Term
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Definition
| an unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage |
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Term
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Definition
| 1st step; noxious stimuli translated into electrical signals at peripheral receptor sites; release of Substance P, prostaglandins (PG) - regulate pain, inflammation, fever, platelet aggregation, renal fcn, GI protection; COX enzymes inhibited by NSAIDs |
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Term
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Definition
| 2nd step; impulses transmitted via 2 types of nerve fibers --> dorsal horn --> ascending pathways --> A-delta fibers ("first pain"), C-fibers ("second pain") |
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Term
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Definition
| 3rd step; brain consciously perceives pain |
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Term
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Definition
| 4th step; information is modulated between thalamus/brain stem & dorsal horn by descending inhibitory pathways; release of NE, SE, GABA, endorphins, enkephalins that inhibit pain in descending pathways |
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Term
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Definition
| nociceptive pain; most common, musculoskeletal pain; pain may be sharp or aching, well-localized; predictably responds to nonopioids & opioids |
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Term
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Definition
| nociceptive pain; pain originating from an internal organ or its covering; diffuse, difficult to localize, perceived as somatic ("referred pain"); predictably responds to nonopioids & opioids |
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Term
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Definition
| arises from nerve damage in PNS & CNS; symptoms: numbness, tingling, burning, shooting, stabbing, weakness; hyperalgesia; allodynia |
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Term
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Definition
| pain from inflammation, degeneration, pressure, or infection of nerve; UNPREDICTABLY responds to opioids & non-opioids; responds more favorably to adjuvant (antidepressants, anticonvulsants) |
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Term
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Definition
| possibly due to overactivity of SNS & other mechanisms; Ex) Complex Regional Pain Syndrome (CRPS) Type 1 & 2; difficult to treat |
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Term
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Definition
| response to precipitating event or trauma; Ex: HAs, muscle sprains, post-surgical pain, cuts, bruises, burns, broken bones; Signs: HPN, tachycardia, diaphoresis, mydriasis, pallor, no comorbid conditions present |
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Term
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Definition
| pain that lasts beyond usual time frame for an acute injury to have resolved (>6 wks or >3 months); associated with serious, progressive, or terminal disorder; Ex: cancer, MS, lupus, arthritis, lower back pain, neuropathic pain; signs seldom present; comorbid conditions often present |
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Term
| Goals for Treatment of Chronic Pain |
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Definition
| keep pt functional; decrease rate of physical deterioration; improve mental health; decrease pain perception & dependence on drug therapy |
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Term
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Definition
| used alone or in combination with adjuvants/opioids in nociceptive pain; have opioid-sparing effects; first-line tx for acute or chronic low back pain; maximize dose before switching therapies |
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Term
| acetaminophen (Tylenol) - with narcotics (Vicodin, Norco, Percocet) |
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Definition
| Clinical Effects: antipyretic, analgesic, no effects on platelets or inflammation; often combined with opioids; Usual dose: 325-650 mg po q4-6 hrs; ceiling analgesic effect: 1000 mg/dose; Toxicity: hepatoxicity; Avoid drinking >3 alcoholic drinks/day; MAX of 4 g/day |
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Term
| NSAIDs - naproxen, ibuprofen, ketoprofen (OTC); nabumetone, diclofenac, ibuprofen, etodolac, celecoxib (Celebrex), IV ketorolac, IV ibuprofen (RX) |
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Definition
| clinical effects: analgesic, antipyretic, anti-inflammatory, anti-platelet, useful for BONE pain; interpatient variability; DO NOT EXCEED max dose; Toxicity: peptic ulcers, renal dysfunction, HTN, skin rash, mild hepatotoxicity, TINNITUS |
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Term
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Definition
