Shared Flashcard Set

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PT 3 - Final
Pain Management
42
Pharmacology
Graduate
12/11/2009

Additional Pharmacology Flashcards

 


 

Cards

Term
What is the difference between acute and chronic pain?
Definition

Acute - identified event, resolves in days/weeks

Chronic - Cause often not easily identified, multifactorial; indeterminate duration; nociceptive and/or neuropathic 

Term
What is nociceptive pain?
Definition

- Direct stimulation of intact nociceptors, transmits along normal nerves

- Described as sharpe, aching, throbbin, somatic is easy to localize while visceral isn't

- In this, tissue injury is apparent, and we will manage it with opiods and adjuvant/coanalgesics

Term
What is neuropathic pain?
Definition

- From disordered peripheral or central nerves

- Comes from compression, transection, infiltration, ischemia, or metabolic injury

- Varied Types:  Peripheral, deafferentation, complex regional syndromes

- Pain may exceed observable injury

- Burning, tingling, shooting, stabbing, or electrical like pain

- Management with opiods and/or adjuvant/coanalgesics

Term
What are some interventional means of neuropathic pain management?
Definition

- Neuronal blockade (sympathetic nerve blocks)

- Neurostimulatory techniques (spinal cord stimulation)

- Intraspinal infusion

Term
What aer some pharmacologic therapies for neuropathic pain?
Definition

- Gabapentin, Carbamazepine, lamotrigine, and new AED's

- Antidepressants

- Opioid analgesics

- Lidocaine (Transdermal, IV, mexiletine)

- Alpha-2 adrenergic agonists

Term
What are examples of different pain rating scales?
Definition

- Visual Analog Scale

- Graphic rating scale (verbal,numerical)

- Numerical Rating Scale (initiate therapy at 3/4)

- Wong-Baker (literally cartoon faces)

- Color (blue is no pain, red is extreme pain)

- Simple Descriptive pain intensity scale (No pain, mild, discomfort, distresssing, horrible, excruciating)

- FLACC (Face, legs, activity, cry, consolability, useful in non-verbal patients, describes behavior in response to pain)

Term
What are some nonverbal signs of acute pain?
Definition

 

Diaphoresis
Decreased food digestion
Tachycardia
Hypertension
Mydriasis
Hormone release
Term
What are some nonverbal signs of chronic pain?
Definition

 

Aggressive behavior
Changes in daily activities
Facial expression
Bodily movements
Vocal
Mood
Change in vital signs
Term
What are the general guidelines for treating chronic pain?
Definition

- Easier to prevent than relieve

- Keep pain diary

- Dose meds around the clock

- Long acting for continuous pain, intermediate for breakthrough pain (look for end of dose failure, incident prophylaxis)

- Dose sliding scales and freq. ranges

Term
What are medications for mild pain?
Definition

- APAP

- NSAIDS

- ASA

- Adjuvants

Term
What are medications for moderate pain?
Definition

APAP with......

- Codeine

- Hydrocodone

- Oxycodone

- Dihydrocodeine

 

 

- Tramadol

- +/- adjuvants

Term
What are medications for severe pain?
Definition

- Morphine

- Hydromorphone

- Methadone

- Levorphanol

- Fentanyl

- Oxycodone

- +/- adjuvants

Term
What two drugs are best for muscoskeletal pain?
Definition

- APAP and ASA

- Both 325-650 q4-6h or 1000mg tid or qid

- Max dose of 4000mg

- Apap drug of choice, potential liver toxicity

- ASA ADR's could be bleeding, ulcers, stomach upset, tinnitus, intx

Term
What is significant regarding NSAIDS?
Definition

- inflammatory disease use or unresponsive APAP therapy

- OTC

- Ceiling effect (wtf is this?)

- Avoid in high risk patients such as elderly and those with heart/renal problems

- Cox 1 inhibition: bleeding, GI, kidney, liver problems

- Cox 2 inhibition:  Decreases inflammation, pain, fever

- Celexicob has same efficacy but less bleeding, ulcers,similar renal effects

Term
What is significant regarding Ultram?
Definition

- Moderate-severe pain

- Duel mechanism with mu-opioid receptor and then NE and 5-HT reuptake

- Usual dose = 50-100 q4-6h

- Onset is 60 minutes

- Also available with APAP

- ADR's include n/v, dizziness, CNS stimulation, constipation, potential for seizures

