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Psych/Neuro EXAM 4
Psych/Neuro EXAM 4 Herndon Opioids
91
Pharmacology
Graduate
09/21/2011

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Term
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Definition
pain
Term
addiction vs. dependence
Definition
used to be called physiologic and psychologic addiction

addiction is a psychologic compusion

dependence is a physiologic, receptor response to an exogenous substance and the result from removing that substance
Term
needing higher doses to elicit the same response
Definition
tolerance

analgesia vs. euphoria:
tolerance to euphoria develops much quicker than tolerance to analgesia

very difficult to decipher between with short acting analgesics

loss of effect of the medication vs. disease process progressing
Term
exhibition of aberrant or addicted behaviors due to undertreatment of a legitimate pain syndrome
Definition
pseudo-addiction
Term
another term used for drug seeking
Definition
malingering
Term
central sensitization vs. windup
Definition
windup is the process which the nervous system acutely prepares nerves for another, similar, noxious stimulus
this is physiologically necessary and protective

central sensitization is the process in which the nervous system changes inappropriately due to ongoing, long-term noxious stimulus
not protective

windup can lead to central sensitization
Term
the physiologic process of nervous system transmission of noxious tissue stimuli
Definition
nociception

pain receptors are called nociceptors
Term
deafferentiation vs. neuropathy
Definition
neuropathy is generally a result of direct damage or demyelination of a nerve

deafferentation refers to afferent nerves being "cut off" from communicating further up the nervous system
nerve is not intact, but is still firing
Term
a heightened response to a normally painful stimuli
Definition
hyperalgesia
Term
perceiving a normally non-noxious stimuli as a noxious stimuli
Definition
allodynia
Term
abnormal sensations in the absence of any kind of stimuli
Definition
paresthesia
Term
classifying pain syndromes
Definition
pain may be acute or chronic
chronic pain is typically defined as pain syndromes lasing > 90 days
acute pain = postoperative pain, breaking a bone

chronic pain may be malignant or non-malignant pain (cancer or non-cancer pain)

non-malignant chronic pain may be nociceptive or neuropathic
nociceptive = stomp on toe
neuropathic = diabetes pain, chemotherapy, shingles, deafferentiation, B12 deficiency, low TSH (hypothyroidism), neurosyphilis

nociceptive pain may be somatic or visceral
somatic = tissue damage of non-hallow organ
visceral = pancreatic pain, stomach, intestine, usually deferred pain (liver pain, but right shoulder hurts)
Term
history and physical for pain
Definition
onset - when did the pain start

PQRST

provoking factors:
chest pain exacerbated by exercise and relieved by rest could be cardiac in origin
chest pain which is exacerbated by lying down or eating certain foods could be gastrointestinal (GERD)

quality of pain
may lead to the underlying issues based on the descriptors (i.e. cardiac, musculoskeletal, visceral, psychosomatic, gastrointestinal)

radiation of pain (where does it go)

severity/concurrent symptoms
intensity

timing/triggers

effect on ADL - a hallmark way to track further therapy and changes

psych - usually limited for chronic pain evaluation

palliation - what has the patient done to treat pain prior
Term
signs of pain
Definition
diaphoresis
tachycardia
tachypnea
hypertension
distraction or silence
grimacing/groaning
guarding

chronic pain does not elicit these changes to the degree that acute pain (such as post-op) does

distraction or silence, grimacing and groaning, guarding are all good signs to look for when evaluating the nonverbal or demented/cognitively impaired individual
Term
how do you measure pain?
Definition
pain is purely subjective

difficult to assess multi-dimensional factors

acute pain elicits sympathetic discharge

chronic pain does NOT elicit sympathetic discharge
Term
pain descriptors
Definition
help to guide in the type/etiology of the discomfort:
cramping
dull
splitting
sore
hurting
crushing
aching
stabbing
tearing
pressing
burning (neuropathic pain)
shooting (neuropathic pain)
radiating (neuropathic pain)
sharp(neuropathic pain)

