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Chronic Pain Management

Terms in this set (116)

Pain has __________ consequences
Psychological
Pain increases ___________
Suicidal ideation
Pain converts from...
Acute to chronic pain
Pain compromises...
Immune function and wound healing
Pain initiates...
Central sensitization and neuronal plasticity
Acute pain - Cause
Generally known
Acute pain - Duration of pain
Short, well-characterized
Acute pain - Treatment approach
Resolution of underlying cause, usually self-limited
Chronic pain - Cause
Often unknown
Chronic pain - Duration of pain
Persists after healing, >/= 3 months
Chronic pain - Treatment approach
Underlying cause and pain disorder; outcome is often pain control, not cure
Nociceptive pain caused by...
Activity in neural pathways in response to potentially tissue-damaging stimuli
Nociceptive pain - Types
Postoperative pain

Mechanical low back pain

Sports/exercise injuries

Sickle cell crisis

Arthritis
Mixed type - Caused by...
A combination of both primary injury and secondary effects
Neuropathic pain - Initiated or caused by...
Primary lesion or dysfunction in the nervous system
Neuropathic pain - Types
Postherpetic neuralgia

Neuropathic low back pain

Distal polyneuropathy (diabetic, HIV)

Central post-stroke pain

Trigeminal neuralgia

CRPS
Descriptions of neuropathic pain - Sensations
Numbness

Tingling

Burning

Paresthetic

Electric like

Shooting

Deep, dull, bonelike ache
Descriptions of neuropathic pain - Signs/symptoms
Allodynia

Hyperalgesia
Descriptions of neuropathic pain - Signs/symptoms

Allodynia
Pain from a stimulus that does not normally evoke pain

-Thermal
-Mechanical
-Touch
Descriptions of neuropathic pain - Signs/symptoms

Hyperalgesia
Exaggerated response to a normally painful stimulus
Assessing the patient with pain
Onset and duration

Location/distribution

Quality

Intensity

Aggravating/relieving factors

Associated features or secondary signs/symptoms

Associated factors

Treatment response
Assessing the patient with pain - Associated factors
Emotional distress

Functional activities
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:
Topical analgesics

Anticonvulsants

Antidepressants

Opioids

Marijuana
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:

Consider _________________ when initiating treatment
Safety and tolerability
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:

Topical analgesics
Capsaicin, lidocaine patch 5%
Capsaicin
Irritant (to cause relief to underlying pain)

Not absorbed
Lidocaine patch 5%
Applied locally at site of pain

Not absorbed into systemic circulation
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:

Anticonvulsants
Gabapentin, lamotrigine, pregabalin
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:

Antidepressants
Nortriptyline, desipramine
Pharmacologic treatment options - Classes of agents with efficacy demonstrated:

Opioids
Oxycodone, tramadol
FDA-Approved Treatments for Neuropathic Pain
Carbamazepine

Duloxetine

Gabapentin

Lidocaine patch 5%

Pregabalin
FDA-Approved Treatments for Neuropathic Pain

Carbamazepine
Trigeminal neuralgia

Burning mouth syndrome
FDA-Approved Treatments for Neuropathic Pain

Duloxetine
Peripheral diabetic neuropathy
FDA-Approved Treatments for Neuropathic Pain

Gabapentin
Post-herpetic neuralgia
FDA-Approved Treatments for Neuropathic Pain

Lidocaine patch 5%
Post-herpetic neuralgia
FDA-Approved Treatments for Neuropathic Pain

Pregabalin
Peripheral diabetic neuropathy

Post-herpetic neuralgia
FDA-Approved Treatments for Neuropathic Pain

Pregabalin

Availability pending based upon...
Controlled substance scheduling by the DEA
Cabamazepine (Tegretol)

FDA-approved medical uses are...
Epilepsy, trigeminal neuralgia, and mixed episodes of bipolar I disorder
Cabamazepine (Tegretol) - MOA
Stabilizes the inactivated state of voltage-gated sodium channel
Cabamazepine (Tegretol) also a __________ agonist
GABA receptor
Cabamazepine (Tegretol)

Potentiates GABA receptors made up of _______________ subunits

May contribute to its efficacy in _________________
Alpha 1, beta 2, and gamma

Neuropathic pain and bipolar disorder
Cabamazepine (Tegretol)

Laboratory research has further demonstrated that carbamazepine is a _________________ agent and possibly even a ______________
Serotonin releasing

