T2 EX4 L14 (PAIN MGMT) (ROB)

Largest diameter afferent fiber?

A-beta fiber (AB)

Afferent fiber which responds to intense painful stimuli resulting in the perception of pain?

A-delta fiber

Unmyelinated afferent fiber?

C fiber

A-delta fibers are associated with...

A. More localized, sharp pain

B. Poorly localized, achy, dull pain

A. More localized, sharp pain

C fibers are associated with...

A. More localized, sharp pain

B. Poorly localized, achy, dull pain

B. Poorly localized, achy, dull pain

Two subtypes of nociceptive pain?

Somatic

Visceral

3 characteristics of somatic nociceptive pain?

Localized

Dull, achy, sharp

Examples; arthritis, trauma, fracture, surgical incision, musculoskeletal pain

3 characteristics of visceral nociceptive pain?

Not well localized

Diffuse, cramping, squeezing, pressure

Examples: gastritis, pancreatitis, appendicitis, kidney stones, menstrual cramps

3 characteristics of neuropathic pain?

Tingling, stabbing, pins & needles, burning, numbness

Dysfunction/damage of the CNS or PNS

Examples: diabetic neuropathy, postherpetic neuralgia, fibromyalgia

What is a unidimensional pain scale

Fr just like a 1-10 scale

What is a multidimensional pain scale

Its like 1-10 but intensity, location, quality, functional impact included

"Red flag" pain symptom examples? (gimme a few)

Chest pain

SOB

Pain w exertion

Pain in pregnancy

Sudden onset of severe pain

Dizziness, visual changes, fever, etc

Non-pharm pain management options? (gimme a few)

Chiropractic care

Muscle relaxation techniques

Heat, ice

Music therapy?

Acupuncture

Nutrition

Meditation

T/F: Dietary intake and obesity are a significant factor in chronic pain.

True

Goal of pain management

Pain management buddy lock in

Acetaminophen dosing in a frail patient?

3,000 mg /24 hours

Pediatric dosing for acetaminophen? (weight based)

10-15 mg/kg/dose q4-6h

Max 5 doses/24 hours OR 75 mg/kg/day

Acetaminophen weight based dosing for adults?

When body weight <50 kg

Weight based 10-15 mg/kg/dose, 5 doses/24 hours

Ibuprofen adult dosing?

200-800 mg q4-6h

Ibuprofen pediatric dosing? (weight based)

10 mg/kg/dose q6-8h

Maximum ibuprofen dose/day for adults?

3200 mg/day

Maximum ibuprofen dose/day for pediatrics?

40 mg/kg/day or 2400 mg/day, whichever is less

T/F: Avoid concurrent use of corticosteroids + NSAIDs.

True

Common amide local anesthetics?

Lidocaine

Ropivacaine

Bupivacaine

Prilocaine

Common ester local anesthetics?

Cocaine

Tetracaine

Procaine

Benzocaine

Adverse effects associated with local anesthetics? (nine)

1. Bradycardia

2. Hypotension

3. Dizziness

4. Seizure

5. Tremor

6. Vomiting

7. Tinnitus

8. Methemoglobin

9. Tongue/perioral numbness

T/F: Patients can have an amide or ester allergy and still tolerate a drug from the opposite class.

True

Treatment for local anesthetic overdose?

IV lipid emulsion 20%

Adverse effects associated with SNRIs? (five)

1. Weight loss

2. N/V, abdominal pain, constipation/diarrhea

3. Increase in blood pressure

4. Hyponatremia

5. Sedation/insomnia

Monitor what in SNRI therapy? (four)

Liver dysfunction

Suicidal ideations

Blood pressure

Sodium levels

T/F: Slowly discontinue SNRI to avoid withdrawal syndrome.

True

About how long does it take to see the benefit of SNRI therapy for pain?

2-4 weeks

About how long does it take to see the benefit of TCA therapy for pain?

2-4 weeks

Adverse effects associated with TCAs? (four)

1. Anticholinergic side effects

2. QTc prolongation

3. Orthostatic hypotension

4. Hyponatremia

Monitor what during TCA therapy?

EKG - QTc, arrhythmias

Suicidal ideations

Liver function

Sodium levels

T/F: TCAs should be used with caution in those with history of seizure disorder.

True

MOA of TCAs?

Inhibition of serotonin and norepinephrine reuptake

__________ amines have more sedating and more anticholinergic effects

A. Secondary

B. Tertiary

B. Tertiary

MOA of gabapentinoids

Modulation of calcium influx at voltage gated Ca channels in the CNS inhibiting excitatory neurotransmitter release

Adverse effects associated with gabapentinoids? (very many)

Dizziness, drowsiness, fatigue

Abnormal gait, confusion, lethargy

Vasodilation

Peripheral edema

Blurred vision

Usual dosing for lyrica?

75 mg BID titrated to effect

Usual dosing for gabapentin?

