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Pain Management Overview
Dr. Rotella's presentation
42
Pharmacology
Graduate
01/22/2012

Additional Pharmacology Flashcards

 


 

Cards

Term

 

 

 

Definition of Pain

Definition

 

 

unpleasant sensory and emotional experience arising from actual or anticipated tissue damage, or described in terms of such damage (not purely physical)

Term

 

 

Morbidity of Pain

Definition

1. Decreased activity

increased risk of DVT, pulmonary compromise (pneumonia and atelectasis), deconditioning (loss of exercise tolerance), disruption of work and social life

 

2. Disordered mood

depression, anxiety, irritability, and increased risk of suicide

 

3. Fight or flight stress response

increased cardiovascular risk (esp. heart attack), decreased immune function-->infections

 

4. Sleep disturbance

 

5. Sexual disfunction

Term

 

 

 

Ethical imperatives in pain management

Definition

"first do no harm"--minimize pain and suffering caused by medical tests/treatments

 

do good (beneficience)--restore function, improve quality of life, relieve suffering

Term

 

 

Double Effect Rule

Definition

ethically permissable to give treatment that may have a harmful effect IF potential benefit outweighs potential harm, physician is not seeking out the harmful effect, patient is fully informed

 

used to justify use of high dose opioids in the terminally ill b/c opioids may cause respiratory depression, but if the goal all along is pain control not euthanasia it's acceptable

Term

 

 

 

Do opioids hasten death in hospice patients?

Definition

No!

well, at least not according to a 2001 Japanese study

 

though this is still held as common knowledge and the double effect rule is used to justify prescribing opioids in hospice care

 

Term

 

 

U.S. Supreme Court: right to palliative care?

Definition
yes 1997 decision stated that all Americans have a right to access palliative care
Term

 

 

U.S. Supreme Court: right to physician assisted suicide

Definition

no

 

each state must make its own laws

Term

 

 

Pain undertreatment=

a. the prudent course of action

b. abuse

c.irrelevant

Definition

b. abuse

2001 California conviction of an internal medicine doctor for elder abuse and reckless negligence for inadequate pain managment

Term

 

 

 

who should be treated for pain?

Definition
anyone with acute or chronic pain deserves compassionate pain management regardless of whether they are terminally ill or not
Term

 

 

 

who should a physician not prescribe scheduled drugs for according to the AMA and the KY board of medical liscensure?

Definition

self

family

staff

Term

 

 

 

Acute pain (vs. Chronic)

Definition

onset at a particular time, usually associated with an injury

resolves in days to weeks

usually nociceptive (intact nerves stimulated by tissue injury)

physical signs: grimacing, sweating, writhing

Term

 

 

Chronic Pain (vs. Acute)

Definition

insidious onset, indeterminate or multifactorial cause

indefinate duration possible

nociceptive (intact nerves stimulated by tissue damage) or neuropathic (pain caused by disordered nerves, may exceed observable tissue damage)

may not appear obvious, may instead present with depression, tiredness, disfunction

Term

 

 

Nociceptive pain

Definition
  • intact nerves (nociceptors) stimulated by tissue injury
  • may  be somatic (well localized, originates from superficial tissues, easy to describe) or visceral (difficult to describe, may be migratory or referred, originates from an organ)
  • treat with opioids (if severe) and/or adjuvants/conalgesiscs like NSAIDs
Term

 

 

 

Neuropathic Pain

Definition
  • damaged nerves continue to transmit pain signals beyond observable injury
  • burning, tingling, aching, jolting, hot/cold, shooting, stabbing, electric
  • caused by compression, transection, infiltration, ischemia, or metabolic injury to the nerve (i.e. diabetic neuropathy)
  • treat with opioids (if severe) and/or adjuvants/conanalgesics--multiple medications required more often than for nociceptive pain alone
Term

 

 

 

Components of pain assessment

Definition

location (primary + referral pattern)

quality (sharp/dull, stabbing, throbbing, etc.)

timing

severity (1-10)

radiation

allieviating & aggravating factors

impact on function!

patient perspective (fear and apprehension can worsen pain)

effect of treatments

Term

 

