PC707 Module 5 Pain PDF

Module 5 Study Guide Module 5 Unit A 1. What is the reason some drugs are scheduled/controlled? Potential for use, misuse, and addiction 2. Do you understand the levels of drug scheduling and refill requirements? DEA Abuse Potential Examples of Som...

Module 5 Study Guide Module 5 Unit A 1. What is the reason some drugs are scheduled/controlled? Potential for use, misuse, and addiction 2. Do you understand the levels of drug scheduling and refill requirements? DEA Abuse Potential Examples of Some effects Medical Use Refills? Schedule Drugs (dependence) I Highest Heroin, LSD Unpredictable, No accepted medical use X psychological or physical dependence, death II high potential for Combination Yes Phone in emergency with No- new RX must be abuse, with use products with less written RX within 72 written. potentially leading than 15 milligrams hours, electronic RX with to severe of hydrocodone secure ID psychological or per dosage unit physical (Vicodin), cocaine, dependence methamphetamine , methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin III moderate to low Products Yes Telephone or fax, Up to 5 refills potential for containing less electronic ok, rewrite RX physical and than 90 milligrams after 6 months psychological of codeine per dependence. dosage unit  (Tylenol with codeine), ketamine, anabolic steroids, testosterone IV low potential for Xanax, Soma, yes Telephone or fax , Up to 5 refills abuse and low risk Darvon, Darvocet, electronic, rewrite RX after of dependence Valium, Ativan, 6 months Talwin, Ambien, Tramadol V Lowest potential antidiarrheal, yes Telephone or fax , Up to 5 refills for abuse and antitussive, and electronic, rewrite RX after dependence analgesic 6 months purposes. Some examples of Schedule V drugs are: cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin 3. Can you list and identify the three types of pain? Nociceptive Pain: Arthropathies, ischemic disorders, myalgias, skin and mucosal ulceration, superficial pain such as burns, and visceral pain such as appendicitis, pancreatitis, renal lithiasis, etc., damage to tissues Neuropathic Pain: (Nerve pain) Neuropathies as in alcoholism and diabetes, cancer-related pain, regional pain syndromes, HIV, multiple sclerosis, phantom limb pain, postherpetic neuralgia, trigeminal neuralgia, post-CVA pain Mixed or Undetermined Etiology: Chronic recurrent headaches, vasculitis 4. Can you identify the CDCs three classifications of pain? © Acute pain (duration of < 1 month)  © Subacute pain (duration of 1-3 months) © Chronic pain (duration of > 3 months) 5. What are some of the concerns and recommendations the journal article discusses about pain in children? © Providers often have misconceptions about the treatment of pain of the pediatric population. Kids are often undertreated due to the following reasons: The idea that infants don’t have pain Lack of assessment and reassessment strategies/tools Inability to quantify pain Lack of knowledge about pain treatment in peds research It might take too much time/effort to tx Fears of adverse effects on child © There are safe and reliable methods of tx pain in peds, but they’re not used frequently enough- info is not applied, and pain is undertreated. Pain is multifaceted (physical/emotional) makes kids and parents feel out of control and worsens the clinical picture for everyone. 6. What are unique concerns about pain management in the elderly? © ¯ renal size and function © ¯ liver function-inhibition of drug metabolism © ­risk of GI bleed w/NSAIDs; hx of MI © Comorbid conditions and D2D interactions “brown bag” © BEERS criteria meds © Increased rates of pain among elderly/arthritis © Cognitive impairment/assessment tools © Decrease initial dose: ¯25 % at 60 yo, ¯ ½ at >80 yo 7. What are the concerns and recommendations for pain management in pregnancy and lactation? © 1st line- non-pharmacological tx, then Tylenol is considered safe © Opioids are lipophilic and cross placental barrier. Opioid use associated with 2.2 x ­ in neural tube defects, miscarriage, preterm birth, stillbirth o ®If opiates are absolutely necessary, use the