Term
| an unpleasant sensory and emotional experience associated with actual or potential tissue damage |
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Definition
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Term
|
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 |
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Term
| needing higher doses to elicit the same response |
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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 |
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Term
| exhibition of aberrant or addicted behaviors due to undertreatment of a legitimate pain syndrome |
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Definition
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Term
| another term used for drug seeking |
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Definition
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Term
| central sensitization vs. windup |
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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 |
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Term
| the physiologic process of nervous system transmission of noxious tissue stimuli |
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Definition
nociception
pain receptors are called nociceptors |
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Term
| deafferentiation vs. neuropathy |
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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 |
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Term
| a heightened response to a normally painful stimuli |
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Definition
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Term
| perceiving a normally non-noxious stimuli as a noxious stimuli |
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Definition
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Term
| abnormal sensations in the absence of any kind of stimuli |
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Definition
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Term
| classifying pain syndromes |
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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) |
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Term
| history and physical for pain |
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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 |
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Term
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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 |
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Term
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Definition
pain is purely subjective
difficult to assess multi-dimensional factors
acute pain elicits sympathetic discharge
chronic pain does NOT elicit sympathetic discharge |
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Term
|
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 |
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Term
| subjective assessment of pain |
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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 |
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Term
| the 4 As of pain assessment and documentation |
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Definition
analgesia
aberrant behavior
adverse effects
activity |
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Term
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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 |
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Term
| NMDA RECEPTOR ANTAGONISTS*** |
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Definition
MEMANTINE
DEXTROMETHORPHAN
METHADONE
KETAMINE
AMANTADINE
LEVORPHANOL |
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Term
|
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 |
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Term
| modulation of pain: excitatory and inhibitory neurotransmitters |
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Definition
excitatory:
glutamate
glycine
inhibitory:
GABA
5HT
NE (alpha 2a)
opioids |
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Term
| opioid receptors and actions |
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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! |
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Term
| opioid receptor signaling |
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Definition
decreased adenylyl cyclase
increased K current
decreased Na
decreased Ca
increased mapK and PLC |
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Term
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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 |
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Term
|
Definition
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Term
|
Definition
fentanyl
sufentanil
alfentanil
remifentanil |
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Term
|
Definition
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Term
|
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 |
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Term
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Definition
| metabolized by 2D6 and 3A4 to oxymorphone (active) and noroxycodone |
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Term
| metabolism of hydrocodone |
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Definition
| metabolized by 2D6 to hydromorphone (active) and then to hydromorphone-3-glucuronide and hydromorphone-6-glucuronide |
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Term
|
Definition
metabolized by 2D6 to M-1 (ACTIVE)
tramadol does not have analgesic activity, must be metabolized to active compound! |
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Term
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Definition
| metabolized to normeperidine (may induce seizures) and meperidinic acid |
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Term
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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 |
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Term
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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 |
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Term
| properties of hydrocodone |
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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 |
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Term
| properties of hydromorphone |
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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 |
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Term
| properties of levorphanol |
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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 |
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Term
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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 |
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Term
| properties of oxymorphone |
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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 |
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Term
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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 |
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Term
| properties of tapentadol (nucynta) |
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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 |
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Term
| properties of buprenorphine |
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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 |
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Term
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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) |
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Term
| properties of butorphanol |
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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 |
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Term
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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 |
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Term
| properties of pentazocine |
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Definition
high history of abuse
mixed agonist/antagonist:
agonist at kappa
antagonist at mu
rarely used in clinical practice today |
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Term
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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 |
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Term
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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 |
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Term
| properties of sufentanil, alfentanil, remifentanil |
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Definition
rarely used in pain management (anesthesia)
sufentanil used in extremely opioid tolerant patients
approximate equianalgesic ratio 0.001:1
parenteral availability only |
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Term
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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 |
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Term
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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 |
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Term
| reasons for using adjuvants |
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Definition
analgesia for mild to moderate pain
synergy with other adjuvants or opioids
targeted polypharmacy (i.e. neuropathic pain) |
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Term
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Definition
NSAIDs
acetaminophen
antidepressants: SNRIs, TCAs
anticonvulsants
anesthetics
antipsychotics
bisphosphonates |
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Term
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Definition
COX-I is constitutive; blocked by unselective NSAIDs
COX-II is inducible/constitutive; blocked by selective NSAIDs
various COX-II/COX-I selectivities |
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Term
| order of COX-II to COX-I selective |
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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 |
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Term
| NSAID ADRs and monitoring parameters |
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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 |
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Term
| NSAID induced GI bleed: risk factors and prevention |
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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 |
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Term
| what pain drugs should be used for patients with CV risk factors? |
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Definition
1st line: opioids, tramadol, acetaminophen
2nd line: non-acetylated salicylate
3rd line: non-selective NSAID (safest is naproxen) |
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Term
| propertiesw of acetaminophen |
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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 |
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Term
antidepressants:
SNRIs vs. SSRIs
secondary vs. tertiary amine TCAs |
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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 |
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Term
| antidpressants used for pain |
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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 |
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Term
| chochrane review of anticonvulsants in DPN |
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Definition
CBZ appears more efficacious than GBP
GBP better tolerated than CBZ
no clear advantage of GBP over CBZ |
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Term
|
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 |
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Term
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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 |
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Term
| properties of carbamazepine |
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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 |
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Term
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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 |
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Term
|
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 |
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Term
| anesthetics used for pain |
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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 |
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Term
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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) |
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Term
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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) |
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Term
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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) |
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Term
|
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 |
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Term
| failed back surgery syndrome |
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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 |
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Term
| neuropathic pain syndromes |
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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 |
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|
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) |
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Term
|
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 |
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Term
|
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 |
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|
Term
|
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) |
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Term
| complex regional pain syndrome |
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Definition
SYMPATHETICALLY MAINTAINED!!!
treatment:
gabapentin (class A)
IV lidocaine (class A)
phentolamine (class A) - alpha blocker
spinal cord stimulation (class A) |
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|
Term
|
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 |
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|
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
|
Definition
by the mouth
by the clock
by the ladder: for severe pain, give a potent opioid
for the individual
with attention to detail |
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|
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 |
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|
Term
|
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) |
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|
Term
|
Definition
caused by:
tumor invasion of the nervous system
chemotherapy
managed same as non-cancer patients |
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|
Term
|
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 |
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|
Term
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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 |
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Term
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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 |
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Term
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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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