help the patient verbalize the quantity or intensity of the discomfort they are experiencing:
nagging
agonizing
annoying
killing
tiring
sickening
terrifying
miserable
torturing
unbearable
troublesome
Term
subjective assessment of pain
Definition
numerous rating and description scales

use tool consistently once chosen

clinically reasonable utility

applicable/valid for proposed patient

ordinal information

agreement with clinical outcomes

single vs. multiple dimensional ratings

in assessing the impact of therapy on activities of daily living, both positive and negative effects should be considered
at low levels of pain, many people can continue to function effectively and few dimensions are affected
when pain reaches the "worst pain" a number of key functional domains begin to be impaired, including mood and activity levels
Term
the 4 As of pain assessment and documentation
Definition
analgesia

aberrant behavior

adverse effects

activity
Term
NMDA glutamate receptor
Definition
mediates slow transmission via Ca channels

activation dependent

NMDA receptor is associated with opioid tolerance: most opioids stimulate the NMDA receptor; ideal situation is for opioids to be NMDA receptor antagonists to prevent tolerance

NMDA receptors are involved in central sensitization
Term
NMDA RECEPTOR ANTAGONISTS***
Definition
MEMANTINE

DEXTROMETHORPHAN

METHADONE

KETAMINE

AMANTADINE

LEVORPHANOL
Term
membrane remodeling
Definition
a lesion in a nerve fiber causes axonal "sprouting"

channels and receptors are redistributed, upregulated, and there is subtype alteration at the sprout

ectopic discharges result

ectopic discharges can cause impulse propagation on the original neuron

pain laminae = I, II, V
non-pain laminae = III, IV

light touch fibers may pass through laminae I, II, or V on the way to laminae III, IV; if a sprout causes ectopic discharges in laminae I, II, V then light touch = allodynia

ectopic discharges in the WRONG laminae (terminating in III normally, but the sprout is terminating in laminae II)

also, there can be adjacent membrane remodeling:
C fiber is injured, and can cause an adjacent A-beta fiber to also start sprouting and causing ectopic discharges
Term
modulation of pain: excitatory and inhibitory neurotransmitters
Definition
excitatory:
glutamate
glycine

inhibitory:
GABA
5HT
NE (alpha 2a)
opioids
Term
opioid receptors and actions
Definition
MU:
analgesia, respiratory, GI, feeding, sedation, prolactin (increased with agonism)

KAPPA:
analgesia, GI, psychotomimesis, feeding, sedation, diuresis

DELTA:
analgesia, feeding

drugs that stimulate kappa and antagonize mu = no respiratory depressant effects (only mu control respiration)

kappa doesn't have dopamine activity

never give a kappa agonist to an actively psychotic patient!
Term
opioid receptor signaling
Definition
decreased adenylyl cyclase

increased K current

decreased Na

decreased Ca

increased mapK and PLC
Term
morphine derivatives
Definition
codeine
naloxone
heroin

those that lack a 6-OH, possibly decreasing risk of cross tolerance of hypersensitivity:
hydrocodone
hydromorphone
levorphanol
oxycodone
oxymorphone
buprenorphine
butorphanol
Term
pentazocine derivatives
Definition
diphenoxylate
loperamide
Term
meperidine derivatives
Definition
fentanyl
sufentanil
alfentanil
remifentanil
Term
metabolism of fentanyl
Definition
metabolized by 3A4
Term
metabolism of codeine
Definition
metabolized by 2D6 to morphine then to morphine-3-glucuronide and morphine-6-glucuronide

codeine does not have analgesic activity! must be metabolized to morphine
Term
metabolism of oxycodone
Definition
metabolized by 2D6 and 3A4 to oxymorphone (active) and noroxycodone
Term
metabolism of hydrocodone
Definition
metabolized by 2D6 to hydromorphone (active) and then to hydromorphone-3-glucuronide and hydromorphone-6-glucuronide
Term
metabolism of tramadol
Definition
metabolized by 2D6 to M-1 (ACTIVE)

tramadol does not have analgesic activity, must be metabolized to active compound!
Term
metabolism of meperidine
Definition
metabolized to normeperidine (may induce seizures) and meperidinic acid
Term
properties of morphine
Definition
gold standard opioid

all equianalgesic tables based upon comparison with morphine

undergoes glucuronidation:
morphine-3-glucuronide (neurotoxicity)
morphine-6-glucuronide (analgesia)