smallest dose for the shortest time © Newborns exposed during pregnancy may need resuscitative measures: risk for respiratory suppression, risk of SIDS, problems suckling, etc. 8. What are the particular legal and ethical concerns related to prescribing opioids for yourself, family, and friends? © Ethically, it's better to say no and tell the family they should get evaluated and get quality care, don’t risk my license, requires a full evaluation to prescribe. State by state Module 5 Unit B 1. What are prostaglandins? What are the risk and benefits of blocking prostaglandins? © Prostaglandins: Protect the mucosal barrier and ¯ hydrochloric acid secretion Renal and cardiac vasodilation, ­ blood flow © Risks of blocking prostaglandins: Cox-2 effects heart: ­CVD risk- ­ with dose and duration; highest risk are Diflucan and celecoxib, then meloxicam and etodalac. ¯est risk for heart: naproxen ASA blocks prostaglandin thromboxane in plts- this effect lasts the duration of the plts, so it takes 7-10 days to build new after d/c ASA ­GIB risk with ­ dose and duration. ­ GI risk: Toradal & Piroxicam, then Ibuprofen & Celoxicam *USE PPI in long-term therapy or with ­ risk factors: >65 yo, daily ASA, previous ulcer, high dose NSAIDs 2. What populations should avoid ASA and NSAIDs? Why? © No ASA in kids: risk of Reye’s Syndrome with viral illness: N/V, listlessness, LOC, death without tx © No ASA in pregnancy >150 mg/day; premature closure of the ductus arteriosis in 3rd trimester © Caution with lactation © Older people: ­risk for GIB and CVD; D2D interactions © NSAIDS reduce clotting effects of ASA © Avoid with hepatitis, dehydration liver dz., cirrhosis, heavy drinkers © No naproxen with BP issues (Na+) © ­ risk of bleed: 11 x with spironolactone, 12 x with steroids, 7x with SSRI 3. What is the difference between Cox 1 and Cox 2? © Cox1: always around, stimulates prostaglandins in the stomach *Blocking= GI concerns © Cox2: Produced by gene transcription with tissue injury- produces vasodilating prostaglandins and site of injury/ swelling & inflammation *Blocking= Cardiac concerns 4. What are the concerns with topical NSAIDs? © Topical NSAIDS: Lower serum concentrations; 4-5 x strength at site of pain, 100x in tendon sheath © Problems- Still GI bleeding concern, lose effectiveness after -2 weeks of use, expensive 5. Who should avoid acetaminophen? © Those with liver disease © Pts on anticoagulants © Heavy drinkers >3 drinks/day © D2D with other liver toxic drugs 6. What is the maximum adult dose of acetaminophen per day? © 4,000 mg/day, 3,000 mg day those with higher risk for toxicity 7. What is the concern with combination products? © They contain drugs (like Tylenol) the pt may not recognize they’re taking and can lead to unintentional OD or an allergic reaction 8. Can you list important patient education for patients treated with acetaminophen (Tylenol)? © < 4gm/day, can be deadly © Don’t drink with Tylenol © Monitor combo products © Child safety and storage 9. What is a common side effect of local anesthetic lidocaine? © Vasovagal response with pain/anxiety 10. What patient teaching is indicated when prescribing capsaicin? © Avoid getting in eyes or mucous membranes (careful disposal) © Child safety © Don’t take PO © It may initially burn, but subsides and acts on nociceptors to ­substance P and ¯ pain © Can be applied to acupressure points for HA, N/V, etc. 11. What type of medications best treat neuropathic pain? © Capsicum- post-herpetic neuralgia, neuropathy © Anticonvulsants, (Gabapentin, Lyrica)- Fibromyalgia © TCAs (Amitriptyline)- Trigeminal neuralgia © SSNRIs (Cymbalta)- neuralgias © Marijuana- peripheral neuropathy 12. What conditions does medical marijuana have FDA approval for? © Chronic non-cancer pain, neuropathic pain, chemo-induced N/V, MS, epilepsy, HIV/AIDs, glaucoma, PTSD, Alzheimer’s related agitation, varies by state… 13. What is the process for recommending medical marijuana? © Usually, the prescriber sends a recommendation letter with pt to the medical dispensary. 