Pain Mgmt 2 Flashcards
(48 cards)
1
Q
What is the opioid antagonist?
- Synthetic
- No histamine release
- IV route
- If no response within __ mins, repeat dose
- Onset is slightly longer if given IM
A
Naloxone (Narcan)
- 5
2
Q
- Is a chronic pain
- Treatment options
–Anticonvulsants
–Tricyclic antidepressants
–Serotonin–norepinephrine reuptake inhibitors
–Opioids
–Topical analgesics
A
Neuropathic Pain
3
Q
Which drug?
- Chronic Pain - Anticonvulsants
- Mechanism: May decrease neuronal excitatory neurotransmitters & nociception through voltage gated Ca channels specifically possessing the alpha-2-delta-1 subunit
A
Gabapentin (Neurontin)
4
Q
Which drug for chronic pain?
-
ADE:
- fatigue
- headache
- abnormality in thinking
- amnesia
A
Chronic Pain Anticonvulsants
Gabapentin
5
Q
Which drug for chronic pain-anticonvulsants?
- Binds to alpha2-delta subunit of voltage-gated calcium channels within the CNS, inhibiting excitatory neurotransmitter release
- Although structurally related to GABA, it does not bind to GABA or benzodiazepine receptors
•Exerts antinociceptive and anticonvulsant activity*
- Decreases symptoms of painful peripheral neuropathies
- May also affect descending noradrenergic and serotonergic pain transmission pathways from the brainstem to the spinal cord
A
Prebgabalin (Lyrica)
6
Q
Which drug for chronic pain-anticonvulsants?
–Peripheral edema
–Weight gain
–Tremor
–Dizziness, ataxia
(no amnesia, no fatigue, no HA)
A
Prebgabalin (Lyrica)
7
Q
Serotonin/Norepinephrine reuptake inhibitor antidepressants and _____
- Block the reuptake of serotonin and norepinephrine enhancing pain inhibition
A
Tricyclic antidepressants
(for chronic pain)
8
Q
What med decreases nerve stimulation?
A
Topically applied local analgesic / anesthetics
- Lidocaine patches
- NSAIDs patches: flector, voltarin
- OTC-Salonpas, Tiger balm
(for chronic pain)
9
Q
Which drug for chronic pain?
–Potent inhibitor of neuronal serotonin and norepinephrine reuptake**
–Weak inhibitor of dopamine reuptake
–No significant activity for muscarinic cholinergic, H-1 histaminergic, alpha-2 adrenergic receptors, or MAO-inhibitory activity
A
Duloxetine (Cymbalta)
10
Q
What are 3 ADE’s of Duloxetine?
A
- Xerostomia (dry mouth)
- Insomnia
- Agitation
(AID)
11
Q
- Treatment for mild pain?
- Always consider what?
A
- Acetaminophen and/or NSAID
- Around the clock regiments
12
Q
- Treatment for moderate pain?
- Always consider what?
A
- Combination opioid & acetaminophen or NSAID
- Around the clock regimens
13
Q
- Treatment for severe pain?
- Always consider what?
A
- Opioid analgesics
- Around the clock regimens
14
Q
Use what route for analgesics whenever possible?
A
PO
15
Q
What 4 opioids should you avoid/exercise caution?
A
- Codeine
- Meperidine
- Agonist / Antagonist agents
- Tramadol
16
Q
Regional Analgesia
- Administered local anesthetics can provide relief of _____
- Positioned by ____ or ______
- _____ in the form of a patch has proven effective in treating focal neuropathic pain
- Regional application of local anesthetics relieve pain by blocking ______
A
- both acute & chronic pain
- injection or topically
- Lidocaine
- nerve impulses
17
Q
ADEs of Regional Analgesia
- High plasma concentrations lead to what?
A
Signs of CNS excitation & CNS depression
- dizziness
- tinnitus
- drowsiness
- disorientation
- muscle twitching
- seizures
- respiratory arrest
(DDD MRTS)
18
Q
Regional Analgesia
- What are the CV effects? (7)
A
- Myocardial depression
- Hypotension
- Decrease CO
- Heart block
- Bradycardia
- Arrhythmias
- Cardiac arrest
19
Q
What are the 3 disadvantages of Regional Analgesia?
A
- need for skillful technical application
- need for frequent administration
- highly specialized follow up procedures
20
Q
Local Anesthetics
- What are the names of 3 Esters?
A
- Procaine
- Chloroprocaine
- Tetracaine
(1 i)
21
Q
Local Anesthetics
- Name the 5 amides
A
- Mepivacaine
- Bupivacaine
- Lidocaine
- Prilocaine
- Ropivacaine
(2 I’s)
22
Q
Intraspinal Opioids
- What are the 4 opioids for the Epidural Route?