3:1 oral to parenteral potency ratio

t1/2 of 2-4 hours

onset of action 30 minutes (oral), 5 minutes (IV)

duration of action = 4 hours

NEVER EXCEED 1600 MG DAILY OF AVINZA DUE TO TOXICITIES ASSOCIATED WITH EXCIPIENTS
Term
properties of codeine
Definition
low potency analgesic

great for antitussive

must be converted to morphine by 2D6

one of the most constipating opioids

approximate equianalgesic ratio 30:1

no better than IBU
Term
properties of hydrocodone
Definition
parent and active metabolite are active

hydrocodone to hydromorphone by 2D6

little effect of metabolite on analgesia

most highly prescribed med in US

approximately 1/2 as potent as morphine

watch the APAP intake!
fasting and APAP intake is the most dangerous; body can't make glutethione to take away the bad metabolite of APAP
Term
properties of hydromorphone
Definition
glucuronidated to similar metabolites as morphine (H-3-G and H-6-G)

4:1 oral to parenteral potency ratio

t1/2 of 2-4 hours

onset of action 30 minutes (oral), 5 minutes (IV)

duration of action 4 hours

approximately 4 times a potent as morphine
Term
properties of levorphanol
Definition
opioid + NMDA activity

t1/2 of 2-4 hours

duration of action 4-8 hours

oral morphine equivalent changes with increasing doses of morphine
Term
properties of oxycodone
Definition
active parent drug

metabolized to oxymorphone via 2D6 and 3A4

CYP enzyme inhibition or induction little effect on analgesia

approximately 2x more potent than morphine

t1/2 of 2-3 hours

quick onset and peak, unknown duration

more lipophilic, more abuse potential with this drug
Term
properties of oxymorphone
Definition
active metabolite of oxycodone

undergoes glucuronidation and reduction

little clinical experience to date

onset and duration similar to others

t1/2 of ~7 hours

10:1 oral to parenteral potency ratio

approximately 4x more potent than morphine
Term
properties of tramadol
Definition
O-demethylated to active metabolite (M1)

weak mu opioid agonist

weak NE/5HT reuptake inhibition

analgesia NOT reversed by naloxone in stuides

caution for seizures and serotonin syndrome

400 mg/day max dose
300 mg/day mase dose for ER
Term
properties of tapentadol (nucynta)
Definition
SNRI (mostly norepinephrine)

equipotent to oxycodone

mu opioid agonist + NE reuptake inhibitor
not as much risk for seizure or serotonin syndrome
will cause BP changes
Term
properties of buprenorphine
Definition
oral (subutex and suboxone)

available as a 7 day patch (Butrans):
5mcg/hr, 10mcg/hr, 20mcg/hr

do not exceed 20mcg/hr (QTc prolongation)

do not reapply to same site for 21 days

initiation:
<30 mg oral morphine equivalence start with 5mcg/hr patch (recommended that the patient be weaned to < 30 mg of ORM before starting the patch!!)
30-80 mg OME start with 10mcg/hr patch
not recommended for > 80 mg OME

could push morphine off the receptor and cause withdrawal symptoms if the patient isn't tapered down
Term
properties of nalbuphine
Definition
metabolized to inactive metabolites hepatically

stimulates kappa, antagonizes mu receptors (use in caution in opioid tolerant)