Term
 Classify the opiod analgesics by their chemical class
Definition
  • Phenanthrenes
  • Morphine
  • Codeine
  • Hydromorphone *
  • Levorphanol *
  • Oxycodone *
  • Oxymorphone *
  • Buprenorphine *
  • Nalbuphine
  • Butrorphanol *
  •  
  • Benzomorphans
  • Pentazocine
  • Phenylpiperidines
  • Meperidine
  • Fentanyl
  • Alfentanyl
  • Sufentanyl
  • Diphenylheptanes
  • Methadone
  • Propoxyphene
Term
What are the benefits of opiods?
Definition

- No ceiling effect

- Titratable

- No irreversible or life-threatening end-organ problems

- Wide variety of formulations,strengths, dosage forms

- Titrate q1-2 days, either by 25%, 25-50%, or 50-100% depending on mild, moderate, or unrelieved severe pain, respectively

- Increase dose when B/T medication used > 3 times/24 hours for 2-3 days

 

Term
What are the Pharmakokinetics of opioids?
Definition

- Conjugated in liver

- Excreted via kidney (90-95%)

- First-order kinetics

- Cmax after 1 hours, 30 minutes, or 6 minutes depending on dosage form

- Half-life at steady state is 3-4 hours

- steady state after 4-5 half-lives or 24 hours

- Duration of effect 3-5 hours with immediate release formulas

- If renal problems decreasing dose or interval (urine problems indicative of this)

Bolus effect: drowsiness 30-60 min. after admin., pain before next dose due, must change up release formula.

- When changing from oral to invasive form, use roughly 1/3 of dose (sig. first pass effect)

 

Term
What are the general rules for figuring out doses when switching up opioids and dosage forms?
Definition

- If going from Morphine to Dilaudid divide dose by 4

- If Morphine PO to more invasive form divide by 3

- If Dilaudid PO to more invasive divide by 5

 

- Could be cross tolerance, so start with 50-75% of equianalgesic dose

- For methadone, start with 10-25% of published equianalgesic dose

- For immediate/intermediate release, tapering is the same as stated before

- For extended release, never chew, may put down feeding tubes, dose q8, 12, or 24h and reassess every 2-4 days when SS is reached

- Methadone adjustment is variable, could be q6-8h, adjust every 4-7 days

Term
What should you use for opioid breakthrough pain doses?
Definition

- Increase breakthrough dose as ATC dose is increased

 - For PO it is 10-20% of total daily dose q1h

- Parenteral = 50-100% of hourly rate q15 (minutes or hours?)

Term
What are  the cross-sensitivity likelihoods for the different opioid classes, and what KIND of opioid are they?
Definition

 

Phenanthrenes
Morphine – N M
Codeine – N M
HydromorphoneSS * M
Levorphanol - SS * M
Oxycodone - SS * M
OxymorphoneSS * M
Buprenorphine - SS * M
NalbuphineSS M
ButorphanolS * M
 
Benzomorphans
PentazocineS M
Phenylpiperidines
MeperidineS D
FentanylS M
AlfentanylS M
SufentanylS D
Diphenylheptanes
Methadone – S U
PropoxypheneS M
 
Likelihood of X-sensitivity
Phenanthrenes – probable
Benzomorphans – possible
Phenylpiperidines – low risk
Diphenylheptanes – low risk
Term
What are the starting doses for PO Morphine, Oxycodone, and Hydromorphone in a patient with severe pain?  How would you titrate this therapy?
Definition

Morphine - 10-15mg

 

Oxycodone - 5-10mg

 

Hydromorphone (Dilaudid) - 2-4mg

 

*If titrated properly, there is no ceiling dose for these opioids

 

Repeat dose or titrate upwards by 50-100% q1-2 hours until adequate analgesia is met ( >50% reduction in pain) or side effects are encountered

Term
What are the sustained release oral opioids available, their starting doses, and how would we titrate using these therapies?
Definition

Available:  Morphine in the form of MS Contin, Oramorph SR, Kadian - starting dose 20-30mg po q12h

 

Oxycodone in the form of Oxycontin - starting dose 20mg q12h

 

Steady state reached by 24 hours

 

Can be titrated every 24 hours for unrelieved pain.  For moderate increase by 25-50% q24h, for severe do 50-100% q24h

