Term
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Definition
• Surgery, acute illness, trauma, labor, and procedures
• Typically nociceptive |
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Term
|
Definition
• Changes in nerve function and transmission over time
• Cancer
• Nociceptive or neuropathic |
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Term
| pathogenesis steps of pain |
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Definition
| transduction -> transmission -> modulation -> preception |
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Term
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Definition
The process by which impulses are sent to the dorsal horn of the spinal cord, and then along the sensory tracts to the brain
So how do we feel pain? Well, it is a four step process that starts with transduction. So there is some kind of injury or stimulus that makes us feel pain. So on the right hand here, I have skin. We have our A-delta and A-beta fibers, which are the myelinated fibers-- which are going to transmit signal very quickly-- in contrast to the C fibers that will transmit signal more slowly. But all of these fibers can perceive that signal that there is some kind of stimulus that requires a pain response. |
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Term
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Definition
The process by which impulses are sent to the dorsal horn of the spinal cord, and then along the sensory tracts to the brain
Well, that signal needs to go somewhere. So it starts in those fibers, and then it travels in a process called transmission, where the impulses are sent to the dorsal horn of the spinal cord and along the sensory tracts up to the brain-- at which point that signal can then be modulated. It can be amplified, or it could be dampened down. And that's an important drug target for us. |
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Term
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Definition
The process of dampening or amplifying the pain-related neural signals
the impulses are sent to the dorsal horn of the spinal cord and along the sensory tracts up to the brain-- at which point that signal can then be modulated. It can be amplified, or it could be dampened down. And that's an important drug target for us. |
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Term
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Definition
The conscious awareness of the experience of pain. Results from the interaction of transduction, transmission, modulation,
psychological aspects, and other characteristics of the individual
that's where alternative non-pharmacologic therapies like pet therapy, for example, can be particularly effective.. feel pain less if we are distracted |
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Term
| nociceptive pain transmission |
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Definition
• Afferent nociceptive pain fibers synapse in dorsal horn of spine • Glutamate
• Substance P • Aspartate |
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Term
| nociceptivec pain modulation |
|
Definition
• Endogenous opiate system
• N-Methy-D-aspartate (NMDA) receptors
• Raphe nuclei in brainstem |
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Term
| nociceptive pain perception |
|
Definition
| • Affected by cognition and behavior |
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Term
|
Definition
- Results from damage or impairment of nervous system
- Peripheral damage
• Alteration of nerve fiber sensitivity, development of collateral nerve fibers
- Central damage
• Hyperexcitability of central neurons, NMDA activation, central disinhibition
• Examples:
• Postherpetic neuralgia
• Diabetic neuropathy
• Fibromyalgia |
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Term
|
Definition
• Provocation/Palliation
- What caused the pain? What makes it better/worse?
• Quality/Quantity
- What does it feel like?
• Region/Radiation
-Where is the pain located? Does it radiate?
• Severity scale
• Timing
- When did the pain start? How long does it last? When does it occur? |
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Term
|
Definition
• Non-pharmacologic
- Relaxation, acupuncture, nerve stimulators, heat/cold, massage
• Pharmacologic
- Oral, intravenous, sublingual, topical ... |
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Term
| goals of pain management therapy |
|
Definition
• Decrease pain
• Improve quality of life
• Improve function
• Decrease side effects |
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Term
| Pain: Management: Principles |
|
Definition
• Easiertopreventpainthantotreatit:consider long-acting scheduled around the clock with short-acting agent prn breakthrough pain
• Usesameagentforbreakthroughpainwhen possible (e.g., oxycodone with Oxycontin, morphine with MS Contin)
• Startlow,goslowinelderlypatients
• Combining drugs from different classes may allow reduced doses and hence fewer adverse effects (e.g., NSAIDs + opiate) |
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Term
| Pain: Management: Opiates |
|
Definition
• Standing regimen may reduce total administered dose
• Rescue dose typically 10–15% of total daily dose
• Increase daily dose if using rescue dose frequently
• Recalculate rescue dose with each increase in total daily dose |
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Term
|
Definition
• Little or no dependency/abuse potential, except spasmolytics
• Can be used in combination with opiates to enhance analgesia or as opiate-sparing agents |
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Term
|
Definition
1. Nonopiod +/- adjuvant
2. opiod for mild to moderate pain +/- nonopiod +/- adjuvant
3. opiod for moderate to severe pain +/- nonopiod +/- adjuvant |
|
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Term
| first line agents for neuropathic pain |
|
Definition
• Anticonvulsants (e.g., gabapentin, pregabalin)
• Antidepressants (e.g., duloxetine, venlafaxine, amitriptyline) |
|
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Term
| second-line agents for neuropathic pain |
|
Definition
• Lidocaine patch
• Capsaicin
• Tramadol |
|
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Term
|
Definition
| • Improve the quality of life for individuals who are suffering from severe diseases |
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Term
| Palliative Care support services |
|
Definition
• Pain management
• Symptom management
• Emotional and spiritual support |
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Term
| procedural ways to reduce pain |
|