equianalgesic to morphine, more dysphoria

available only parenterally

use in labor and delivery usually (women have more kappa receptors)
Term
properties of butorphanol
Definition
metabolized priimarily to hydroxybutorphanol (inactive) hepatically

kappa agonist, sigma agonist, mu antagonist
sigma is a PCP receptor = high abuse potential

available as nasal spray and parenteral

don't convert in opioid tolerant individuals
Term
properties of naloxone
Definition
pure opioid antagonist

used for opioid overdose reversal

limited data to suggest low doses potentiate analgesia

may be effective orally for opioid bowel syndrome
Term
properties of pentazocine
Definition
high history of abuse

mixed agonist/antagonist:
agonist at kappa
antagonist at mu

rarely used in clinical practice today
Term
properties of meperidine
Definition
currently being phased out:
ceiling dose due to toxic metabolite (normeperidine)
accumulation in renal insufficiency

caution reversing overdose with naloxone: seizures may result

still used in acute pancreatitis (no data to support) and post anesthesia rigors

duration of analgesia 2-3 hours

oral meperidine of little analgesic use
Term
properties of fenatnyl
Definition
metabolized via 3A4 to inactive metabolites

t1/2 of ~3 hours IV
t1/2 of ~17 hours transdermal
t1/2 of ~7 hours transmucosal

onset of analgesia:
IV is almost instantaneous
transdermal 12-24 hours
transmucosal 5-15 minutes

duration of analgesia:
IV duration ~30-60 minutes
transdermal not applicable
transmucosal unknown

fentanyl patches: matrix vs. reservoir (liquid)

oral transmucosal fentanyl (Actiq) and fentanyl buccal tablet:
FOR CANCER PATIENTS ONLY THAT ARE OPIOID TOLERANT (buccal tablet)
titration should always begin at the lowest available dose due to variance in transmucosal absrption
Term
properties of sufentanil, alfentanil, remifentanil
Definition
rarely used in pain management (anesthesia)

sufentanil used in extremely opioid tolerant patients

approximate equianalgesic ratio 0.001:1

parenteral availability only
Term
properties of methadone
Definition
active parent

metabolism via N-demethylation:
3A4, 2C19, 2D6 to inactive metabolites

opioidergic, NMDA antagonism, NE/5HT reuptake inhibition

t1/2 of 7-59 hours

dosing changes dramatically in various clinical situations!!

may cause QTc prolongation and Torsades
must monitor EKGs!

changes in equianalgesic potency based on previous morphine equivalents
Term
ADRs of opioids
Definition
CNS:
dependence, substance abuse, sedation, psychotomimetic, vertigo, myoclonus, respiratory depression, neurocognitive

GI:
constipation (need a stool softener and a stimulant laxative), nausea, spinchter of oddi pressure changes, LES/cardiac spinchter changes

GENITO-URINARY:
urinary retention

INTEGUMENTARY:
flushing, urticaria, pruritus (opioids cause mast cell lysis -> release of histamine; not an allergic reaction)

METABOLIC:
stimulate ADH, prolactin, somatotropin, loss of libido

CARDIOVASCULAR:
hypotension and reflex tachycardia

HEPATIC:
rare

RENAL:
rare

OCULAR:
miosis

IMMUNE:
decrease in immune function with chronic dosing

OTHER:
hypogonadism - in men will present with low testosterone levels (depressed, no energy, low libido, elevated pain scores); women will present with ammenorrhea, hair loss, depression, low libido
Term
reasons for using adjuvants
Definition
analgesia for mild to moderate pain

synergy with other adjuvants or opioids

targeted polypharmacy (i.e. neuropathic pain)
Term
types of adjuvants
Definition
NSAIDs
acetaminophen
antidepressants: SNRIs, TCAs
anticonvulsants
anesthetics
antipsychotics
bisphosphonates
Term
COX-I vs. COX-II
Definition
COX-I is constitutive; blocked by unselective NSAIDs