 

Functions which may be deranged by pain

Definition

motor

sensory

activities of daily life

personal relationships

social roles

Term

 

 

components of the nervous system involved in nociceptive pain

Definition

don't freak out, he rattled these off but doesn't expect us to trace it out or anything, more of a quick review

 

proprioceptors, nociceptors, touch and pressure receptors, sensory nerves, dorsal root ganglia, interneurons, motor reflex arcs, decussating tracts in the spinal cord, periaqueductal grey, thalamus, cortex

Term

 

 

 

Allodynia

Definition

pain in response to a normally non-painful stimulus

 

often follows prolonged acute pain, mechanism of a lot of chronic pain

 

without adequate pain control nerves in the affected region become deranged:  nociceptors (C fibers) broaden the base of stimuli which excite them and begin to fire in response to touch as well as pain

 

protective mechanism to prevent further tissue damage

 

treat all acute pain swiftly to avoid nerve damage while you do the work-up to determine underlying cause of acute pain

Term

 

 

 

Sympathetically mediated pain

Definition

develops in response to severely prolonged acute pain

 

C fibers (nociceptors) deranged and begin to respond to sympathetic stimulation (vasodilation/constriction)

vicious cycle

often irreversible-->severe chronic pain

 

treat all acute pain swiftly to avoid nerve damage while you do the work-up to determine underlying cause of acute pain

Term

 

 

 

General approach to pain management

Definition
  • match intensity of medication to severity of pain (WHO analgesi ladder)
  • educate patient and family
  • re-assess therapy regularly
  • holistic care (psychological, spiritual, social, practical)
Term

 

 

WHO analgesi ladder for cancer pain

Definition

1. mild pain: aspirin (ASA), acetaminophen, NSAIDs...

 

2. moderate pain: acetaminophen + codeine or hydrocodone or oxycodone or dihydrocodeine, tramadol...

 

3. severe pain: morphine, hydromorphone, methadone, levorphanol, fentanyl, oxycodone...

Term

 

 

 

Organs damaged by long-term acetaminophen use

Definition

 

Liver

 

Kidneys (renal papillary necrosis)

 

maximum recommended dose recently lowered to 3000mg/day

Term

 

 

Organs damaged by long-term NSAID use

Definition

Stomach (bleeding ulcers)

 

Renal failure

 

Heart attacks

 

Increased propensity to bleed

 

Term

 

 

 

Adverse effects of corticosteriods

Definition

 proximal myopathy, steroid psychosis, aseptic necrosis of hips may occur in short-term

 

long-term use can cause Cushing's syndrome which can lead to diabetes, cardiovascular disease, osteoporosis, mood disorders, sexual disfunction, infertility, and skin infections

Term

 

 

Adverse effects of Opioids

Definition

high risk for addiction and diversion (to black market)

 

common: constipation (prescribe prophylactic laxatives as a precaution) and when starting therapy: dry mouth, nausea, vomiting, sedation, sweats

 

uncommon: bad dreams,  hallucinations, dysphoria, delirium, myoclonus, seizures, pruritis, respiratory depression (especially in patients niaive to opioids!!!), urinary retention

 

no end-organ damage, unlike acetaminophen, steriods, and NSAIDs

Term

 

 

Which adjuvant analgesics are useful to supplement opioids for inflammatory pain?

Definition

corticosteriods i.e. dexamethasone

 

reduce inflammation in CNS edema, visceral invasion by cancers, bone pain

 

beware long-term use in non-terminal patients (Cushing's syndrome)

Term

 

 

 

Which adjuvant analgesics are useful to supplement opioids for neuropathic pain?

