Chapter 26: Pain Management and Substance Use Disorder Treatment

300 practice flashcards reviewing pain pathways, opioid agonists, opioid agonist-antagonists, opioid antagonists, and antimigraine agents.

What is the clinical definition of pain presented in the lecture?

A sensory and emotional experience associated with actual or potential tissue damage.

Why is pain considered one of the most challenging clinical problems for patients?

It is one of the hardest sensations for patients to cope with.

Into what two primary categories is pain duration classified?

Acute or chronic.

Where in the body do pain-relieving drugs primarily work to alter pain impulses?

In the central nervous system (CNS).

What class of drug derivatives is broadly used to treat many types of pain?

Opium derivatives.

For what specific type of pain are antimigraine drugs reserved?

The treatment of migraine headaches.

Which nerve fibers transmit unpleasant pain stimuli from the initial injury site to the brain?

Nociception fibers, specifically A-delta and C fibers.

What physical sensations are transmitted by larger A fibers?

Sensations associated with pressure, stretch, and vibration.

What are the structural and conduction properties of C fibers?

They are small, unmyelinated, and slow conducting.

What are the structural and conduction properties of A-delta fibers?

They are small, myelinated fibers that transmit acute pain.

Where do spinothalamic tracts form synapses during pain transmission?

With various nerve cells that transmit information to the cerebral cortex.

According to Gate Control Theory, how is pain transmission modulated in the spinal cord?

Interneurons along the spinal cord act as 'gates' by blocking ascending transmission of pain impulses.

What two mechanisms can close spinal gates according to Gate Control Theory?

Stimulation of A fibers and descending impulses coming down the spinal cord from higher brain levels.

What diagram illustrates the neural pathways of pain, including nociceptors, spinothalamic tracts, and brain processing centers?

The Neural Pathways of Pain diagram depicting sensory input from skin receptors up through the medulla, thalamus, and cortex.

Where are opioid receptors located in the human body?

In the CNS, on nerves in the periphery, and on cells in the gastrointestinal (GI) tract.

Which endogenous neurochemicals normally modulate pain information entering the brain?

Endorphins and enkephalins.

Why is pain assessment described as subjective?

Because pain is an individual sensory and emotional experience evaluated through subjective patient reporting and pain scales.

What non-psychoactive portion of the cannabis plant relieves pain?

Cannabidiol (CBD).

Which portion of the cannabis plant possesses psychoactive, antiemetic, and analgesic properties?

Delta-9 tetrahydrocannabinol (THC).

What is the trade name of the FDA-approved purified CBD medication used to treat seizure disorders?

Epidiolex.

In which organ are both THC and CBD metabolized?

The liver.

What effect does co-administration of clarithromycin, itraconazole, or ritonavir have on cannabis levels?

It can increase cannabis levels.

What effect does co-administration of carbamazepine, phenobarbital, or rifampin have on cannabis levels?

It can decrease cannabis levels.

How do different opioid drugs vary in their clinical activity?

They vary based on the specific type of opioid receptors with which they react.

What three major CNS effects are produced by opioid administration?

Analgesia, sedation, or euphoria.

What legal and safety regulatory classification applies to opioids?

They are classified as controlled substances.

What text box provides clinical guidance on Focus on Opioid Use in Pediatrics?

Box 26.1.

When may opioids be used in the pediatric population?

When pain is severe enough to be refractory to nonopioid analgesics including NSAIDs and acetaminophen.

Which pediatric pain conditions commonly require at least short courses of opioid treatment?

Pain associated with surgical procedures, sickle cell disease, cancer, and trauma.

What principle should guide the dosage amount and duration of pediatric opioid prescriptions?

They should be prescribed for the duration and quantity expected for adequate treatment using the minimum amount to treat pain.

Why must the minimum effective opioid dose be used in pediatric patients?

To decrease the risk of abuse, misuse, and addiction.

What age group is specifically cited as experiencing occurrences of opioid-related overdoses?

Kids between 0 and 14 years of age.

What safety precaution should be encouraged to decrease accidental pediatric opioid overdose?

Keeping medications in a locked cabinet.

Why are codeine and tramadol NOT recommended for use in children younger than 12 years old?