COX-II is inducible/constitutive; blocked by selective NSAIDs

various COX-II/COX-I selectivities
Term
order of COX-II to COX-I selective
Definition
most COX-II selective to most COX-I selective

more COX-II selective:
lumiracoxib, etoricoxib, rofecoxib, valdecoxib, etodolac, nimesulide, diclofenac, celecoxib, meloxicam

more COX-I selective:
fenoprofen, ibuprofen, tolmentin, naproxen, aspirin, indomethacin, ketoprofen, flurbiprofen, ketorolac
Term
NSAID ADRs and monitoring parameters
Definition
gastric/duodenal ulceration and bleed

hypertension

acute renal failure/insufficiency

bleeding diathesis/increased INR

cardiovascular
NSAID associated CV risks appear to be COX selective associated (more COX-II selective = increased CV risks)
cardiac collateralization
stress priming

monitoring parameters:

creatinine at baseline and 1-2 weeks post initiation

annual Hbg/Hct or if symptomatic (to tell if the patient is bleeding

BP
Term
NSAID induced GI bleed: risk factors and prevention
Definition
risk factors:
prior peptic ulcer disease
prior NSAID GI complication
advanced age
concurrent corticosteroid or anticoagulant use
high doses of NSAIDs
combination of NSAIDs

prevention:
eradication of H. pylori
PROTON PUMP INHIBITORS OR MISOPROSTOL
Term
what pain drugs should be used for patients with CV risk factors?
Definition
1st line: opioids, tramadol, acetaminophen

2nd line: non-acetylated salicylate

3rd line: non-selective NSAID (safest is naproxen)
Term
propertiesw of acetaminophen
Definition
dosing of 4gm/24 hours (3gm/24 hours OTC)

dosing of 2400mg/24 hours in elderly and alcohol abuse

evidence to suggest LFT spikes at 4gms or less in healthy adults
Term
antidepressants:
SNRIs vs. SSRIs
secondary vs. tertiary amine TCAs
Definition
SNRIs vs. SSRIs
need the NE more than the 5HT (NE is always inhibitory for pain, 5HT may or may not be inhibitory for pain)

secondary amine TCAs are just as effective as tertiary amines with less ADRs
Term
antidpressants used for pain
Definition
TCAs (NE>5HT):
amitriptyline
nortriptyline
imipramine
desipramine

SSRIs (5HT > NE):
generally ineffective

SNRIs (NE = 5HT)
venlafaxine (dapaminergic)
desvenlafaxine
duloxetine
milnacipran (savella) - for fibromyalgia

atypicals (NE>5HT)
mirtazapine (alpha adrenergic) - makes you hungry, sleepy
bupropion (dopaminergic) - avoid in seizure disorder, eating disorder, anxiety disorder
Term
chochrane review of anticonvulsants in DPN
Definition
CBZ appears more efficacious than GBP

GBP better tolerated than CBZ

no clear advantage of GBP over CBZ
Term
properties of gabapentin
Definition
saturable gut and CNS kinetics

somnolence

renally eliminated unchanged

minimum effective dose for neuropathy: 900 mg/day (initial target)
1800 mg (600 mg TID) is the max dose (not much response above this

of the anticonvulsants, gabapentin has become the generally accepted first line agent for PDN

in clinical studies, response to therapy evidenced by statistically significant reductions in pain scores within as short as several weeks
Term
properties of valproate
Definition
correlation between pain and serum concentrations is unknown

hepatic enzyme elevation

weight gain

causes teratogenicity

may be used in patients with comorbid seizure disorder
Term
properties of carbamazepine
Definition
unequivocal efficacy in studies for almmost every subtype of neuropathic pain

difficult to interpret target dose

need to monitor:
serum concentrations (autoinduction), CBC, lytes
Term
properties of pregabalin
Definition
dizziness and somnolence

works exactly the same as gabapentin

can titrate this quicker than gabapentin and tends to have less edema

if a patient fails gabapentin, they can still respond to pregabalin
Term
properties of topiramate
Definition
paresthesias, renal stones, cognitive slowing

improvement in Hgb A1c

causes weight loss

drink copious amounts of water with this drug! risk of kidney stones
Term
anesthetics used for pain
Definition
lidocaine transdermal patch:
lidoderm
available as 4%
may cut
do not exceed 3 patches at once (for risk of cardiac arrhythmias)
patches cannot be on longer than 12 hours!!!