| IV parenteral NSAID; Dose: 15-30 mg IV q6 hrs, max 40-60 mg daily; 6-12 mg IV = 30 mg IV morphine; use for max of 5 days; Monitor: renal fcn, comorbid conditions, risk of bleed, epidural/intrathecal use; D-D interactions: clopidogrel (Plavix), warfarin (Coumadin) |
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Term
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Definition
| new parenteral NSAID; Dose: 400-800 mg IV q6 hrs PRN; MAX: 3200 mg/day; SEs: N/V, flatulence, HA, hemorrhage, dizziness, pruritus; |
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Term
| Opioid's Role in Pain Therapy |
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Definition
| most potent analgesics; used in acute or chronic, moderate-severe pain; multiple routes; no ceiling; no maximum dose |
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Term
| Major Adverse Effects of Opioids |
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Definition
| euphoria, dysphoria; somnolence, dizziness, confusion, lethargy, hallucinations, myoclonus, hyperalgesia, seizures, RESPIRATORY DEPRESSION; N/V, CONSTIPATION, biliary spasm, urinary retention; postural hypotension; pruritus, urticaria, sweating, flushing |
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Term
| Contraindications & Precautions when using Opioid Analgesics |
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Definition
| respiratory dx, renal impairment, hepatic impairment, paralytic ileus |
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Term
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Definition
| true form is uncommon; Sx: angioedema, bronchospasm, severe hypotension, tachycardia, skin rxn (rash) OTHER than itching, flushing, or hives; morphine & codeine are most likely |
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Term
| Opioids histamine-releasing symptoms |
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Definition
| mild hypotension, flushing, itching, diaphoresis, hives |
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Term
| Tx of Histamine-releasing Symptoms |
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Definition
| 1) use nonopioid analgesic; 2) slow IV rate of administration or avoid IV; 3) avoidance of codeine, morphine, & meperidine; 4) consider use of H1-antagonist; 5) use a more potent opioid less likely to release histamine (hydrocodone, propoxyphene) |
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Term
| Treatment of True Opioid Allergies |
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Definition
| 1) use a nonopioid analgesic (APAP, NSAID); 2) opioid in a chemical class different from one to which pt reacted, close monitoring |
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Term
| morphine (MS Contin, MS IR, Kadian, Avinza) |
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Definition
| GOLD STANDARD opioid; Dosage forms: tabs/caps, soln, IV/IM, rectal suppository, intrathecal; metabolized to active metabolites (M-6-G), (M-3-G); accumulates in RENAL FAILURE; avoid in elderly; reduce dosing interval in severe hepatic impairment; reduce morphine dose if taking lorazepam, amitriptyline, nortriptyline (inhibitors of glucuronidation) |
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Term
| codeine (Tylenol #3 w/ APAP) |
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Definition
| weak mu-agonist; 200 mg PO = 30 mg morphine PO; Dosage forms: oral, IV; Metabolism: 10% --> morphine; poor metabolizers/inhibitors of 2D6 --> reduced analgesia |
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Term
| hydrocodone (Vicodin, Lortab, Norco) |
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Definition
| 30 mg PO = morphine 30 mg PO but considered weaker; Dosage forms: oral (tab, elixir, soln); ONLY in combo with APAP; MAX dose of APAP = 4 g/day; Metabolism: 5-10% converted to hydromorphone, 45% excreted unchanged |
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Term
| oxycodone (Oxycontin, Percocet) |
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Definition
| 20-30 mg PO = morphine 30 mg PO; Dosage forms: oral only - IR, ER caps, elixir; alone or in COMBO w/ APAP; less incidence of histamine release; converted by 2D6 & 3A4 to minimally active metabolites; acute hepatic impairment --> decrease oxycodone dose; NO ACCUMULATION --> good for pts with organ failure |
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Term
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Definition
| 1.5 mg IV = morphine 10 mg IV; Dosage forms: IR tabs only, soln, IV/IM, rectal, intrathecal; Metabolism: glucuronidated to active H-3-G; ideal for pts on potent CYP inhibitors/inducers or impaired HEPATIC fcn |
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Term
| oxymorphone (Opana, Opana ER, Numorphan) |
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Definition
| 10 mg PO = morphine 30 mg PO; IR & ER tabs; provides continuous release with minimal serum fluctuations; bioavailability increases in liver dx & in CrCl<30 mL/min --> reduce dose |
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Term