2 yo © Marinol (dronabinol)- THC product, ­appetite, N/V related to chemo, weight loss tx with HIV/AIDs © Cesamet (nabilone)- synthetic cannabinoid used to treat severe nausea and vomiting associated with chemotherapy. Module 5 Unit C 1. What is the difference between acute/abortive versus prophylactic treatment of migraines? © Acute/abortive meds are given at the time of onset of HA. These include: o NSAIDs © Opioids © IB/ID receptor agonists (Triptans) o ®Sumatriptan (Imitrex)- selective activation of 5ht receptors/ suppresses CGRP release; constricts intracranial blood vessels and suppresses inflammatory neuropeptides © Ergot Alkaloids o ®Dihydroergotamine Ergotamine- Alters neurotransmitters, constricts intracranial blood vessels and inflammatory peptides © Calcitonin gene-related peptide (CGRP) antagonists o ®Ubrogepant- decreases inflammation and vasodilation in the brain © Caffeine- o vasoconstricts © Anti-emetics- o often Reglan, due to decreased gastric mobility r/t HA and N/V r/t pain © Prophylactic HA medications: Reduce frequency, intensity, and duration. Given when >2/week abortive treatments, neuro impairment r/t HA, major disruptions to ADLs, symptomatic meds ineffective attacks >24 duration. These meds include: o Beta Blockers ®Propranolol (Inderal); Atenolol (Tenormin), timolol- B-adrenergic blockade prevents arterial dilation  o Antiseizure agents ®Topiramate (Topamax)- Broad spectrum anti-seizure agent ®Divalproex (Depakote ER)- May augment the inhibitory effects of GABA o TCAs ®Amitriptyline (Elavil)- block reuptake of NE and 5-HT o Calcitonin gene-related peptide (CGRP) antagonists ®Erenumab (Aimovig)-One-month injection. Decreases inflammation and vasodilation in the brain o Estrogen withdrawal HA- give birth control or estrogen replacement o Botulinum toxin ®Botox Injection- prevents the release of acetylcholine at the neuromuscular junction *Alternative tx’s with good data: Magnesium citrate, butterbur, CoQ10, Riboflavin 2. What is the difference between acute/abortive treatment of gout and prophylactic treatment of gout? © Medications for gout are used to relieve the pain (acute) and then to help lessen the occurrence (prophylactic) of another gouty attack by lowering the uric acid levels © Acute Gout o NSAIDs for pain/inflammation o Glucocorticoids for pain/inflammation o Colchicine decreases WBCs in joint cavity/¯inflammation and pain © Prophylactic Gout o Colchicine decreases WBCs in the joint cavity/¯ inflammation and pain o Canakinumab (Ilaris) inhibits a proinflammatory cytokine and ¯ inflammation; o Allopurinol (Zyloprim) inhibits XO/uric acid formation o Probenecid (Probalan) increases uric acid secretion 3. Can you list the three FDA-approved drugs for the treatment of Fibromyalgia? © Milnacipran (Savella) has been shown to decrease fibromyalgia pain and fatigue and improve function © Duloxetine (Cymbalta)- SNRI, also indicated for concomitant depression © Pregabalin (Lyrica)- Anticonvulsant, demonstrates benefits in FM by improving pain, reducing fatigue, and improving sleep as well as overall well-being 4. What is the level of evidence for prescribing opioids and muscle relaxants to patients with Fibromyalgia? © The primary medications approved by the FDA and used to tx fibromyalgia are Duloxetine (Cymbalta), milnacipran (Savella) and pregabalin (Lyrica). Off label use with these medications have B and C ratings and are not first line (Arthritis Foundation, Module 5-C lecture notes): o Cyclobenzaprine (muscle relaxant) has a chemical structure that is similar to TCAs, which might explain its benefit in improving sleep, stiffness, and fatigue (FDA grade B)  o Opioids have not demonstrated effectiveness (FDA grade C) Module 5 Unit D 1. What are the CDCs new recommended approach to deciding whether or not to prescribe opioids? © (CDC) 2022 updated guidelines on prescribing opioids for pain: o Need for an individual approach to pain management o Nonopioid therapies, whenever appropriate o Opioid therapy for patients with acute pain when the benefits are expected to outweigh the risks o Non-opioid treatment options such as NSAIDs and exercise should considered first o For moderate to severe pain, discuss risks, benefits, and alternatives