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36 Cards in this Set
- Front
- Back
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Describe the different types of pain
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Acute - surgery or trauma
Chronic - associated with malignant disease (cancer, aids, ms, als etc) Chronic pain not associated with malignant disease (headache, nerve injury, fibromyalgia, myofascial pain) |
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We also classify pain by pathophysiology - differentiate nociceptive (somatic, visceral)
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Somatic - tissue damage, well localized
Visceral - poorly localized, dul aching (intense autonomic activity - sweating, tachycardia) |
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and neuropathic pain
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damage to the nerve either in periphery or central nervous system (burning, electric shock)
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Physiologic effects of pain
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Increased catabolic demands
increased risk of thromboembolic event Respiratory effects Increased sodium/water retention Decreased GI motility Tachycardia, increased BP Decreased immune response |
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Disadvantages of NSAIDs
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Risk of adverse effects (GI bleed, nephrotic syndrome)
Avoid in elderly patients In advanced OA, inflammatory component no longer present |
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Muscle relaxants MOA
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Primarily work by sedating the CNS - they don't target a specific muscle group
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Advantages of muscle relaxants
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Useful in acute musculoskeletal pain
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Disadvantages of muscle relaxants
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Not useful for chronic pain (tolerance develops)
Many require monitoring liver function (avoid in liver dysfunction) Drowsiness Lack of quality evidence |
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What is the exception to the rule of tolerance with muscle relaxants?
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baclofen
tizanidine ***work at spinal cord level - often indicated in spinal cord injurys, ms*** |
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List of muscle relaxants
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Baclofen
Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxolone Methocarbamol Orphenadrine Tizanidine Benzodiazepines |
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Glucosamine and Chondroitin
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Some patients report benefit
Avoid in severe shellfish allergy Increases anticoagulant effect No product regulation Expensive |
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Lidocaine 5% patch
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Applied for 12 hours then removed
Can be cut to shape area Localized effect First line treatment for postherpetic neuralgia Limited area, expensive |
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Interference with transmission to CNS (adjuvant analgesics) - indicated for other things than analgesia but can be used for some types
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Antidepressants
Anticonvulsants Capsaicin cream |
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Anti-depressants (advantages)
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Treat co-morbid depression
First line treatment of neuropathic pain Once daily dosing, inexpensive |
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Anti-depressants (disadvantages)
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Tricyclics (first line neuropathic pain) - drowsiness, cause QT prolongation (avoid in arrhythmias/other meds that prolong QT)
SNRIs (increase BP, insomnia) Lower seizure threshold Serotonin syndrome ***SSRIs have not been shown to be effective for pain*** |
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Anticonvulsants (advantages)
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Tolerance to adverse effects
Second line for neuropathic pain |
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Anticonvulsants (disadvantages)
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Cognitive effects
Expensive Multiple daily dosing Most require liver function monitoring Gabapentin cleared renally (exception) |
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Capsaicin cream MOA
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Depletes substance P - needed for transmission of pain message
Requires repeated transmission over 2 weeks to see effect |
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What classes of pain medication alter pain perception in the brain?
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Acetaminophen
Tramadol Weak opioids (codeine, hydrocodone, combination products) Strong opioids (Morphine, hydromorphone, oxycodone, fentanyl, methadone, buprenorphine) |
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Acetaminophen maximum dosing
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Most widely used agent in the world
Max dose 4 g/day, 325 mg limit per tablet McNeil (makers of Tylenol) action July 2011 Extra strength OTC product max dose 3 g/day If a physician is prescribing for OA you can safely dose up to 4 grams |
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Acetaminophen (advantages)
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First line for OA
Good adverse effect profile |
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Acetaminophen (disadvantages)
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Decrease dose by 25-50% in elderly
Present in many combo products |
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Tramadol MOA
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Primary: serotonin reuptake inhibition
Secondary: mu opioid receptor agonist Withdrawal can occur from upregulation of both receptors - taper if used regularly |
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Tramadol indication
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Moderate-Moderately severe pain
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Tramadol precautions
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Hepatic and Renal impairment
History of seizures History of opioid addiction or dependence |
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Mu receptor actions
Delta receptor actions Kappa receptor actions |
Analgesia, Respiratory depression
Analgesia Analgesia, Dysphoria and psychomimetic effects |
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Opioid classifications
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Full agonist
Partial agonist Mixed agonist-antagonist - different activity at different receptors Antagonist |
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What is dependence?
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A physiologic phenomenon
Nearly universal for patient receiving opioids for 7-10 days - Need to be tapered or withdrawal will occur |
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Tolerance?
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Physiologic phenomenon
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Addiction?
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Psychologic phenomenon
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Types of opioid tolerance
Analgesia |
May occur in first days to weeks - Rare after pain relief achieved with consistent dosing without increasing or new pathology
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Respiratory depression/sedation
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Occurs 5-7 days after consistent opioid administration
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Cognitive impairment, urinary retention, itching
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Occurs 7-14 days after consistent opioid administration
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Constipation
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Tolerance does not occur - scheduled stool softeners and stimulant laxatives needed with regularly scheduled opioids
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What is REMS?
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Risk Evaluation and Mitigation Strategy (REMS)
FDA-mandated requirements to minimize the risks associated with certain medications Can be mandated for any medication or class |
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Components of REMS
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- Medication guide or patient package insert
- Communication plan (letters to providers, professional education etc.) - Elements to assure safe use (special requirements or restrictions) - Implementation system (monitor, evaluate, and improve elements) - Timetable for assessment |