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Definition
| 100 mg IV = morphine 10 mg IV; Dosage forms: IM/SC, oral; JCAHO--> reduce use in hospitals; Active metabolite is CNS toxic --> agitation, tremor, myoclonus, hallucinations, grand-mal seizures; accumulates in renal failure; drug is partial SSRI --> D-D interaction with TCAs, SSRIs, MAO-Is |
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Term
| fentanyl (Actiq, Sublimaze, Duragesic, Fentora) |
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Definition
| 0.1 mg IV = morphine 10 mg IV; Dosage forms: transdermal, transdermal iontophoretic system, transmucosal, IM, IV, NO TABS/ELIXIR; highly lipophilic, no histamine release (good choice for critically-ill hypotensive pt); metabolized in liver, good choice for RENAL IMPAIRMENT |
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Term
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Definition
| used for acute & chronic pain; MoA: mu, sigma, kappa-agonist, NMDA antagonist, inhibits SE/NE; Dosage form: IV, SC, oral, rectal, epidural; highly lipophilic, highly-protein bound, long t1/2 = 20-35 hrs, 4-10 days to achieve SS; best effect after 5 days; titrate by 1/3 of dose on day 1 to 5; CYP3A4 inducers --> precipate withdrawal --> rescue doses; CYP3A4 inhbitors --> increase pk conc --> reduce dose; Side Effect: QT prolongation/torasade de pointes (especially with coingested cocaine) |
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Term
| propoxyphene (Darvon, Darvocet, Darvon Compound) |
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Definition
| WEAK mu-agonist; oral alone or combo w/ APAP, aspirin & caffeine; active metabolite is cardiotoxic --> accumulates in renal insufficiency |
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Term
| mixed agonists-antagonists - butorphanol (Stadol), nalbuphine (Nubain), buprenorphine (w/ naloxone = Suboxone) |
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Definition
| agonist at kappa, antagonist at Mu-1; for mild to moderate pain; lower risk of abuse, respiratory depression; may cause withdrawal in opioid-dependent pts; have ceiling effect so there is a max dose; SEs: dysphoria, opioid withdrawal |
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Term
| tramadol (Ultram, Ultracet) |
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Definition
| 120 mg PO = morphine 30 mg PO; oral form; binds mu receptors, weakly inhibits NE & SE uptake; may treat neuropathic pain; S/E: LESS respiratory depression, increased risk of seizures, sedation, diarrhea, nausea; active metabolite 100x more potent; metabolized in liver by CYP2D6: poor metabolizers --> less analgesia; 2D6 inhibitors --> less analgesia; reduce dose in renal impairment |
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Term
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Definition
| newly approved central analgesic for acute, moderate to severe pain; 3x weaker than morphine; MoA: weak mu-agonist, inhibits NE reuptake; inactive metabolites, don't need renal adjustment; avoid in severe renal impairment; possible SE syndrome |
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Term
| General Principles for Chronic Pain |
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Definition
| 1) PO if possible; 2) by the clock or around-the-clock; 3) give long-acting opioid + rescue dose for breakthrough pain; 4) keep regimen simple |
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Term
| Recommended starting doses for morphine (MS Contin, MS IR, Kadian, Avinza) |
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Definition
| oral: 5-30 mg q3-4 hr; IV: 1-2.5 mg q5 min |
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Term
| hydromorphone (Dilaudid) started doses |
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Definition
| Oral: 2-4 mg q3-6 hr; IV: 0.1-0.5 mg q5 min |
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Term
| fentanyl (Duragesic) transdermal patch starting dose |
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Definition
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Term
| Starting Opioids in Opioid-Naive Patients |
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Definition
| 1) start with IR opioid q4 hrs prn; 2) ask pt to keep a pain diary; 3) calculate total amt of opioid in 24 hrs to determine daily need; 4) convert to long-acting agent once good pain control is achieved; 5) may increase opioid q24 hrs depending on half-life |
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Term
| Management of Breakthrough Pain |
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Definition
| 1) calculate rescue dose at 5-15% of total daily dose q1-4 hrs PRN; 2) attempt to use same agent for rescue agent; 3) assess # of rescue doses used & efficacy: <50% pain --> double dose, 50-100% pain --> increase by 50%, nearly 100% of pain --> keep dose same; 4) if using >3 rescue doses/day regularly good relief, may increase long-acting agent; 5) if pain occurs at end of dosing interval, consider frequency of long-acting agent; 6) if pain occurs in response to activity, counsel to take dose 30-45 min prior to activity |
