Witches and Wizards: Chronic Pain

Question 1

neuropathic pain

Answer 1

pain iniiated or caused by a primary lesion or dysfuncton in the nervous system

Question 2

nociceptive pain

Answer 2

pain causde by inury to body tissues

Question 3

musculoskeletal pain

Answer 3

pain caused y a lesion or disease of the musckuloskeletal system including muscles, ligaments, tedons, cartilaginous structures or oints

Question 4

T/F: physicians have an excellent udnerstanding of chronic pain

Answer 4

lol no

Question 5

PQRSTU of pain

Answer 5

• palliative/provocative: what causes and relieves it
• quality
• radiation
• severity
• temporal
• u: how are u affected

Question 6

why codeine not effectve in geriatrics

Answer 6

has to be converte to morphine in liver. old people have reduced hepatic conversion

Question 7

how should chroic pain meds be given

Answer 7

around the clock, routinely, NOT PRN

Question 8

adjuvant pain meds

Answer 8

• APAP
• NSAIDs
• duloxetine
• lidocaine

gabapentin and capsaicin too?

Question 9

treatement of neuropathic pain

Answer 9

• first line:
  
  • pregabalin, gabapentin
  • SNRI (duloxetine)
  • TCAs (caution in odler adults)
• second line: topical agents (lidocaine, capsaicin) - can consider these first line in geriatrics dt less CNS ADR

Question 10

APAP pros

Answer 10

• good for mild-moderate
• safe in geriatrics
• adjuctive
• starting point

Question 11

APAP cons

Answer 11

• hepatic failure
• can’t use with EtOH
• DDI with warfarin
• TDD is 4gm
• pt perception (APAP got a bad rep)
• failure to complete adequate trial (give it a week)

Question 12

NSAID pros

Answer 12

• good for mild-moderate
• musculoskeletal (inflammation, cancer)
• topical agent

Question 13

NSAID cons

Answer 13

• limit use to select pt when other therapeis have failed
• ceiling effect
• absolute CI: PUD, CKD, HF
• realative CI: HTN, H pylori, hx PUD
• GI risk
• CV risk (CHF, MI)
• renal risk
• coagualtioin
• DDI: asa

Question 14

steroid use in pain anagament

Answer 14

only for pts with inflammatory disorders or metastati bone pain

Question 15

opioids pro

Answer 15

• moderate-severe
• no ceiling dose
• multiple routes of admin
• long acting agens

Question 16

opioids con

Answer 16

ADR
- resp depresssion (toxicity: severe resp depression, apnea)
- lethargy/sedatoin (todxiity: decreased level of consciousness, unaraousbale)
- delirium, hallucinations
- ocular miosis (toxiity: pinpoint pupils)
- constipation
- n/v
- orthostasis
- urinary incontinence

Question 17

if using an opioid in geriatirc pt, whcih are preferred

Answer 17

• morphine
• hydrocodone
• oxy
• hydromorphone
• fentayl

Question 18

treatment of opiodi inducedd n/v

Answer 18

• haloperidol
• chlropromazine, prochlroperazine
• antihistamies (diphenydramine, hydroxyzine, meclizine)
• antichoinergics (scopolomine)
• ondansetron
• metaclopramide
• lorazepam

most have DA or ACh effect

Question 19

treatment of opioid inducedd constipation

Answer 19

• stool softner: docusate (not useful on own because the constipatio is dt gut being paralyed and something is needed to help push)
• stimulant: bisacodyl, senna
• osmotics: glycern suppository, lactulose, peg, sorbitol
• saline: mag citrate
• opioid antag: methylnaltrexone, naloxone
• lubricant: mineral oil

Question 20

opioid guidelines (approach to treatment)

Answer 20

1. non-pharm and non-opioid first
2. establish treatment goals
3. risk v benefit consideration and talk about this with pt
4. IR preferred for starting
5. start low, go slow
6. for acute, ds should be 3 (very rarely >7)
7. evaluate pts within 1-4 weeks of start (risk v benefit analysis again)
8. screen pt for risk fctors for opioid related harm
9. review pmp
10. annual drug screens in chronic users
11. big risk with conmittnat benzos use
12. if use dsiroder devleoped, get help @ 1-877-8-HOPE-NY