A
- Morphine
- Hydromorphone
- Fentanyl
- Sufentanil
23
Q
Intraspinal Opioids
- What are the 2 opioids for Subarachnoid/Intrathecal route
A
- Morphine
- Fentanyl
24
Q
Which intraspinal opioid has the quickest onset of pain relief?
A
Fentanyl (5 mins)
25
Which intraspinal opioid has the longest duration of pain relief?
Morphine
26
**Which drug for Intrathecal/Subarachnoid Therapy?**
_MOA:_
* Selectively binds to N-type voltage-sensitive calcium channels located on the nociceptive afferent nerves of the dorsal horn in the spinal cord
* Blocks the excitatory neurotransmitter release and reduces sensitivity to painful stimuli
* No action on the mu receptor
Ziconotide
27
What are the "more serious" ADEs of Ziconotide for Intrathecal Therapy (4)
**Neurocognitive:**
* Confusion
* Dizziness
* Hallucinations
* Urinary retention
28
What are the "less serious" of Ziconotide for Intrathecal therapy? (4)
* Sedation
* Somnolence
* Nausea
* HA
29
* What is 1st line therapy for both _localized_ & _diffuse_ neuropathic and nociceptive pain
* Is used in place of an opioid for those pts intolerant to opioid
* ONLY administered intrathecally
* 1st line for treating intractable **cancer pain** (localized & diffuse)
Ziconotide for Intrathecal therapy
30
How should Acute, Subacute, and Chronic low back pain be treated initially?
Nonpharm therapy
* heat
* massage
* acupuncture
* CBT
* mindfulness based stress reducations to physical therapy
31
2 treatments for acute low back pain
* NSAIDs
* Skeletal muscle relaxants
32
What is 1st and 2nd line for chronic low back pain?
**1st:** NSAIDs
**2nd:** Duloxetine & Tramadol
33
Which med is NOT recommended in Fibromyalgia?
Opioids
34
Acetaminophen & NSAIDs are rarely effective in which type of pain?
Neuropathic Pain
35
1st line for Neuropathic pain? (4)
* TCAs (tricyclic antidepressants)
* SNRIs (duloxetine)
* AEDs (pregab, gaba)
* 5% lidocaine patch
36
2nd line tx for neuropathic pain (2)
* Central analgesics
* Opioids
37
3rd line tx for neuropathic pain?
* Capsaicins
38
2 resources for prescribing opioids
* www.agencymeddirectors.wa.gov
* www.ncbi.nlm.nih
39
**Heroin**
* Derived from \_\_\_\_
* _\*\*\*Name for it?\*\*\*_
* Acetyl group facilitates what?
* Metabolized to what?
* Urine Drug Screen for Heroin can be positive for ___ and \_\_\_\_
* 3 contaminants?
* poppy
* Diacetylmorphine
* crossing BBB (blood brain barrier)
* Morphine
* UDS: Morphine & Codeine
* quinine, scopolamine, strychnine
40
**True or Pseudo opioid allergy?**
* IgE mediated
* T-cell mediated
* Bronchospasm
* Angioedema
True
41
**True or Pseudo opioid allergy?**
* histamine release from cutaneous mast cells
* non-immunologic effect
* _Sxs:_ itching, flushing, sweating
Pseudoallergy
42
**True or Pseudo opioid allergy?**
* Hives
* Tachycardia
* Hypotension
Pseudo, but are also seen w/ true
| (so both?)
43
Pseudoallergy depends on what?
the concentration of the opioid at the mast cell
* potency
* dose
* route of administration
44
**Choosing an Analgesic (A or B)?**
* Flushing, itching, hives, sweating, mild hypotension
A
45
**Choosing an Analgesic. (A or B)**
* Severe hypotension
* Rash
* Breathing, speaking, swallowing difficulties
* Swelling of face, lips, mouth, pharynx, or larynx
B
46
**A**
* Sxs due to:\_\_\_\_\_
* Result of histamine release
* Give the patient _____ (\_\_\_\_, \_\_\_\_)
* Avoidance of what 3 meds?
* What is the high potency drug least likley to release histamine?
* What is the lowest potency drug which would cause histamine release?
* If needed, concurrent administration of \_\_\_\_\_.
* pseudoallergy
* non-opioid analgesics (acetaminophen, NSAIDs)
* codeine, morphine, meperidine
* Fentanyl = highest
* Meperidine = lowest
* Antihistamine
47
**B**
* This pt may have experienced \_\_\_\_\_
* Give non-opioid: acet / NSAIDs
* Give an opioid in a different chemical class, ____ or \_\_\_\_
* a true allergy
* **Phenylpiperidines** (meperidine, fentanyl, sufentanil, remifentanil
* **Diphenylheptanes** (methadone, propoxyphene)
48
**What group?**
* Hydrocodone
* Oxycodone
* Nalbuphine
* Butorphanol
* Levorphanol
* Pentazocine
Morphine