Definition

constant burning/tingling: tricyclic antidepressants (desipramine, nortriptyline)

 

spasmodic shooting/Stabbing: anticonvulsants (valproate, phenytoin, carbamazepine) but narrow therapeutic index

 

any kind of neuropathic pain: gabapentin (neurontin) and pregabalin (lyrica)

Term

 

 

classes of adjuvant analgesics to supplement opioid use

Definition
  • local anaesthetics (lidocaine)
  • antispasmodics (hyoscyamine for smooth muscle, baclofen for skeletal)
  • sympatholytics (clonidine)
  • atypical opioids (methadone, tramadol)
  • NMDA receptor antagonists (ketamine)
  • corticosteroids (dexamethasone)
  • tricyclic antidepressants (nortriptyline)
  • anticonvulsants (phenytoin)
  • NSAIDs
  • Acetaminophen
  • Aspirin
Term

 

 

Non-pharamacologic pain managment techniques

Definition
  • neurostimulation (TENS, acupuncture)
  • anesthesiologic (nerve blocks)
  • surgical
  • physical therapy
  • cognitive therapy (relaxation, hypnosis)
  • biofeedback
  • behavior therapy
  • massage
  • art/music/aroma therapy
Term

 

 

 

Trifold goals of medical treatment

Definition

Survival

 

Function

 

Comfort

Term

 

 

 

Reasons doctors refuse to prescribe opioids

Definition
  • fear of causing/abetting addiction
  • fear of legal repercussions
  • distrust of patients
  • under-valuation of comfort goal
  • uncertainty
  • lack of time and energy
Term

 

 

Reasons doctors over-prescribe opioids

Definition
  • fear of confrontation
  • desire to be the good guy for their patients
  • unquestioning trust in patients
  • over-valuaion of comfort goal of medical treatment
  • uncertainty
  • lack of time and energy
Term

 

 

 

Is prescription drug abuse increasing, decreasing, or holding steady currently?

Definition

Increasing!

 

Now the biggest drug addiction problem in the U.S.-->lost productivity, health problems, increased costs of police  and judicial systems, more people in jail, more people using social welfare programs

 

FDA and palliative care community often at odds in terms of desired legislation

Term

 

 

 

Substance Abuse

Definition
  • maladaptive pattern of use not related to therapy
  • recurrent adverse consequences
  • compulsive use despite harm
  • use outside of socially acceptable norms
Term

 

 

 

Addiction

Definition

Neurobiological disease not equivalent to physical dependence (withdrawl) or tolerance (requiring a higher dosage to achieve desired effect) both of which are to be expected even in appropriate long-term opioid use

 

addiction includes impaired control, compulsive and continued use despite harm, craving, expense of tremendous energy in obtaining substance, psychological dependance in addition to physical dependance

 

addiction is influenced by genetic, psychosocial, and environmental factors and is not the inevitable consequence of exposure to an addictive substance

Term

 

 

 

Drug diversion

Definition

Theft, trade, and fraud centered around illigetimate sale of prescription drugs, often opioids

 

 

Term

 

 

 

Prescription Drug Addiction risk factors

Definition

family history

alcoholism

other illicit drug use

mental illness

Term

 

 

 

Clinical tools to decrease the risk of opioid abuse and drug diversion

Definition
  • informed consent
  • controlled medication agreement (one doctor/one pharmacy, random urine/serum drug screening, no early refills, must notify police if meds stolen, have patient sign agreement)
  • EKASPER (Ky all schedule prescription electronic reporting--allows doctor to see how many controlled substance prescriptions the patient has gotten--do not show patient or put in chart!)
  • consultation (pain & addiction specialists etc.)
Term

 

 

Red Flags for Drug Abuse or Diversion

Definition
  • lost or stolen medications
  • multiple doctors and pharmacies
  • calling off-hours for early refills
  • odd allergies to all but favorite medication
  • unwilling to accept adjuvant therapies or consultations
Term

 

 

EKASPER

Definition
Ky all schedule prescription electronic reporting--allows doctor to see how many controlled substance prescriptions the patient has gotten--do not show patient or put in chart!
Term

 

 

 

Substance users/abusers at end of life

Definition

Often have pain with terminal illness like any other patient

 

deserve compassion and pain management too

...and probably a consultation with pain and addiction specialists to help determine how best to treat their pain

Term

 

 

DESK

Definition

a non-judgemental approach to difficult discussions of undesired behavior

 

D.escribe the behavior

E.xplain why it is a problem

S.how what behavior is desired

K.now the consequences if undesired behavior continues

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