Acute pain management

Define pain

unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Pain is often (objective/subjective)?

subjective

What type of pain is protective, physiological, when your body is physically hurt

nocicpetive

what are the two subtypes of nocic[etive pain

1. somatic 

2. visceral 

what is somatic pain

arises from skin, bone, joint, muscle, or connective tissue (well localized)

what is visceral pain

arises from internal organs (pain from other structures)

acute pain is normally _____

nociceptive

what is a characteristic seen in chronic pain more so acute

dependence/tolerance 

what is a characteristic in acute pain that is not so much seen in chronic

organic cause 

A in the ABCDEs of pain management

Assess pain systematically

B in ABCDE

baseline medication utilization

C in ABCDE

choose most appropriate medication

D in ABCDE

determine adjuncts or supportive care as well as follow up monitoring plans

E in ABCDE

educate the patient

what is essential in clinical presentation

comprehensive patient hx and physical exam

what is the best clinical presentation tool

patient report

what is the P in PQRST assessment tool

provokes/palliates 

what is the Q in QRST

quality

what is the R in QRST

radiation/region

what is the S in QRST

severity

what is the T in QRST

temporal factors

common assessment used in practice to determine pain severity

visual analog scales and critical care pain observation tool

(VAS)(CPOT)

what is the primary goal in treating acute pain

rapid pain relief or reduction in intensity of pain 

key point to remember when utilizing pharm therapy

most effective with fewest side effects

Which pharm therapy is recommended for mild-moderate pain

NSAIDS or APAP

which pharm tx is most recommended for moderate-severe pain

opioids

which route of administration is most preferred

oral (onset of analgesia ~45min)

if immediate relief is needed what route is the go to

parenteral

ATC or PRN is recommended

ATC

It is easier to _____ pain than to treat once it occurs

prevent

Use of PRN dosing has what issues`

• negative connotations

• wide swings in drug concentrations 

• may require escalating doses to relieve pain, which may lead to more side effects

True or false: APAP has anti-inflammatory properties

false

usual dose of APAP

325-1000mg every 4-6 hours

max dose of APAP

4g/day

APAP max dose in patients with hepatic dysfunction, alcohol use or poor nutritional intake

2g/day

major ADR of APAP

hepatotoxicity

Ofirmev is

IV APAP

True or false: Ofirmev had clinically meaningful reduction in opioid induced ADR

false

what property do NSAIDs have that APAP does not have

anti-inflammatory

Higher doses of NSAIDs are typically required for what property

anti-inflammatory

most common NSAIDs for acute pain

“Nik”

naproxen, ibuprofen, ketorlac

dose of Ibuprofen

200-800mg every 4-6 hours

max dose of ibuprofen

3200mg/day

dose for naproxen

varies by product

275-550mg every 6-12 hours

max dose of naproxen

1100mg/day

routes of administration available for ketorlac

IV/IM (oral not as common)

ketorlac dose IV

15-30mg every 6 hours

ketorlac dose IM

up to 60mg every 6 hours

max dose of ketorlac

60-120mg/day

which NSAID has a max 5 day use and why

ketorlac because increased risk of GI bleed

which NSAID do you use lower dose based on age, Scr, weight

ketorlac

risk factors for GI bleed

• prior bleed

• GI ulcer

• corticosteroid use

• anticoagulants

• chronic NSAID use

• smoking

• H.pylori

• alcoholism

• older age

What is the relative risk of GI bleeds of NSAIDs

ibuprofen<ASA<naproxen<ketorlac

what medication may be considered in those with hx of gastric ulcers taking NSAIDs

PPI

major counseling point with NSADIs

take with food or milk

NSAIDs (increase/decrease) platelet aggregation

decrease

how do NSAIDs affect GFR

decrease it

risk factors for renal ADR in patients taking NSAIDs

chronic/dual NSAID use, dehydration, CHF, hepatic disease, concomitant ACEi use

why is there such variability in opioids with efficacy and side effects

mu receptor subtype variability

true or false: pain can always be eliminated

false; unpleasantness decreases

increased _____ of opioids may ____ side effects

increase, increase

main ADR of opioids

constipation, N/V, sedation, pruritis/rash, urinary retention, respiratory depression

only side effect where tolerance does NOT develop

constipation

respiratory depression is less pronounced in which patients 

severe/chronic pain 

the respiratory center is less responsive to ____ causing depression

carbon dioxide

what is also depressed in relation to respiratory depression

cough

how does respiratory depression manifest

decreased respiratory rate

what are 2 opioids that have the most histamine release

meperidine and morphine

naturally occurring opioid

moprhine

this opioid is the gold standard for severe pain

morphine

this opioid has a similar pharm profile to morphine with fewer side effects

hydromorphonew

which opioid can be used in renal impairment

hydromorphone

Fentanyl

which opioids do not release histamine

hydrocodone

which opioid is only available as combination product

hydrocodone

which opioid is the most potent, more lipophilic, and shorter acting

fentanyl

Step 1 recommendations for mild pain

non-opioid ± adjuvant

step 2 recommendation for mild to moderate pain

opioid + non-opioid ± adjuvant

step 3 recommendation for moderate to severe pain

opioid + non-opioid and/or adjuvant

adjuvants can be used for

neuropathic pain or bone pain

mild to moderate opioid choices

combination products, codeine, tramadol (non-opioid)