Definition
| nerve blocks, steroid injections, trigger point injections, stimulators, pumps |
|
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Term
| psycho-behavioral ways to reduce pain |
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Definition
| CBT/ACT, treat mood/trauma issues, address substances, meditation |
|
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Term
| physical ways to reduce pain |
|
Definition
| exercise, manual therapies, acupuncture, orthotics, TENS, other modalities (heat, cold, stretch) |
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Term
|
Definition
| NSAIDS, anticonvulsants, antidepressants, topical agents, opiods, others |
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Term
| other medications for pain |
|
Definition
• Local anesthetics
• Bisphosphonates
• Calcitonin
• Capsaicin
• Calcium channel blockers
• Baclofen
• Antidepressants
• Anticonvulsants
• Corticosteroids |
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Term
| pain management for Life expectancy: weeks—days left |
|
Definition
• Maintain adequate pain management
- Do not reduce opioid doses for blood pressure, respiratory rate, or level of consciousness
- Reduce by 25–50% per day if necessary to avoid opioid withdrawal
• Titrate opioids to optimal comfort
• Recognize and treat opioid-induced neurotoxicity (myoclonus and hyperalgesia)
• Modify routes of administration, as needed |
|
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Term
| Routes of Administration of pain medications |
|
Definition
• Elixir
• Transmucosal
• Intranasal
• Topical creams/gels
• Rectal |
|
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Term
| management of constipation side effect |
|
Definition
| Senna laxatives, bowel stimulants, alternative agent |
|
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Term
| management of opiod-induced hyperalgesia |
|
Definition
Reduction/elimination of current opioid dose
Use less neurotoxic agents (ex: fentanyl) |
|
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Term
| management of sedation S/E |
|
Definition
|
|
Term
| management of puritis S/E |
|
Definition
| Switch opioids, antihistamines |
|
|
Term
| management of urinary retention S/E |
|
Definition
|
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Term
|
Definition
- Lidocaine (Lidoderm®) patch
• Local anesthetic
• Minimal systemic absorption
• 12 hours on, 12 hours off- Capsaicin
• Depletes substance P from nociceptive nerve fibers
• Causes burning, stinging, erythema |
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Term
| Musculoskeletal Pain agents |
|
Definition
- Spasmolytics
• Baclofen
• Tizanidine
• Cyclobenzaprine (Flexeril®)
• Methocarbamol (Robaxin®)
• Carisoprolol (Soma®)
• Metaxalone (Skelaxin®) |
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Term
|
Definition
If we look at a zoom-in of where these drugs work, I'm not going to talk about dantrolene today, because it does work directly on the muscle and can cause muscle weakness that's significant as a result. So when we look today at how we use dantrolene, it's actually used almost exclusively for the off-label indication related to hyperthermia, which is an extremely rare complication of anesthesia.
Instead, I'm going to focus in on our other spasmolytics like tizanidine, baclofen, and some benzodiazepines-- specifically diazepam, which all primarily works for these gabaergic pathways. These drugs reduce spasticity. But while they can help with actually relaxing the muscles, they have not been as effective in restoring function or mobility, unfortunately. All the drugs in this class should be avoided in the elderly, primarily because of the anti-cholinergic effects that they have, which is what put them on the BEERS criteria list. |
|
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Term
|
Definition
• Reduce spasticity (increased basal muscle tone with muscle weakness)
• Avoid in elderly (BEERS criteria drugs)
• Valium (diazepam) most effective benzodiazepine to treat spasticity |
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Term
| Spasmolytics: Baclofen MOA |
|
Definition
| GABAb agonist, facilitates spinal inhibition of motor neurons |
|
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Term
| has SE: sedation, weakness, constipation. At high doses/intrathecal administration, sudden cessation can precipitate a potentially fatal withdrawal syndrome |
|
Definition
| Baclofen. Can administer intrathecally to reduce dose and hence reduce adverse effects |
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Term
| Spasmolytics: Zanaflex (Tizanidine) MOA |
|
Definition
| Alpha-2 adrenergic agonist in the spinal cord |
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Term
| Has S/E: weakness, sedation, hypotension, xerostomia, bradycardia. Monitor LFTs, caution with psychiatric illness (hallucinations). Reduce dose in renal impairment. Avoid in hepatic impairment |
|
Definition
|
|
Term
| Spasmolytics: Flexeril, Amrix (Cyclobenzaprine) MOA |
|
Definition
| inhibits muscle stretch reflex in spinal cord |
|
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Term
| Has S/E: drowsiness, dizziness, xerostomia, confusion, hallucinations. Avoid extended-release cap in hepatic impairment, elderly |
|
Definition
| Spasmolytics: Flexeril, Amrix (Cyclobenzaprine) |
|
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Term
| Spasmolytics: Soma (Carisoprodol) C-IV MOA |
|
Definition
| central depressant, active metabolite meprobamate has anxiolytic and sedative properties |
|
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Term
| Has S/E: drowsiness, dizziness, headache. Use caution in renal or hepatic impairment. Avoid use >2–3 weeks due to lack of evidence supporting long-term efficacy |
|
Definition
Spasmolytics:
Soma (Carisoprodol) C-IV |
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Term
| Spasmolytics: Robaxin (Methocarbamol) MOA |
|
Definition
| skeletal muscle relaxation by general CNS depression |
|
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Term
| Has S/E: bradycardia, hypotension, dizziness, drowsiness. Reduce dose in hepatic impairment |
|
Definition
| Spasmolytics: Robaxin (Methocarbamol) |
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Term
| Spasmolytics: Skelaxin (Metaxalone) MOA |
|
Definition
| disrupts spasm-pain-spasm cycle likely through general CNS depression |
|
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Term
| Has S/E: dizziness, drowsiness, irritability, blood dyscrasias. Avoid in renal and hepatic impairment |
|
Definition
| Spasmolytics: Skelaxin (Metaxalone) |
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