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Term
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Definition
| 1) decrease by 10%/wk or 25-50% every 3 days; 2) may consider clonidine if BP is stable; 3) monitor for pain or withdrawal symptoms; 4) onset of symptoms depends on half-life of opioid |
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Term
| Barriers of Adequate Pain Management |
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Definition
| lack of experience or training of HCP; lack of priority in treating pain; fear about meds, doses, & ADRs; fear of addiction by pt & HCP; regulations of controlled substances; poor adherence |
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Term
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Definition
| physiologic response --> pt requires increasing doses to achieve same analgesic response |
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Term
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Definition
| physiologic response --> pt requires continued dosing to prevent withdrawal symptoms |
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Term
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Definition
| psychological response --> misusing a substance for other purposes, despite negative consequences to person; a primary, chronic neurobiological dx w/ genetic, psychosocial, environmental factors; characterized by: loss of control, compulsive use, use despite harm |
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Term
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Definition
| aberrant drug-related behaviors driven by uncontrolled pain; some behaviors displayed; behaviors cease when pain is controlled |
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Term
| Treating Pts with Addiction & Pain |
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Definition
| 1) conduct risk assessment: low risk of abuse --> acute pain, cancer pain, no history of abuse or psychopathology; 2) if aberrant drug-related behavior identified: structure therapy to match perceived risk of liability, Proactively: goals of therapy, written guidelines; Reactively: frequent visits, small drug qtys, urine tox, long-acting agents w/ no rescue doses, refer to addiction-medicine community |
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Term
| Indications for Opioid Rotation |
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Definition
| poor analgesic efficacy; intolerable adverse effects; problematic drug-drug interactions; need for different route of administration; change in clinical status or clinical setting; financial or drug-availability considerations |
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Term
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Definition
| 1) decrease dose by 25-50%; 2) use dose as calculated if pt's pain was less than controlled on previous dose & withdrawal is a concern; 3) increase dose if pain is severely uncontrolled |
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Term
| Pharmacokinetics of transdermal fentanyl patch (Duragesic) |
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Definition
| highly lipophilic, forms depot in subcutaneous fat; onset of analgesia is 12-16 hrs; T1/2 is 17 hrs after removal; avoids first-pass metabolism; increase in body temp above 40 degrees C may increase fentanyl absorption by 1/3rd |
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Term
| Role in Therapy of TDF (Duragesic) |
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Definition
| Tx: persistent, moderate-to-severe pain in opioid-tolerant pts; for pts taking oral morphine 60 mg/day for 1 wk or longer; Caution use in: cachectic, elderly, debilitated, morbidly obese pts; concomitant P45 3A4 inhibitors --> increase drug levels (ketoconazole, diltiazem, grapefruit juice); SEs: less constipation, mild erythema, mild-moderate pruritus |
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Term
| Converting from Opioid to Fentanyl Patch |
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Definition
| 1) morphine oral 60 mg/day = 25 mcg/hr TDF, 2:1 ratio; 2) calculate total analgesic doses for past 24 hrs --> equianalgesic dose of ORAL morphine; 3) convert using 2:1; 4) do NOT have to reduce by 25-50% for impartial cross-tolerance; 5) once patch is applied, continue current analgesic regimen for 1st 12 hrs |
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Term
| Converting from Fentanyl to Oral Opioid |
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Definition
| 1) use same 2:1 ratio to calculate oral morphine equivalent; 2) remove TDF patch once new opioid is available; 3) for 1st 12 hrs after patch removal, use previous rescue dose; 4) 12 hrs after removing patch, start 50% of new opioid regimen; 5) 24 hrs after patch removal, increase to 100% |
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Term
| Converting from IV fentanyl to TDF |
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Definition
| 1) use 1:1 ratio; 2) 6 hrs after applying TDF, reduce IV infusion by 50% but keep boluses; 3) 12 hrs after applying TDF, d/c IV drug but keep boluses; 4) 24 hrs after applying TDF, d/c IV drug |
