thera pain mgmt

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coal
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235290
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thera pain mgmt
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2013-09-17 10:44:24
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thera pain mgmt
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thera pain mgmt
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  1. patient description of nocioceptive pain
    sharp, dull, stabbing, throbbing, aching
  2. patients description of neuropathic pain
    electric, burning, tingling, numbing, shooting
  3. what meds affect the stimulation pathway
    • local anesthetics
    • NSAIDS
    • capsaicin
  4. what meds affect the transmission pathway
    • opioids
    • local anesthetics
    • electric nerve stimulation
  5. what meds affect modulation pathway
    • opiods
    • anticonvulsants
    • serotonin/NE reuptake inhibitors
    • NMDA antagonists
    • APAP
    • alpha-2 agonists
  6. what meds affect perception pathway
    cognitive behavioral therapy
  7. pain mgmt. goals
    30% reduction in avg pain scores and improved quality of life without causing significant adverse drug-related effects or stimulating aberrant drug-related behaviours
  8. Tx for step 1 of WHO pain ladder
    • acetaminophen
    • NSAIDS
    • anticonvulsants
    • antidepressants
  9. Tx for step 2 of WHO pain ladder
    • tramadol
    • hydrocodone/APAP
    • codeine/APAP
  10. Tx for step 3 of WHO pain ladder
    • morphine
    • oxycodone
    • hydromorphone
    • fentanyl
    • methadone
  11. APAP bottom line
    • up to 4 grams/day safe in majority
    • avoid if severe chronic liver disease
    • avoid if > 3 alcoholic beverages consumed/day
  12. NSAID COX non-selective
    • ibuprofen
    • naproxen
    • ketorolac
    • diclofenac
  13. NSAID COX-2 preferential
    • meloxicam
    • etodolac
    • nabumetone
  14. NSAID COX selective
    celecoxib
  15. what are the risk factors assessed if a pt needs antiplatelet therapy with no GI problems or on anticoagulants
    • more then one; give a PPI
    • > 60 yo
    • corticosteroid use
    • dyspepsia or GERD symptoms
  16. gabapentin dosing
    • 300 mg TID (100 if frail or elderly)
    • titrate up by 300mg/day every 3-7 days
    • goal dose = 600 mg TID or higher for at least 4 weeks
    • average effective dose 2400mg/day
    • max dose 3600mg/day
    • absorption is non-linear and saturable
  17. pregabalin dosing
    • 50 mg TID
    • titrate to 100mg TID in one week
    • first line for neuropathic pain
  18. TCA (amitriptyline and nortriptyline) dosing
    • start low and go slow
    • 25mg hs (10mg if elderly or frail)
    • titrate up by 10-25 mg/day every 3-7 days
    • usual effective dose is 75-100 mg/day
  19. differences between amitriptyline and nortriptyline
    • nor - less AE, secondary amine, more NE reuptake
    • ami - more AE, more anticholinergic activity, tertiary amine
  20. muscle relaxants and pain mgmt
    • benefit mostly due to sedative effects rather than direct effects on the muscles
    • should not be used for chronic pain
    •   limited efficacy
    •   tolerance develops
    •   high rate of AE
  21. who does NOT receive benefits from opiods
    • long term (> 90 days) Tx of nocioceptive pain
    • widespread soft tissue pain
    • fibromyalgia
    • migraines or tension HA
    • pain associated w/ functional GI problems
  22. who gets small to moderate benefits from opiods
    • short term (<90 days) Tx of nocioceptive pain
    • neropathic pain
    • chronic cancer pain
  23. codeine
    • prodrug, metabolized by CYP2D6
    • avoid use in children
    • do NOT use equianalgesic chart to dose, 200 mg can cause severe respiratory depression
  24. tramadol
    • mild mu-opioid agonist
    • inhibits 5HT reuptake
    • mild to moderate nocioceptive pain or 2nd line for neuropathic pain
    • 25-50 mg q6h
    • can increase up to 100 mg q6h
    • change to q12h - severe renal or hepatic disease
    • avoid in pts w/ seizure disorders
    •              potential for serotonin syndrome
  25. hydrocodone
    • primarily for moderate-severe nocioceptive pain
    • #1 prescribed drug in america
    • PO q 4-6h prn
    • all contain APAP
  26. morphine
    • gold standard of opiods
    • preferred opioid for acute & chronic pain & acute coronary syndrome
    • SA q3-4h
    • LA q8-12h, MS Contin, Kadian, Avinza
    • SR q12-24h, Oramorph
    • lower risk for euphoria than oxycodone & hydromorphone
    • renally eliminated
    • more histamine release
  27. hydropmorphone
    • < renal Cl than morphine
    • >euphoria than morphine
    • SA - dilaudid, 2-4mg q6h prn
    • LA - exalgo
    • parenteral - .4-.8mg q4h prn
  28. acetaminophen dosing
    • 325-1000 mg q4-6h
    • most common dose is 650-1000mg q6h
    • kids 10-15mg/kgq6-8h
  29. fentanyl
    • primary uses
    •   IV in acute care settings
    •   transdermal for pt w/ chronic pain
    • very rapid onset and duration of action
    • safest opioid in renal dysfunction
    • SA buccal & sublingual -actiq, subsys,fentora
    •   only for breakthrough pin in opioid experienced pts
    • LA patch - duragesic
    •   replace q 72h
    •   NOT for acute pain
    • 2:1 ratio 2mg/day = 1mcg/hr
  30. methadone
    • never used for breakthrough or acute pain
    • very long half life 15-120 hrs
    • start 2.5mg q6h
    • then q8-12h once dose stablilized
    • opioid addiction - high dose QD
    • dose titrated upward no more often than q7d
    • safe in renal dysfunction
    • increased efficacy for neuropathic pain
    • increased risk for QT prolongatoin
    • need X DEA to prescribe for opioid addiction
  31. oxycodone dosing
    IR 5-10mg q6h prn
  32. WHO titration guidelines if pts pain is still mild-moderate
    increase TDD by 25-50%
  33. WHO titration guidelines if pts pain is still severe
    increase TDD by 50-100%
  34. "generals" for switching opioids
    • reduce dose by 50% if
    •   pt is elderly or frail
    •   on very high doses of opioids
    • reduce by 30% if
    •   pt has adequate pain control on current regimen
    • consider no reduction if
    •   pt severely uncontrolled pain on regimen
    •   changing to another formulation of the same opioid
  35. fentanyl patch strengths
    12,25,50,75,100 mcg
  36. AE of opioids
    • constipation
    • respiratory depression
    • sedation
    • N/V
    • urticaria
    • euphoria - addiction risk
    • urinary retention
    • HoTN
    • long term use
    •   hypogonadism
    •   ED
    •   immunosuppression

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