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patient description of nocioceptive pain
sharp, dull, stabbing, throbbing, aching
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patients description of neuropathic pain
electric, burning, tingling, numbing, shooting
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what meds affect the stimulation pathway
- local anesthetics
- NSAIDS
- capsaicin
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what meds affect the transmission pathway
- opioids
- local anesthetics
- electric nerve stimulation
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what meds affect modulation pathway
- opiods
- anticonvulsants
- serotonin/NE reuptake inhibitors
- NMDA antagonists
- APAP
- alpha-2 agonists
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what meds affect perception pathway
cognitive behavioral therapy
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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
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Tx for step 1 of WHO pain ladder
- acetaminophen
- NSAIDS
- anticonvulsants
- antidepressants
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Tx for step 2 of WHO pain ladder
- tramadol
- hydrocodone/APAP
- codeine/APAP
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Tx for step 3 of WHO pain ladder
- morphine
- oxycodone
- hydromorphone
- fentanyl
- methadone
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APAP bottom line
- up to 4 grams/day safe in majority
- avoid if severe chronic liver disease
- avoid if > 3 alcoholic beverages consumed/day
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NSAID COX non-selective
- ibuprofen
- naproxen
- ketorolac
- diclofenac
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NSAID COX-2 preferential
- meloxicam
- etodolac
- nabumetone
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NSAID COX selective
celecoxib
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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
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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
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pregabalin dosing
- 50 mg TID
- titrate to 100mg TID in one week
- first line for neuropathic pain
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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
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differences between amitriptyline and nortriptyline
- nor - less AE, secondary amine, more NE reuptake
- ami - more AE, more anticholinergic activity, tertiary amine
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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
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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
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who gets small to moderate benefits from opiods
- short term (<90 days) Tx of nocioceptive pain
- neropathic pain
- chronic cancer pain
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codeine
- prodrug, metabolized by CYP2D6
- avoid use in children
- do NOT use equianalgesic chart to dose, 200 mg can cause severe respiratory depression
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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
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hydrocodone
- primarily for moderate-severe nocioceptive pain
- #1 prescribed drug in america
- PO q 4-6h prn
- all contain APAP
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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
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hydropmorphone
- < renal Cl than morphine
- >euphoria than morphine
- SA - dilaudid, 2-4mg q6h prn
- LA - exalgo
- parenteral - .4-.8mg q4h prn
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acetaminophen dosing
- 325-1000 mg q4-6h
- most common dose is 650-1000mg q6h
- kids 10-15mg/kgq6-8h
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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
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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
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oxycodone dosing
IR 5-10mg q6h prn
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WHO titration guidelines if pts pain is still mild-moderate
increase TDD by 25-50%
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WHO titration guidelines if pts pain is still severe
increase TDD by 50-100%
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"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
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fentanyl patch strengths
12,25,50,75,100 mcg
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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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