyl-D-aspartate (NMDA) receptors

Question 7

The endogenous opiate system contains what receptors?

Answer 7

μ, δ, and κ

Question 8

The CNS also contains a highly organized…

Answer 8

descending system for control of pain transmission.

Question 9

What NTs in the CNS are involved in pain control?

Answer 9

Endogenous opioids
Serotonin
NE
GABA

Question 10

What functions can modify pain?

Answer 10

Cognitive & behavioral

Question 11

What type of changes in our neurobiochemical makeup can worsen pain?

Answer 11

Depression & anxiety

Question 12

What is inflammatory pain?

Answer 12

The body shifting from: preventing tissue damage –> promotion of healing

Question 13

What does the inflammatory process lead to?

Answer 13

Reduced pain threshold

Injured area becomes more sensitive to pain

Decreased movement

Question 14

What is inflammatory pain associated with?

Answer 14

Increase in excitability or responsiveness of neurons within the CNS (central sensitization)

Question 15

What are major causes of hypersensitivity to pain after injury?

Answer 15

Peripheral & central sensitization

Question 16

Neuropathic pain is a result of…

Answer 16

nerve damage

Question 17

What can be thought of as an abnormal operation of the nervous system?

Answer 17

Functional pain

Question 18

How is neuropathic & functional pain described?

Answer 18

Burning, tingling, shock-like, shooting

Hyperalgesia (painful response to noxious stimuli)

Allodynia (painful response to normally nonnoxious stimuli)

Question 19

Which type of pain often manifests long after the actual nerve-related injury or when no actual injury is identified?

Answer 19

Neuropathic & functional pain

Question 20

What are non-pharm therapies in acute & chronic pain?

Answer 20

Physical manipulation
Heat or cold
Massage 
Exercise 
TENS
Cognitive, behavioral, social

Question 21

What is the tx goal in acute vs chronic pain?

Answer 21

Acute = pain reduction

Chronic = functionality

Question 22

What are sx of acute pain?

Answer 22

Sharp, dull, shock-like, tingling, shooting, radiating

Flunctuates in intensity, varies in location

Occurs in a timely relationship w/ a noxious stimuli

Question 23

Describe chronic pain

Answer 23

Can appear to have no noticeable suffering

Attention to mental/emotional factors that alter the pain threshold

Question 24

What are sx of chronic pain?

Answer 24

Sharp, dull, shock-like, tingling, shooting, radiating

Flunctuates in intensity, varies in location

Occurs w/out a temporal relationship w/ a noxious stimuli

Question 25

What are non-opioid analgesics?

Answer 25

Salicylates: ASA, Choline & Mg trisalicylate Acetaminophen Ibuprofen Ketorolac (Pyrrolacetic acid) Celecoxib (Cox2 selective)

Question 26

What is the max daily dose of ibuprofen?

Answer 26

3200mg - inflammatory 1200mg - analgesic/fever/dysmenorrhea

Question 27

How is ketorolac administered?

Answer 27

Parenterally

Question 28

In cardiac pts where low dose ASA is indicated, when should celecoxib be given?

Answer 28

After the ASA dose

Question 29

What are 2 ADEs of NSAIDs?

Answer 29

Upper GI bleed | Acute renal failure

Question 30

What should you monitor in pts taking NSAIDs?

Answer 30

CBC Guaiac (if black tarry stools) Serum creatinine

Question 31

What is an ADE of acetaminophen?

Answer 31

Hepatotoxicity

Question 32

What should you monitor in pts taking acetaminophen?

Answer 32

Transaminases (ALT/AST) Liver tests (PT/INR, albumin) Acetaminophen [ ]

Question 33

When are NSAIDs/acetaminophen/ASA used?

Answer 33

Mild-Mod pain

Question 34

What drugs are phenanthrenes?

Answer 34

Morphine Hydro-morphone/codone Oxy-morphone/codone Codeine

Question 35

What are characteristics of both morphine and codeine?

Answer 35

Naturally occurring Histamine release

Question 36

What is the drug of choice for severe pain?

Answer 36

Morphine

Question 37

When do you use codeine?

Answer 37

In mild-mod pain & cough suppression

Question 38

What does codeine depend on for metabolism to morphine?

Answer 38

CYP450 2D6

Question 39

When do you use hydrocodone & oxycodone?

Answer 39

Mod/severe pain

Question 40

What drugs are phenylpiperidines? (used in severe pain)

Answer 40

Meperidine (Demerol) Fentanyl (Sublimaze, Duragesic, Actiq)

Question 41

What is a contraindication of meperidine?

Answer 41

Renal failure

Question 42

What are ADEs of meperidine?

Answer 42

Tremors, myoclonus, seizures Mydriasis

Question 43

What is meperidine's active metabolite?

Answer 43

Normeperidine

Question 44

When should you NOT use fentanyl transdermal?

Answer 44

Acute pain

Question 45

What drug is a diphenylheptane?

Answer 45

Methadone

Question 46

What drug causes QT prolongation?

Answer 46

Methadone

Question 47

Titrations of methadone should be avoided more frequently than...

Answer 47

every 2 wks

Question 48

What drugs are agonist-antagonist or partial agonists?

Answer 48

Pentazocine Butorphanol Nalbuphine Buprenorphine (Butrans, Subutex)

Question 49

What are characteristics of buprenonorphine?

Answer 49

2nd line for mod-severe pain Detailed dosing conversion Must complete training to Rx

Question 50

Buprenorphine may precipitate...

Answer 50

withdrawal in opiate-dependent pts

Question 51

Is naloxone effective in reversing resp. depression?

Answer 51

May not be

Question 52

What are central analgesic?

Answer 52

Tramadol* | Tapentadol

Question 53

What are ADEs of opioids?

Answer 53

Resp. depression Constipation Sedation (decreases over time) N/V (decreases over time)

Question 54

Who is at higher risk of developing resp. depression when taking opioids?

Answer 54

OSA | COPD

Question 55

What is an opioid antagonist?

Answer 55

Naloxone (Narcan)

Question 56

What is important to know about pregabalin (Lyrica) ?

Answer 56

Exerts antinociceptive & anticonvulsant activity

Question 57

What adjunctive therapies are available for chronic pain?

Answer 57

TCAs, SSRIs, SNRIs (topical) Duloxetine (Cymbalta)

Question 58

What is the MOA of duloxetine?

Answer 58

Potent inhibitor of serotonin & norepinephrine reuptake

Question 59

What are NSAIDs & skeletal muscle relaxants recommended for?

Answer 59

Acute low back pain

Question 60

What are 1st line & 2nd line agents for chronic low back pain?

Answer 60

``` 1st = NSAIDs 2nd = Duloxetine & tramadol ```

Question 61

What is NOT recommended for tx of fibromyalgia?

Answer 61

Opioids!

Question 62

What drugs are rarely effective for neuropathic pain?

Answer 62

Acetaminophen & NSAIDs

Question 63

What is a true allergy? Give an examples.

Answer 63

IgE-mediated or T-cell mediated Ex. bronchospasm

Question 64

Is angioedema a true allergy?

Answer 64

Usually, but pseudoallergy is also possible

Question 65

What is pseudoallergy? What causes it?

Answer 65

Common rxn to opioids Histamine release, a nonimmunologic effect

Question 66

What are sx of pseudoallergy?

Answer 66

Itching, flushing, sweating