Term
What is significant regarding the Fentanyl patch?
Definition

- No analgesic effect for 12-24h

- Steady state only after 72 hours - therefore replace or increment q72 hours

- Do NOT use for initial dose titration

- Fentanyl levels decay w/ half-life of 17 hours after removal of patch

- Need "breakthrough" medication

- One 25 microgram/hr patch = 60mg of morphine a day

Term
What exactly is "breakthrough" pain?
Definition

- Idiopathic/Spontaneous

- Disease progression

- Incident

- End-of-dose failure

Term
Drug Profile:  Hydrocodone
Definition

- Mild to moderate pain

- Only available in combo

- Onset of actoin 10-20 minutes

- Duration = 3-6 hours

- Dose is 1-2 q4-6h

- Dose is limited by APAP

- Better accepted than codeine

Term
Drug Profile:  Codeine
Definition

- Mild to moderate pain

- Metabolized into morphine by the body

- Often combined with APAP

- 60 mg of Codeine = 600mg of aspirin

- Usualy dose = 15-60mg q4-6h

- APAP limits overall dose

- ADR's include drowsiness and constipation

- Smoking DECREASES effectiveness

Term
Drug Profile: Propoxyphene
Definition

- Mild to moderate pain

- Often combined with APAP or ASA

- Dose is 100mg q4h

- MDD = 600mg

- Active metabolite is Norpropoxyphene, causes pulmonary edema and cardiotoxicity

Term

Drug Profile: Morphine

 

Definition

- Oral, rectal, parental formulations

- LA and immediate release

- Onset = 15-60 minutes

- Duration is 4-6h or 8-12h

- Two main metabolites, M3G and M6G (active)

- Caution in renal impairment

Term
Drug Profile:  Oxycodone
Definition

- In combo with APAP or ASA for mild-moderate pain

- Long and short acting oral formulations

- Onset = 10-15 minutes

- Duration = 4-6h

Term
Drug Profile:  Fentanyl
Definition

- Oral, parenteral, and transdermal formulations

- Transdermal patch for stable, chronic pain

- Opioid naive should start with 25mcg/hr

- Can use multiple patches at once

- Need to rotate sites

- Make take about 16 hours for analgesia to set in

- Difficult to adjust dose/convert from another opioid

- Absorption increases with heat

Term
Drug Profile:  Hydromorphone
Definition

- Oral, parenteral, rectal formulations

- No LA formula

- Oral

- Onset = 15-30 minutes

- Duration = 4-6 hours

- More potent than morphine

Term
Drug Profile:  Methadone
Definition

- Oral, rectal, parenteral dosage forms

- Onset = 30-60 minutes

- Duration = 4-6h (for acute) / >8h for chronic

- Half-life is long and variable (12 to 190 hours)

- Low abuse potential

- Stigma

- Multiple conversion methods

Term
What is good about combining therapies?
Definition

AMDA (American Medical Directors Association) and AGS (American Geriatric Society) have stated that combining low doses of different analgesics may produce pain relief with a lower incidence of side effects (synergistic effect)

 

Term
There are many adjuvants available for different kinds of pain, what adjuvants are available for peripheral neuropathies?
Definition

- Burning, pins and needles type pain

- Use Tricyclics:  Amitriptyline, Nortriptyline, Imipramine, Desipramine, Doxepin, or Venlafaxine

Term
There are many adjuvants available for different kinds of pain, what adjuvants are available for refractory pain?
Definition

- Antiarrhythmics

- Use Lidocaine, Mexilitine

Term
There are many adjuvants available for different kinds of pain, what adjuvants are available for lancinating, shooting, stabbing, burning?
Definition

- Use anticonvulsants, antihypertensives, or topicals

Drugs:  Gabapentin, Carbamazepine, Valproate, Clonidine, Capsaicin

Term
There are many adjuvants available for different kinds of pain, what adjuvants are available for Bone Pain?
Definition

- Dull and aching feeling

- Use:  NSAIDS, Bisphosphonates, Steroids, Calcitonin

Term
There are many adjuvants available for different kinds of pain, what adjuvants are available for muscle spasms?
Definition

For Muscle Spasms use: 

 - Baclofen

- Carisoprodol

- Methocarbamol

- Orphenadrine

Term
How would you best manage opioid-related side effects?
Definition

- ATC opioids call for ATC laxatives (stimulants preferred)

- Patients do not develop tolerance for this

- For N/V eat and drink slowly, avoid irritating/fatty foods, sit upright, oral hygiene freq., treat with phenothiazines, metoclopramide, haloperidol, dexamethasone, lorazepam

- For diarrhea, perform good personal hygiene, avoid high reside foods like raisin bran, avoid food temp. extremes, avoid caffeine and replenish fluids.

- For sedation, use stimulants, reduce dose, patients not in pain sleep longer (FYI)

- Anaphylactic rxns common

- Urticaria and Pruritus due to mass cell destabilization, treat with 2nd gen. antihistamines

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