Due to variable metabolism and medication exposure that has led to fatal overdoses.

Under what age is the safety of methadone NOT established?

Under the age of 18 years.

What is the drug of choice if a child older than 13 years requires an opioid agonist-antagonist?

Buprenorphine.

What is the drug of choice for reversal of opioid effects and opioid overdose in children and adolescents?

Naloxone.

What pediatric formulations are preferred for severe, chronic pain versus acute pain lasting a short time?

Longer-acting formulations for severe/chronic pain; shorter-acting agents for acute pain anticipated to last a short time.

What text box provides clinical guidelines on Focus on Opioid Use in Older Adults?

Box 26.2.

Why should older patients be specifically asked whether they would like pain medication?

Because they have higher incidences of chronic pain syndromes than younger adults.

What is the primary goal of pain treatment in older adults?

To decrease pain to enhance quality of life and functional ability.

What routine evaluations are indicated for older adults receiving opioid therapy?

Assessments of pain, functional status, kidney function, liver function, drug interactions, and adverse effects.

Why is starting with low opioid doses especially important in older adults?

Due to increased prevalence of kidney and liver impairment.

What particular risks are heightened with opioid use in older adults?

Increased risk of sedation, cognitive impairment, falls, fractures, and constipation.

What fall precautions should be instated when older adults are prescribed opioids in the hospital?

Side rails, call light, and assistance with ambulation.

What risks are associated with prescribing opioids to older adults after a hospital stay?

Higher risk of mortality and additional healthcare utilization.

Which three opioids should be avoided whenever possible in the older adult population?

Meperidine, tramadol, and codeine.

Why is tramadol particularly problematic in older adults?

It is problematic if taking another serotonergic medication and/or if the patient has kidney or liver impairment.

What drug combination increases mortality risk in older adults and should be avoided?

The combination use of opioids and benzodiazepines.

Which medication is recommended over methadone for acute and maintenance treatment of opioid use disorder in older adults?

Buprenorphine.

Why is methadone not as safe as buprenorphine in older adults?

Due to higher risks of respiratory depression and QT prolongation, long half-life, and multiple dangerous drug-drug interactions.

What controlled schedule category applies to most opioid agonists?

Schedule II (C-II).

What are the primary clinical indications for opioid agonists?

Relief of severe acute or chronic pain, analgesia during anesthesia, and specific indications based on receptor affinity.

What is the fastest administration route to achieve a therapeutic response with opioid agonists?

Intravenous (IV) route.

How are opioid agonists metabolized and excreted?

They undergo hepatic metabolism and are generally excreted in the urine and bile.

What absolute contraindications exist for opioid agonists?

Known allergy and diarrhea caused by toxins.

What boxed warning is associated with opioid agonists?

Risk of abuse, misuse, and addiction.

What GI condition serves as a contraindication for some opioid agonists?

Presence of GI obstruction.

Which underlying respiratory conditions require caution when prescribing opioid agonists?

Respiratory dysfunction, asthma, or emphysema.

Why are recent GI/GU surgery, acute abdomen, and IBD listed as cautions for opioid agonists?

Opioids reduce GI motility and tone, which can complicate surgical recovery, obscure diagnostic signs, or exacerbate inflammation/obstruction.

Why is head injury listed as a caution for opioid agonist therapy?

Opioids can increase intracranial pressure and obscure clinical signs of neurological deterioration.

Name three alcohol and cerebrovascular conditions requiring caution with opioid agonists.

Alcohol use disorder, delirium tremens, and cerebral vascular disease.

What major body system adverse effects are most common with opioid agonists?

Respiratory depression, orthostatic hypotension, GI effects, and neurologic effects.

What general drug classes interact adversely with opioid agonists to increase CNS depression?

Barbiturate general anesthetics, other CNS depressants, phenothiazines, and MAOIs.

Which specific medications and supplements interact with tapentadol?

SSRIs, MAOIs, TCAs, and St. John's wort.

What adverse interaction occurs when combining opioid agonists with anticholinergic agents?

Increased risk of severe urinary retention and severe constipation.

What adverse interaction occurs when combining opioid agonists with antihypertensive agents?