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Term
| Pt Education for TDF (Duragesic) |
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Definition
| apply to nonirritated skin; clip hair at application site, DO NOT SHAVE; clean site with clear water & allow to dry completely; firmly press patch into place, hold for 30 sec; do NOT use soap, etc to remove transdermal gel if it accidnetly touches skin - copious amts of H2O; avoid hyperthermic situations (hot tubs, saunas, tanning beds); avoid alcohol or other CNS depressants; remove prior to MRI |
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Term
| Patient-Controlled Analgesia (PCA) |
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Definition
| administered IV, SC, or epidurally; for acute, moderate-severe pain; computerized pump with syringe, cartridge, or infusion bag locked inside pump; pt administers own dose by pressing button; program with bolus dose, lock out period, hourly or 4-hr limit; used to MAINTAIN, not achieve analgesia |
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Term
| Tx of Nausea/Vomiting SE of Opioids |
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Definition
| usually transient; tx with scheduled antiemetics (promethazine, ondansetron, metoclopramide, or other serotonin antagonists); or change route of administration |
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Term
| Tx of Orthostatic Hypotension caused by Opioids |
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Definition
| more susceptible in hypovolemic pts; may be due to histamine release; oxycodone & fentanyl --> less histamine release; codeine & morphine --> more histamine release |
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Term
| Tx of Urinary Retention caused by Opioids |
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Definition
| more common with epidural, spinal analgesia; common in men; |
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Term
| Tx of Pruritus caused by Opioids |
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Definition
| may be due to histamine, incidence is 2-10%; common with epidural, in face, neck, upper thorax; higher incidence in OB pts due to estrogen interaction; give nalbuphine 1-5 mg IV q6 hrs or diphenhydramine |
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Term
| Tx of Constipation due to Opioids |
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Definition
| delays gastric emptying; encourage hydration, physical activity; DO NOT use psyllium; OTC: senna, docusate, bisacodyl; Rx: lactulose, polyethylene glycol (Miralax), methylnaltrexone (last resort!) |
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Term
| Tx of Sedation caused by Opioids |
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Definition
| usually transient; warning sign of accumulation; may occur when doses are increased substantially; avoid by reducing dose, changing opioid, adding a stimulant |
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Term
| Tx of Respiratory Depression |
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Definition
| observe decrease in RR & cough reflex; sedation precedes it; Tx: naloxone (Narcan) --> mu-antagonist, reverse toxic effects of opioids, 0.4-2 mg q20-60 min --> SEs: severe, life-threatening, HTN, tachycardia, tachypnea, arrhythmias, pulmonary edema, cardiac arrest; |
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Term
| Procedure in treating Respiratory Depression |
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Definition
| 1) stimulate pt & support respiration; 2) stop all opioids; 3) dilute 0.4 mg Narcan in 10 cc NS; 4) give 1 cc/min until awake, alert, & RR 10-12/min; 5) evaluate for other contributing factors; 6) consider resuming opioids at 50% reduction; 7) due to short half-life, may need to repeat in 30-60 mins |
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Term
| Patient Counseling on Opioids |
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Definition
| 1) watch for clouded mentation, avoid driving, operating heavy machinery, or drinking alcohol when starting, increasing or switching drugs; 2) avoid abruptly stopping opioid; 3) sign opioid contract; 4) avoid crushing, chewing, or breaking long-acting preparations; 5) watch total daily dose of APAP w/ combo pills; 6) educate on differences b/w long-acting & rescue meds; 7) for rescue meds, administer prior to painful incident; 8) educate on drug-specific pts |
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Term
| local anesthetics - benzocaine, lidocaine, dibucaine, tetracaine, pramoxine, diphenhydramine, tripelennamine |
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Definition
| MoA: locally & reversilby blocks Na channels in peripheral nerves; ADRs: allergic rxns, systemic: CV & CNS excitiation, convulsions, hypotension, methemoglobinemia; DO NOT GIVE ORALLY --> severe rxns & death |
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Term
| lidocaine 5% (Lidoderm Patch) - Rx |
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Definition
