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26 Cards in this Set

  • Front
  • Back
Assessing Severity of Pain
- Numeric scales
- Visual analog scale (VAS)
- Wrong-Baker FACES of Pain Rating Scale
Physiological Responses to Pain
Increased RR, HR, and BP

Pain and anxiety are reinforcing phenomena
Acetaminophen + Hydrocodone
- Acetaminophen with hydrocodone decrease dosing flexibility and frequently lead to unintended toxic side effects
- chronic admin of acetaminophen >5g/day has been assoc w/ hepatic enzyme changes
- NSAIDs used additively with opiates have analgesic effects --> good for controlling moderate to severe pain
- NSAIDs have antiplatelet effects
Tramadol vs other opioid analgesics
- tramadol is a synthetic codeine analog
- weak miu-opioid receptor agonist
- part of its analgesic effect is due to inhibition of uptake of NE and serotonin
Morphine AE
- nausea, vomiting, itching, constipation
- nausea/vomiting/itching can be reduced w/ antihistamines
- stimulative laxative to tx constipation (senna tablet orally at bedtime in addition to docusate orally twice daily)
- for more resistant constipation, lactulose can be used every hour
- oral naloxone can also work
Acute severe pain: First line of tx
- morphine or hydromorphone
- ketorolac (injectable NSAID) is most beneficial postoperative if used in combination w/ the opioids
Ceiling Effect
- NSAIDs have an analgesic ceiling effect
- NO ceiling effect for pure opioid agonists (morphine, hydromorphone, fentanyl)
- Combination of opioid + NSAID --> ceiling effect of NSAID should be dose-limiting factor
- Mixed agonist-antagonist opioids (pentazocine, butorphenol, nalbuphin) and the partial agonist opioids (buprenorphine) have a ceiling effect and are poor choices in pts w/ severe pain [if combined w/ pure opioid agonist --> can cause acute pain and opioid w/drawal sx]
Analgesic Nephropathy
after many yrs of exposure to damagind analgesics, renal papillary necrosis results --> chronic interstitial nephritis develops in response and can lead to --> progressive chronic renal failure
Decrease in Renal Blood Flow
- in pts w/ compromised renal hemodynamics (eg dec circulating volume), the kidney --> PGE2 and PGI2 to offset effects of vasocontricting mediators (angII, epinephrine)
- NSAID decreases PGE2: inc sodium/water retention, peripheral edema, wt gain, inc BP, and CHF
- NSAID decreases PGI2 --> hyperkalemia and ARF
Acute Interstitial Nephritis
- dev't of ARF due to a dramatic inflammatory infiltration of the interstitial compartment of the kidneys
- type I HS rxn
- NSAIDs can cause it
Three-step WHO pain ladder for cancer pain relief
1. non-opioid analgesic
2. opioid for mild to moderate pain added
3. opioid for moderate to severe pain substituted

- Only one drug from each of the three groups should be used at the same time
- If a drug ceases to be effective, prescribe a drug that is stronger, NOT a similar drug
Opioids for mild-moderate pain
- Codeine, Hydrocodone, Oxycodone
- Meperidine
- Propoxyphene
Opioids for moderate-severe pain
- Morphine, Hydromorphone, Oxymorphone
- Levorphanol
- Fentanyl
- Methadone
Breakthrough Pain
- transitory flares of pain at rest and movement
- when such pain lasts for longer than a few mins, extra doses of analgesics (i.e. breakthrough or rescue doses) will provide relief
- use immediate-release prep of same opioid that is routinely used
Adjuvant Drugs in Cancer Pain Management
- treat adverse effects of analgesics (anti-emetics and laxatives)
- to enhance pain relief (corticosteroids or hydroxyzine)
- to treat psychological disturbances such as insomnia, anxiety, and depression (sedatives, anxiolytics, antidepressants)
Amitriptyline
- TCA
- act as modulators of descending inhibitory pathways via inhibition of reuptake of NE and serotonin
- particularly useful in tx neuropathic pain
Corticosteroids
- reduce inflammation by inhibiting PG synthesis and they may reduce axonal sprouting and neurkinin conc in sensory fibers near injured tissue
- dexamethasone most often used
Analgesics not recommended for routine dosing
- Meperidine - principal metabolite normeperidine has a lot of AE
- Propoxyphene - acc of norpropoxyphene, a toxic metabolite; affects elderly pts and those w/ renal dysfunction
- Mixed opioid agonist-antagonist (pentazocine, butorphanol, nalbuphine, dezocine) shouldn't be taken in pts already taking pure agonist opioid (codeine, hydrocodone, hydromorphone, methadone, morphine, oxycodone); have a ceiling effect; psychotomimetic AE in some
Pain/Nausea relief
- Immediate relief - Meperidine IM every 3 hrs
- Diclofenac, tenoxicam, and ketorolac: therapeutic benefits in both pain relief and decreased likelihood of progression to acute cholecystitis
- Antispasmodics = papaverine, atropine
- Nausea - metoclopramide, prochlorperazine, or ondansetron IV
Types of pain
- Nociceptive
- Inflammatory
- Neuropathic
- Functional
Nociceptive Pain
- transient pain
- nociceptors located in cutaneous tissue, bone, muscle, connective tissue, vessels, and viscera
- receptors classified as thermal, chemical, or mechanical
Inflammatory Pain
- when tissue damage occurs despite the nociceptive defense system, inflammatory pain ensues
- body changes focus from protecting against painful stimuli to protecting injured tissue
- inflamm response contributes to pain HS that serves to prevent contact or movement of the injured part until healing is complete
Neuropathic Pain
- chronic nonmalignant pain involving disease of the central and peripheral nervous systems
- peripheral or central in nature
- ex: post-herpetic neuralgia, peripheral or polyneuropathic pain, trigeminal neuralgia, CRPS
Functional Pain
- pain sensitivity due to an abnormal processing or function of the CNS in response to normal stimuli
- ex: fibromyalgia, IBS
Management of Neuropathic Pain
antidepressants
- TCA - amitriptyline and imipramine [via inhibition of NE and Serotonin reuptake]
- Venlafaxine and duloxetine - SSRIs and SNRI
- Anticonvulsants - Gabapentin, Pregabalin, carbamazepine, oxcarbazepine, phenytoin, sodium valproate, clonazepam, topiramate, lamotrigine
- Other - Hydroxyzine, corticosteroids, clonidine, lidocaine, capsaicin
Trigeminal Neuralgia tx
Carbamazepine = DOC

Gabapentin and lamotrigine