to opioids 2. What are the CDCs new recommended approach on how to prescribe opioids. © Clinicians work with patients to determine whether opioids be continued or tapered © Offer prescription of naloxone (Narcan) to accompany opioid prescriptions © Start with the lowest effective dose for the shortest period of time. © Immediate-release opioids should be prescribed instead of extended-release or long-acting opioids 3. What are the primary receptors and the result of activation involved with opioid medications? © Whatever stimulates Mu, also stims Kappa © Mu receptors- analgesia, respiratory depression and euphoria © Kappa receptors- Analgesia, sedation 4. What is the difference between agonist, partial agonist, and antagonist? 5. What is the difference between affinity and activation of receptors? © Affinity is the strength of the connection with the receptor site © Activation is the strength of the impact (tramadol vs. Fentanyl). o Narcan has a very strong affinity, stronger than an opiate agonist, with the receptor site, so it blocks the activation of the receptor 6. Can you list important patient education for patients being treated with opioids? © ETOH use with opiates increases respiratory depression © S/sx of overdose, Narcan if prescribed © Dosing schedule: onset of action and duration of effect- realistic expectations of when they will come on and when to expect the peak effect so they don’t take more than needed © Safe disposal © Safe storage- children and pet safety, keep locked and away from children and adolescents 7. What is a prescription drug monitoring system (PDMS), a prescription drug monitoring program (PDMP), and how does it help combat drug misuse? © A prescription drug monitoring program (PDMP) is an electronic database that tracks controlled substance prescriptions. Information from PDMPs can help clinicians identify patients who may be at risk for overdose and provide potentially lifesaving information and interventions. PDMP data also can be helpful when patient medication history is unavailable and when care transitions to a new clinician. © Tells us: What other prescriptions do they have at home, how quickly are they using them? Are they perhaps being abused? 8. What are pain contracts, and how do they impact primary care? © As a contract often initiated by pain clinics in a given state, if a patient goes to pain clinic, check their contract terms. © A pain management agreement or opioid contract, is a written agreement between a patient and their provider that outlines the conditions for prescribing or discontinuing opioid medications. The goal is to ensure that patients take their medication as prescribed and that both parties are on the same page before starting therapy. o How the medication is used- dose, indication, timing o Only one pharmacy can dispense, they report to prescription monitoring database (PMP) o Pt agrees to communicate with the HCP about pain o Provider can require drug testing or personal appts. for drug changes o Consequences (d/c meds) if contract not followed 9. How is it possible that giving an opioid-addicted person an opioid receptor partial agonist can trigger withdrawal? © The partial agonist can have a stronger affinity to the receptor and block the weaker agonist (the opiate) 10. What drugs in this unit prolong QT interval? © Methadone and cocaine 11. What are the effects of opioid use in the preconceptual period? © Women taking opioids prior to conception and post-conception risk miscarriage, birth defects, stillbirth, and newborn abstinence syndrome. Women who use opioids in the peri-conceptual period have a 2.2-fold increase in the fetal risk of neural tube defects. Fetal exposure to opioids can have detrimental consequences, including profound congenital cardiac, intestinal, and spinal defects. 12. What are the FDA's recommendations on using codeine and tramadol in children? © Codeine should not be used to treat pain or cough and tramadol should not be used to treat pain in children younger than 12 years due to the risk of serious side effects, including slowed or difficult breathing and death. Use in children