continuous intraincisional anesthetic:
OnQ pain pump and others
lidocaine, bupivacaine, mepivacaine

capsaicin:
zostrix
Qutenza - every 3 month patch; have to apply a topical anesthetic before applying Qutenza; leave on for 1 hour and it's good for 3 months
Term
types of pain
Definition
acute (<30 days)
chronic (3-6 months)
nociceptive (tissue injury)
neuropathic (nerve injury)
bone (prostaglandin mediated metastasis)
sympathetic pain - COMPLEX REGIONAL PAIN SYNDROME = SYMPATHETICALLY MAINTAINED PAIN; drugs that will work = adrenergic blockers (clonidine)
Term
post operative pain
Definition
second leading cause of surgical avoidance

most common reason for readmission

new data on empiric analgesia: peri operative pregabaline or gabapentin

control pain with IV push opioids

maintain with IV patient controlled analgesia (PCA)
IV PCA is the mainstay of postop pain management

basal rate infusions should be reserved only for opioid tolerant patients (those that came into the hospital on opioids)
Term
chronic pain syndromes
Definition
chronic low back pain
failed back surgery syndrome
neuropathic pain syndromes
sympathetically maintained pain syndromes
central pain syndromes (pain arises from the CNS; result of damage to the CNS i.e. stroke)
Term
chronic low back pain
Definition
incidence of 10-15%

herniation or degeneration of lumbar disk

risk factors include: depression, disputed compensation issues, other chronic pain, and job dissatisfaction

controversy over need for imaging and what type (MRI vs. radiography)

pharmacologic therapy:
NSAIDs - no good data
muscle realxants - no data to support use for greater than 6-8 weeks for pain management
TCAs - have been shown to be effective
opioids/tramadol - have been shown to be effective; tramadol is probably the best

non-pharm therapy:
surgery
physical therapy +/- cognitive behavioral treatment
Term
failed back surgery syndrome
Definition
unrelieved pain following lumbar spine surgery

epidural corticosteroid gold standard despite equivocal data

opioids outperform NSAIDs

spinal cord stimulation:
new "hot" therapy
based on gate control theory

evidence to support surgery is poor
Term
neuropathic pain syndromes
Definition
peripheral:
painful diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
complex regional pain syndrome
sciatica/radiculopathy
phantom limb pain
HIV

central:
central poststroke pain
multiple sclerosis
spinal cord injury pain
Term
painful diabetic neuropathy
Definition
prevention with strict glycemic control (A1c < 7)

treatment:
duloxetine - only FDA approved therapy
TCAs (class A)
anticonvulsants (class A)
opioids (class A)
tramadol (class A)
Term
post herpetic neuralgia
Definition
prevention:
antiviral within 72 hours
oral corticosteroids ineffective
epidural bupivacaine blockade

treatment:
TCAs (class A) - amitriptyline, nortriptyline, desipramine, maprotiline
gabapenting and pregabalin (class A)
opioids (class A) - tramadol, oxycodone, morphine
Term
trigeminal neuralgia
Definition
therapies with class A evidence:
carbamazepine
baclofen

therapies with uncontrolled or anecdotal evidence:
phenytoin
clonazepam
valproate
oxcarbazepine
gabapentin
IV lidocaine
tizanidine
microvascular decompression surgery
Term
central post stroke pain
Definition
experienced by 8% of stroke patients

characterized by abnormal temperature and pain in area affected by stroke

burning, scalding, freezing

may manifest up to 6 months following stroke

treatment:
carbamazepine (class A)
gabapentin (anecdotal)
amitriptyline (class A)
levorphanol (class A)
Term
complex regional pain syndrome
Definition
SYMPATHETICALLY MAINTAINED!!!

