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Flashcards in Pain Palliation Deck (29)
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1
Q

Somatic Nociceptive Pain

A
  • Dull
  • Aching
  • Well-localized
  • Skin, bone, joint, soft tissues

EX:
-Mets to bone or fractures

2
Q

Visceral Nociceptive Pain

A
  • Diffuse
  • Deep
  • Aching
  • Gnawing
  • Poorly localized

EX:

  • Bladder distension/cramping
  • Intestinal distention
  • Constipation
  • Angina
3
Q

Neuropathic Pain

A
  • Burning
  • Shooting
  • Pricking
  • Parasthesias

EX:

  • Phantom limb pain
  • SCI Pain
  • Stroke
  • Diabetic Neuropathy
  • Post-herpetic neuralgia
4
Q

Pain + Cancer

A
  • One of the most common and feared symptoms

- Negative impact on several life factors and overall QoL

5
Q

Acute Pain + Cancer

A
  • Diagnose via biopsy or lumbar puncture

- Intervene with stent placement paracentesis, or chest tube insertion

6
Q

Chronic Pain + Cancer

A
  • Tumor-related

- Somatic, visceral, or neuropathic

7
Q

Durations of Pains

A
  • Acute: seconds to less than 3 months
  • Peripheral nociceptors activated and COX enzymes/prostaglandins are released
  • Chronic: >= 3 mo
  • Sensitization at the level of spinal neurons via multiple mechanisms
  • Breakthrough: Seconds to hours
  • Due to movement, spontaneous, or from weaning off drugs or effect of drug in a well-treated patient
8
Q

Chemo-Related Pains

A
  • Oral mucositis**
  • Neuropathy**
  • Arthralgia/myalgia
  • Hand-foot syndrome
  • Chemo-induced headaches
9
Q

Opioid Indications

A
  • Treating moderate to severe pain that doesn’t respond to non-opioids alone
  • Used for acute and breakthrough pain, cancer pain, visceral/somatic pain, opioid sparing regimens, and treating addiction
  • Possible AE: Cough, diarrhea, dyspnea, opioid dependence
10
Q

Opioid MoA

A
  • Bind to receptors in CNS
  • Inhibits transmission of nociceptive input from periphery to spinal cord
  • Alters limbic system activity
  • Modifies sensory and affective aspects of pain
11
Q

Opioids + Renal Failures

A

Caution with:

  • Meperidine
  • Morphine
  • Codeine
  • Tramadol
12
Q

Opioids + Liver Failure

A
  • Codeine
  • Meperidine
  • Methadone
13
Q

Opioid Escalation Strategies

A
  • For moderate to severe pain increase opioid TDD by 50-100% regardless of starting dose
  • For mild to moderate pain, increase by 25-50% of TDD regardless of starting dose
  • Increase short-acting opioids safely every 2 hours
  • Long acting opioids can be safely increased every 24 hours (excluding methadone and patches)
14
Q

Fentanyl Patches

A
  • Good for chronic, stable pain
  • DON’T give to opioid naive patients
  • NOT good for rapid escalations
  • > 12 hour onset of action and 3 days to steady state
  • Unusual conversion to MME
15
Q

Transmucosal Fentanyl

A
  • Required REMS training for providers
  • Buccal tabs, film, oral lozenge, nasal or SL spray, SL tablet
  • Starting dose: 100 mcg with duration of axn 1-2 hours (opioid TOLERANT)
  • Only use in failed standard IR therapies
16
Q

Methadone

A
  • Treat opioid dependent patients
  • Long duration of action, efficacious, cheap
  • Good for chronic pain
  • Comparative efficacy to morphine for cancer pain
  • Mu agonist and NMDA antagonist
  • May help overcome tolerance and toxicities
  • Extensively metabolized hepatically (avoid in liver failure)
17
Q

Cardiac Concerns + Opioids

A
  • Caution in combination with other QT prolonging agents
  • EX: antipsychotics, antidepressants, antibiotics, antiemetics
  • Low potassium/magnesium can increase risk
18
Q

Good Methadone Patients

A
  • True morphine allergies
  • Significant renal impairment
  • Neuropathic pain
  • High pill burdens
  • Difficulty swallowing or PEG tube
  • Benefit from long-acting opioids
19
Q

Bad Methadone Candidates

A
  • Many DDI in regimen with methadone
  • History of syncope or arrhythmias
  • Live alone
20
Q

Cannabis + Cancer Pain

A
  • Elevated levels of CB1 found in brain areas that modulate nociceptive processing
  • Agonists of CB1 and 2 have peripheral analgesic axns and possibly anti-inflammatory
  • Doesn’t work at same sites at opioids
  • Opioid-sparing effects
  • Used in peripheral neuropathy
  • Also helps with anxiety, sleep, and N/V in cancer patients
21
Q

Reasons to Change Opioids

A
  • Lack of response
  • AE
  • Change in patient status
  • Drug/Formulation availability
  • Formulary issues
  • Health care beliefs
22
Q

Hyperalgesia

A
  • Paradoxical reaction where patient becomes more sensitive to certain stimuli and could experience pain from normal stimuli
  • Accompanied by neuroexcitatory signs/symptoms (confusion, hallucinations, myoclonus)
  • Usually high dose opioids >1000 mg OME
  • Treat by reducing dose, rotating opioid to synthetics, supportive measures
23
Q

Incomplete Cross-Tolerance

A
  • Profound response in untolerated receptors when switching opioids
  • Decreased new opioid dose by 25-50% of patients current MME
24
Q

Chronic Opioid AE

A
  • Constipation
  • No tolerance develops
  • Treat with stimulant (senna +/- osmotic agent)
25
Q

Acute Opioid AE

A
  • N/V
  • Sedation
  • Confusion/hallucinations
  • Pruritis/itching
  • Lasts a week or less
  • Treat by lowering doses, changing agents, or adding other supportive drugs (antihistamines, steroids, antipsychotics, dopamine antagonists, Zofran)
26
Q

Neuropathic Pain Options

A
  • TCAs: amitriptyline, nortriptyline, desipramine (effective at 50-150 mg)
  • SNRIs: duloxetine (<60 mg BID), venlafaxine
  • Topicals?
  • Calcium Channel Alpha-2 ligands: Gabapentin, pregabalin (inhibits calcium influx and diminishes neuronal hyperactivity)
27
Q

Ketamine

A
  • Anesthetic with analgesic, dissociative, sedative, and amnestic properties
  • Subanesthetic dosing to treat intractable pain (severe neuropathic pain not responding to opioids)
  • May reduce opioid tolerance
  • Antagonizes NMDA receptors on dorsal horn of spinal cord
28
Q

Bone Metastases Care

A
  • Corticosteroids
  • NSAIDs
  • Calcitonin
  • Bisphosphonates
  • Denosumab
  • External beam radiation therapy
  • Radiopharmaceuticals
29
Q

Patient Perspective + Opioids

A
  • Identify fears/concerns about opioid use and cancer pain
  • Address potential self management
  • Educate about appropriate use and SE
  • Maintain good provider/patient communication