| Tx: localized pain, 1st line treatment for neuropathic pain, for postherpetic neuralgia; Adv: no significant accumulation, lower risk of D-D interactions; Apply 1-3 patches to PAINFUL SKIN AREA q12 hrs then off for 12 hrs; Pt Ed: wash hands before & after applying patch, do not place over burns, cuts, or irritated skin, slight stinging or burning remove right away |
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Term
| counterirritants - methyl salicylate, camphor, menthol, capsicum preps, etc |
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Definition
| MoA: localized sensation of cold, warmth, or mild burning that indirectly relieves pain in underlying muscles & joints; For: temporary relief of minor aches & pains; ADRs: excessive irritation or blistering, allergic rxns, systemic toxicity if taken orally, use salicylate based ingredients w/ caution in pts w/ aspirin sensitivity |
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Term
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Definition
| derivative of hot chili peppers; depletes substance P; apply topically 3-4x/day for 2-4 wks; wash hands thoroughly after application; avoid use with heat |
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Term
| capsaicin 8% patch (Qutenza) |
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Definition
| administered for 1 hr in MD's office; pre-medicate with oral analgesic or topical anesthetics; monitor pt's BP; |
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Term
| Patient Education on Topical Anesthetics & Counterirritants |
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Definition
| do NOT apply to broken skin; do NOT cover area with bandage; do NOT use with a heating pad; do NOT use near eyes or mouth |
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Term
| diabetic peripheral neuropathy |
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Definition
| tingling in feet, "burning, shooting, tingling, sharp" pain; allodynia, hyperalgesia or numbness; present at rest, worse at night, improved by walking; Tx: glycemic control, foot care, & drug therapy |
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Term
| post-herpetic neuralgia (PHN) |
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Definition
| inflammed nerves caused by herpes zoster which becomes active again; if pain persists for 4 months after initial onset of rash; incidence increases with age; Tx: herpes zoster vaccine, antivirals, symptomatic drug therapy |
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Term
| tricyclic antidepressants - amitriptlyine, imipramine, doxepin, nortriptyline, desipramine |
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Definition
| used for 1st or 2nd line tx of neuropathic pain; MoA: blocks reuptake of NE & SE; S/Es: drowsiness, confusion, dry mouth, orthostatic hypotension, weight gain, urinary retention, constipation, arrhythmias; use lower doses than for depression; INEXPENSIVE |
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Term
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Definition
| SE-NE reuptake inhibitors (SNRIs); tx of fibromyalgia & diabetic neuropathy; SEs: nausea, somnolence, constipation; NOT recommended for pts with ESRD, liver failure, or high alcohol intake |
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Term
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Definition
| anticonvulsant; MoA: binds to alpha-delta subunit, inhibiting excitatory NTs which participate in nociception; Tx: postherpetic neuralgia or neuropathic pain; S/Es: somnolence, dizziness, ataxia, fatigue, peripheral edema, nystagmus, diplopia; Monitor renal fcn |
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Term
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Definition
| anticonvulsant; MoA: binds to alpha-delta subunit of VG-Ca channels w/in CNS, inhibiting excitatory NT release; Onset in 1st wk; Sched V drug; Tx: diabetic neuropathy (MAX dose = 300 mg/day), postherpetic neuralgia (MAX dose = 600 mg/day); S/Es: sedation, dizziness, peripheral edema, weight gain, angioedema, rhabdomyolysis |
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Term
| NMDA receptor antagonists |
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Definition
| methadone, dextromethorphan, amantidine, ketamine |
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Term
| benzodiazepines - diazepam, oxazepam, midazolam |
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Definition
| may relieve anxiety or muscle spasms contributing to pain; risk of dependence, addiction |
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Term
| muscle relaxants - baclofen, cyclobenzaprine, metaxalone, carisoprodol, methocarbamol, tizanidine |
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Definition
| short-term use for low back pain |
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Term
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Definition
| useful in bone pain; useful when inflammation is cause of pain; epidural drug may provide short-term relief of low back pain |
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