Increased risk of orthostatic hypotension.

Identify an indicated clinical reason why an opioid agonist may be prescribed from multiple choice Question #1.

Analgesia during anesthesia.

What is the mechanism of action of opioid agonists-antagonists?

They act as partial agonists at mu-opioid receptors and antagonists at kappa-opioid receptors in the CNS.

What CNS responses are produced by opioid agonists-antagonists?

Analgesia, sedation, euphoria, and hallucinations.

What are the primary indications for opioid agonists-antagonists?

Treatment of moderate to severe pain, and treatment of opioid use disorder.

How are opioid agonists-antagonists absorbed and eliminated?

Readily absorbed after IM administration; reach peak rapidly given IV; metabolized in liver and excreted in urine or feces.

What specific allergy is a contraindication for nalbuphine?

Allergy to sulfites.

What cardiac conditions require caution when using opioid agonists-antagonists?

Acute MI, documented CAD, or volatile BP.

What respiratory adverse effects are associated with opioid agonists-antagonists?

Respiratory depression with apnea and suppression of cough reflex.

What GI adverse effects can opioid agonists-antagonists produce?

Nausea, vomiting, constipation, and biliary spasm.

What neurological and psychiatric adverse effects can opioid agonists-antagonists cause?

Light-headedness, headache, dizziness, psychoses, anxiety, fear, hallucinations, and impaired mental processes.

How does the risk of physical dependence and sweating with opioid agonists-antagonists compare to opioid agonists?

Sweating and dependence are less likely than with opioid agonists.

What drug interaction occurs when giving an opioid agonist-antagonist to a patient with physical dependence on opioid agonists?

It can precipitate acute withdrawal symptoms.

What is the primary action of opioid antagonists?

They block opioid receptors and reverse the effects of opioids.

What are the indications for opioid antagonists?

Reversal of the adverse effects of opioid use and treatment of opioid overdose.

What is the most common adverse effect resulting from opioid antagonist administration?

Acute opioid abstinence syndrome.

What CNS effects commonly occur when reversing opioid analgesia postoperatively with an antagonist?

CNS excitement and reversal of analgesia.

What organ impairment risk is associated with naltrexone?

Naltrexone (Kloxxado, Narcan, and others) may cause liver impairment.

Why might larger doses of an opioid antagonist be required in certain toxicity cases?

To reverse the effects of buprenorphine, butorphanol, nalbuphine, or pentazocine.

Identify an indicated reason for prescribing an opioid antagonist from multiple choice Question #2.

Treatment of opioid overdose.

What cranial nerve activation causes meningeal blood vessel inflammation in migraine headaches?

Activation of the trigeminal nerve.

What are the characteristic pain location and quality of migraine headaches?

Severe, throbbing headaches on one side of the head.

How much more frequently do migraines occur in females compared to males?

Three times more likely to occur in females.

What distinguishes a common migraine from a classic migraine?

Common migraines have no aura, while classic migraines usually present with an aura.

What box details Focus on Migraine Treatments in Pediatrics?

Box 26.5.

What are the three core components of best pediatric migraine management?

Lifestyle measures, acute treatment, and preventative treatment.

List the first-line preventative medication classes and drugs used for pediatric migraines.

Beta-blocker (propranolol), TCA (amitriptyline), antihistamine (cyproheptadine), and antiseizure medications (topiramate and valproic acid).

Are CGRP antagonists approved for pediatric use under age 18?

No, CGRP antagonists are not approved for use in those younger than 18 years.

What are the first-line treatments for acute migraine management in children?

Nonopioid analgesics acetaminophen and NSAIDs.

At what age may triptans be used in children if migraines are refractory to first-line agents?

In children at least 6 years old.

What text box outlines Focus on Migraine Treatments in Older Adults?

Box 26.6.

At what age does migraine prevalence typically begin to decline?

After age 39 years.

Why are NSAIDs problematic for acute migraine treatment in older adults?

Older adults may have contraindications due to comorbidities and higher risk of GI bleeding.

Why are ergot and triptan drugs risky in older adults with chronic conditions?

They cause vasoconstriction that can exacerbate CV disease, kidney impairment, or liver impairment.