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34 Cards in this Set
- Front
- Back
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where exactly does pain come from? how would you describe how pain worked to a patient? |
the brain, not damaged tissue use the ladder, signal and translation from back to spine to brain, and back down |
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what defines acute pain? chronic pain? where in the spine does herination usually happen, leading to sciatic pain? |
sudden onset, injury, days to months in duration pain beyond expect duration of healing, 3-6 months, emotional distress (fear, anger, decrease quality of life) L5 and S1 |
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describe somatic pain what drug classes treat this kind? describe nerve pain treated with? |
sore, aching, dull, tight, twisting NSAIDs, APAP, muscle relaxants, opioids burining, eletric, tingling, numbing, stabbing antidepressants and anticonvulsants, methadone, ketamine |
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what is the first thing you should do if you are determining a patients pain medication? |
the pain assessment with PQRST U |
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what does PQRSTU stand for? |
Palliative/aggravating factors- what makes it better or worse Qualtiy- what does it feel like Radiation- does pain travel Severity/Sleep- intensity scale, insomnia Time You- how does it affect you, emotions relationships, self worth, family life, a place to refer |
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what is a good question to ask when determining realistic goals and expectations for a patient? other than physical, what other things can pain affect in a patient? |
ask them what functional goal they want to have, ask them what they want to accomplish, never make any promises pschological, spiratual, social, judgement, employement |
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what are NSAIDS usually given with? how long can ketorolac be taken for? counseling points for Nsaids? |
PPI or H2 blocker 5 days only take with food, prior to painful time, prn if possible, monitor for dark/tarry stool |
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what in APAP causes toxicity? how long should muscle relaxants be used for? |
metabolite NAPQI builds up and cannot be removed b/c glutathione is saturated short term only |
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what are the two types of muscle relaxants? what drugs are in each type? when should you try these? what happens if you take muscle relaxants for too long? |
antispastic- baclofen (back bain) anti spasmaodic- cyclobenzaprine, methocarbamol, carisoprodol after NSAIDS, good in combo tolerance, rotate them, one not better than the other |
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what muscle relaxants are less sedating? what would make you not want to use metaxolone? what muscle relaxants are very sedating? |
methocarbamol and metaxolone and baclofen expensive cyclobenzaprine, tizanidine |
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why is carisoprodol avoided? what are the common side effects of cyclobenzapirne? what do you have to monitor for tizanidine? |
risk for addiction anticholiergic effects, similar to TCA liver function |
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when are short acting opioids used? long acting? MOA of tapentadol? |
for initial, acute, or breakthrough pain maintencance mu receptor agonist and SNRI |
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how long can the half life of methadone be? what is unique about the MOA? at what QT intervals can you use/not use methadone? what is unique about all the different formulations of methadone? |
5-120 hours mu, delta, kappa, nmda block, ssri, snri activity QTc less than 450 use it QTc 450-499 monitor greater than 500 dont use all have similar bioavailability and efficacy |
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is methadone easy to convert? what should you convert to? what is the highest allowable dose usually? what is the usual dosing regimen? |
no, no linear relationship with other opioids convert to morphine first, 10 mg morphine equals 1 mg of methadone, then adjust to whatever 30 mg every 8 hours every 8-12 hours, always go with lower dose and longer time interval |
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how many mgs of methadone is equal to 3 mg of morphine? how long until you can change the dose of methadone? what can affect the metabolism of methadone? |
1 mg a week 3a4 inducers or inhibitors |
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your on methadone and you are given a drug that is a CYP 3a4 inhibitor, what should you do? "" inducer? why should you avoid methadone in non compliant? |
reduce methadone dose by 25% slowly increase dose after 1 week quick to withdrawal, takes time for full effect |
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when should you not use methadone? |
poor/limited prognosis, noncompliance, excessive fatigue at present, elderly, qtc greater than 500 |
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patient counseling for methadone? what should be done with the opioid you are currently on when you are changing to methadone? |
sedation first week, respiratory depression, take religiously, do not adjust dose, full week to see response, phone call after first week never take it again, do a hard change, but can use short acting opioid for breakthrough during the first week |
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a patient is on methadone for a week and still has pain. What should you do? what are the clinical pearls of methadone? |
after a week, you can increase the dose by 25-50% long acting available as liquid (good for bypass surgery) good for nerve pain b/c of NMDA block |
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what causes hyperalgesia? how do you treat it? common max dose of morphine? |
excessive opioids that agonize NMDA receptors reduce/stop current opioid and then use a NMDA antagonist 120 mg |
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what does the medication use agreement ensure? what permits this what cant the patient do? what are they subject to? how often are the piss tests? if a piss test is positive, what should you do? |
patient provider safety, one PCP one pharmacy no early refills cant abuse and medication is only part of the answer to pain, random piss test, still can get opioids for emergnecy every 1-3 months confirmatory piss test |
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is fentanyl on a standard piss test? what is heorin metabolized into? what is codeine metabolized into? what does morphine/hydrocodone get metabolized into? |
no, must be special ordered morphine and then hydromorphone morphine and hydrocodone hydromorphone |
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what does oxycodone get metabolized into? what is alprazolam metabolized into? what is chlorizaepoxide/clorazepate metabolized into? |
oxymorphone alpha hydroxy alprazolam nordiazepam |
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what is nordiazepam metabolized into? what is diazepam metabolized into? what is temazepam metabolized into? what drug will not show up on a piss test? |
oxazepam nordiazepam and temazepam oxazepam get three metabolites from diazepam oxycodone |
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what antidepressant is used for nerve pain? what anticonvulsants? topical agents? |
duloxetine nortriptyline amitripyline gabapentin, pregabalin, topiramate lidocaine, capsaicin |
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at what dose does gabapentin become effecitve? is gabapentin dose adjusted for anything? common adverse effects? what drug would you never use in combo? |
1800-2400 mg/day for renal not hepatic weight gain, edema pregabalin, same mechanism |
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is gabapentin or pregabalin a controlled substance? because this substance is controlled, what should you be cautious of? |
only pregabalin substance abuse history need to fail on gabapentin to get this one, same poop for the dose adjustments |
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what is the target dose for topiramate? adverse effects? adjusted for anything? |
start at 25 mg qd and increase to 100-200 mg daily weight loss and dizziness renal |
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what is duloxetine indicated for? start and target dose for duloxetine? how long and at what dose until you see the desired effect? any adjustmetns? |
somatic and nerve pain 30 mg qd increase at one week to 60 mg 6 weeks at 60 mg for liver |
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what is amitriptyline indicated for? what are anticholinergic effects? what is the starting and target dose? how is this drug different from notriptyline? |
pain, depression, sleep dry mouth, blurry vision, constipation, difficult urination (cant see, cant pee, can spit, cant poop) 25 mg HS increase to 100 mg start dose is 10 mg, less adverse effects |
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what form of lidocain is more versitle and less expensive? what is the strength of capscain is used of diabetic pain? important counseling point here? |
ointment 0.075%, encourge this for all diabetics do not cover or heat, or touch eyes |
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other than drugs, what are some other things you should reccommend for pain? what is the main goal? what is used for unilateral limb pain? |
PT, aqua therapy, graded motor imaging, pyschosocial support, spiritual care to break the pain mood link graded motor imaging |
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what is the goal pain reduction you want to shoot for? what is the best muscle relaxant for elderly what should you do if your patient is taking a lot of opioids? what is voltaren gel useful in? |
VAS reduction by 2-3 points or overall reduction of 30% baclofen, least sedating switch to methadone superficial joint pain and arthritis |
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