treatment:
gabapentin (class A)
IV lidocaine (class A)
phentolamine (class A) - alpha blocker
spinal cord stimulation (class A)
Term
fibromyalgia
Definition
presence of 11 or more of the 18 tender points identified

nociceptive flexion reflex

central sensitization vs. inflammatory mediators
disinhibition syndrome - body does not have enough descending pathway activity
no inflammatory process

ALL FIBROMYALGIA PATIENTS have insomnia!
first thing to treat is sleep
then cardiovascular exercise
then drugs

treatment:
pregabalin (strong, FDA approved)
amitriptyline (strong)
cyclobenazaprine (strong)
tramadol (modest)
fluoxetine (modest)
venlafaxine (modest)
duloxetine (modest)
Term
epidemiology of cancer pain
Definition
up to 70% of patients with cancer will present with pain

over 50% report moderate to severe pain in the last months of life

43% of patients with cancer reported being unsatisfied with their pain treatment
Term
etiology of malignant pain
Definition
acute:
occuring at the time of diagnosis

chronic:
associated with tumor progression or treatment

co-morbid chronic pain syndromes
Term
the WHO analgesic ladder
Definition
by the mouth

by the clock

by the ladder: for severe pain, give a potent opioid

for the individual

with attention to detail
Term
3 step analgesic ladder for cancer
Definition
STEP 1:
non opioid: aspirin or APAP

STEP 2:
opioid for mild to moderate pain - codeine
PLUS
non opioid - aspirin or APAP

STEP 3:
opioid for moderate to severe pain - morphine
PLUS
non opioid - aspirin or APAP
Term
types of malignant pain
Definition
direct nociceptive pain
neuropathic pain
bone pain - hardest type of cancer pain to treat; opioids will work, but anti-inflammatory drugs are the mainstay of treatment (high dose IBU, indomethacin, corticosteroids); it is a prostaglandin mediated pain
visceral pain - designed to sence expansion, stretch, contortion; gabapentin, TCAs, pregabalin
breakthrough pain
spiritual pain (anxiety driven)
Term
neuropathic cancer pain
Definition
caused by:
tumor invasion of the nervous system
chemotherapy

managed same as non-cancer patients
Term
bone pain
Definition
may be due to direct prostaglandin involvement or tumor infiltration

most common primary malignancies:
breast, prostate, lung

most common sites of metastasis:
thoracolumbar spine, pelvis, lower limbs

treatment options:
NSAIDs
bisphosphonates - stablize bone metastases; pamidronate first line, zolendrenic acid
corticosteroids (especially if spinal cord stenosis)
opioids
radiation - fights the cancer directly, not immediately effective for pain
radiopharmaceuticals (strontium or samarium = "radioactive bisphosphonates")

NSAIDs logically make sense but...we get nervous about using NSAIDs in patiens on cancer chemotherapy due to potentially low platelet counts
Term
spiritual pain
Definition
continued escalation of opioids w/o relief

pain and opioid utilization decreased with counseling, especially clergy

address anxiety and depression specifically as contributors to spiritual pain
Term
breakthrough pain
Definition
3 types recognized:
idiopathic
incident
end of dose

pain diary will assist classification

breakthrough doses should be 10-20% of total 24 hour opioid intake

remember pure mu opioids preferred
Term
pain emergency
Definition
rapid titration of IV opioids

1st dose should be 10-20% of previous 24 hour use of opioids

reassess patient after 15 minutes (morphine starts working in 5 minutes, peaks in 15 minutes); if the pain hasn't changed at all, you double the dose of the bolus

if the pain decreases but less than 50% repeat the dose

if the pain decreases by > 50% is considered a success

amount of opioids it takes to control pain is 4 hour equivalent

patients pain must be stable prior to conversion to home pain regimen
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