100-300 mg TID titrated to effect

Medications used to treat spasticity? (four)

1. Baclofen

2. Tizanidine

3. Dantrolene

4. Diazepam

Medications used to treat spasms? (eight)

1. Cyclobenzaprine

2. Carisoprodol

3. Chlorzoxazone

4. Methocarbamol

5. Metaxalone

6. Orphenadrine

7. Tizanidine

8. Diazepam

Side effects associated with muscle relaxants and spasmolytics? (three)

1. Xerostomia

2. Dizziness, drowsiness, confusion

3. Nause/constipation/diarrhea

T/F: For treatment of spasticity/spasms, non-benzodiazepine medications are preferred over benzodiazepines.

True

Usual dosing for methocarbamol?

1,000 mg TID

Usual dosing for metaxalone?

400-800 mg TID

Usual dosing for carisoprodol?

250-350 mg TID

Usual dosing for orphenadrine? (PO and IV/IM)

100 mg BID PO

60 mg BID IV/IM

Usual dosing for chlorzoxazone?

250-500 mg TID

For which of the following anti-spasmodic agent(s) should we consider lower initial PO doses in ESRD and advanced hepatic disease & titrate with caution? (select all that apply)

A. Orphenadrine

B. Carisoprodol

C. Metaxalone

D. Diazepam

E. Cyclobenzaprine

B. Carisoprodol

D. Diazepam

E. Cyclobenzaprine

MOA of ketamine?

NMDA receptor antagonist

Adverse effects associated with ketamine? (three)

1. Decreased/increased heart rate & blood pressure

2. Hallucinations, dreamlike state, delirium

3. Respiratory depression

How do we treat dissociative reactions associated with ketamine therapy?

With benzodiazepines

T/F: Ketamine safe in pregnancy.

True

Opioid analgesics are indicated for the treatment of...

Moderate to severe pain not tolerable after non-opioid analgesics have been optimized

T/F: ER opioid analgesics should not be used PRN, they should instead be given on a scheduled basis.

True

Initial dosing for fentanyl?

25-50 mcg q1-3 hours PRN

T/F: Morphine requires renal adjustment.

True

In CrCl 15-50 mL/min, how do we dose/adjust morphine?

50% of original dose

In patients with a CrCl <15 mL/min or on dialysis, how do we approach morphine dosing?

Not recommended

T/F: Methadone associated with QTc prolongation.

True

T/F: Methadone should NOT be used PRN, all doses should be scheduled.

True

Define paresthesia

An abnormal sensation, whether spontaneous or evoked (not unpleasant)

Define dyesthesia

An abnormal sensation, whether spontaneous or evoked

Always unpleasant

Define hyperalgesia

Increased pain from a stimulus that normal provokes pain

Define allodynia

Pain following a stimulus that does not normally provoke pain

Pathophys behind opioid induced constipation? (OIC)

GI effects via kappa receptor in the stomach and small intestine and mu receptors in the small intestine and proximal colon

First-line therapy for opioids-induced constipation (OIC)?

Laxatives

We like PEG for an osmotic, BISACODYL or SENNA for stimulants

Treatment options for laxative-refractory OIC? (three)

1. Peripherally acting mu-opioid receptor antagonists (PAMORAs); naldemedine, naloxegol, methylnaltrexone

2. Intestinal secretagogues; lubiprostone

3. Selective 5-HT agonists; prucalopride

First-line treatment for pain management?

Non-pharm

Physical modalities, CBT, spiritual care, anti-inflammatory diet, etc

First-line therapy for acute sickle cell crisis?

Opioids, with consideration given to baseline opioid use

Focus points of enhanced recovery after surgery (ERAS)? (five)

1. Pre-op lifestyle changes (smoking cessation, weight loss, BG regulation, etc)

2. Pre-op education

3. Multimodal analgesic therapy

4. Early catheter removal

5. Early mobilization

Goals of ERAS? (three)

1. Improved surgical outcomes

2. Decreased complications

3. Decreased length of stay

What drugs can be dosed via patient controlled analgesia (PCA)?

Morphine

Hydromorphone

Fentanyl

Patients with chronic pain may experience... (five)

1. Reduction in quality of life and physical function

2. Psychological changes (anxiety, depression, poor emotional function)

3. Sleep disturbances

4. Impaired interpersonal relationships

5. Changes in employment status

When considering comorbidities to make therapeutic selections for patients with chronic pain, what do we look for? (four)

Osteoarthritis (add NSAIDs, SNRI)

Fibromyalgia (add SNRI, gabapentinoid, TCA, cyclobenzaprine)

Lower back pain (Nerve ablation, NSAIDs, duloxetine)

Neuropathic pain (add gabapentinoid, SNRI, TCA, lidocaine topical)

When are opioids considered for chronic pain?

Considered only with failure or contraindications to non-pharmacologic and non-opioids

1st line pharmacotherapy for pregnant patients?

1st line = acetaminophen

NSAIDs okay per FDA at 20 weeks or later

T/F: NSAIDs safe with lactation

True

T/F: Opioids last-line but okay in lactation.

True

T/F: Opioids okay but last-line in pregnancy.

True