Serotonin reuptake inhibitor
Cabamazepine (Tegretol) - Drug interactions

A ___________ inducer
CYP450
Cabamazepine (Tegretol) - Drug interactiosn

Increased clearance of drugs like _______________
Warfarin

Phenytoin

Theophylline
Cabamazepine (Tegretol) - Drug interactions

Decreased metabolism of carbamazepine
Erythromycin

Ranitidine

Propoxyphene,

Calcium channel blockers
Cabamazepine (Tegretol) - Drug interactions

Accelerates elimination of _____________
Benzodiazepines
Cabamazepine (Tegretol) - Drug interactions

Increases breakdown of _________________
Estrogen and progesterone
Cabamazepine (Tegretol) - Drug interactions

________________ raises the bioavailability of carbamazepine by inhibiting _______________ in the gut wall and in the liver
Grapefruit juice

CYP3A4
Cabamazepine (Tegretol) - Side effects

US label warnings
Drowsiness, dizziness, headaches and migraines, motor coordination impairment, nausea, vomiting

Aplastic anemia and agranulocytosis

Increased risk of suicide

Risks to the fetus

Stevens Johnson syndrome
Cabamazepine (Tegretol) - Side effects

US label warnings

Aplastic anemia and agranulocytosis
Decreased white blood cell or platelet counts
Cabamazepine (Tegretol) - Side effects

US label warnings

Risks to the fetus
Specifically congenital malformations like spina bifida
Duloxetine (Cymbalta)
Serotonin-norepinephrine reuptake inhibitor (SNRI)
Duloxetine (Cymbalta) - Indications
Major depressive disorder

Generalized anxiety disorder

Fibromyalgia

Neuropathic pain.
Duloxetine (Cymbalta)

First line agent for the treatment of...
Chemotherapy induced neuropathy, fibromyalgia in the presence of mood disorders and treatment of diabetic neuropathy
Duloxetine (Cymbalta)

2004: US FDA approved duloxetine to treat...
Chronic musculoskeletal pain including osteoarthritis and chronic lower back pain
Duloxetine (Cymbalta)

Inhibits the ___________________ in the CNS
Reuptake of serotonin and norepinephrine
Duloxetine (Cymbalta)

No significant affinity for...
Cholinergic, histaminergic, opioid, glutamate, and GABA reuptake transporters
Duloxetine (Cymbalta)

Undergoes extensive ________ but no _____________
Metabolism

Active metabolites
Duloxetine (Cymbalta)

Decreases ___________ activity
Pro-inflammatory cytokine
Duloxetine (Cymbalta)

Analgesic effect in the treatment of __________________ such as ________________ are believed to be due to ____________ blockade
Diabetic neuropathy and central pain syndromes

Fibromyalgia

Sodium ion channel
Duloxetine (Cymbalta)

Side effects
Nausea, xerostomia, headache and dizziness, sexual dysfunction

Discontinuation syndrome

Uncontrolled narrow-angle glaucoma

CNS depressant drugs
Duloxetine (Cymbalta)

Discontinuation syndrome
(Abrupt) dysphoric mood

Irritability

Agitation

Dizziness

Sensory disturbances
Duloxetine (Cymbalta)

Uncontrolled narrow-angle glaucoma
An increased risk of mydriasis (dilation of the pupil)
Duloxetine (Cymbalta)

Concomitant use in patients taking __________________ is contraindicated
Monoamine oxidase inhibitors (MAOIs)
Triptans: Sumatriptan (Imitrex)

A family of ________________
Tryptamine-based drugs
Triptans: Sumatriptan (Imitrex)

Used to treat:
Migraine, cluster headaches / Trigeminal neuralgia

Patient who do not respond to NSAIDs or OTC drugs
Triptans: Sumatriptan (Imitrex)

Reduce the symptoms in _______ patients
70-80%
Triptans: Sumatriptan (Imitrex)

MOA
Agonist effects on serotonin 5-HT1B/D receptors in blood vessels (constriction) and brain nerve endings

Inhibition of pro-inflammatory neuropeptide release
Triptans: Sumatriptan (Imitrex)

_______________ receptors
G protein coupled
Triptans: Sumatriptan (Imitrex)

Rizatriptan (Maxalt)
Has central trigeminal anti-nociceptive activity
NSAIDs: Indomethacin

___________ derivatives
Acetic acid

Indomethacin, Diclofenac, and Ketorolac
NSAIDs: Indomethacin

Used when __________ is ineffective
ASA
NSAIDs: Indomethacin

MOA
Inhibit cyclooxygenase and promote the incorporation of arachidonic acid into triglycerides
NSAIDs: Indomethacin

Side effects
Side effects include CNS effects

Dizziness, Headache, Confusion

Ocular effects: Blurred vision
NSAIDs: Indomethacin

Promotes closure of _____________________
PDA in premature infants
NSAIDs: Indomethacin

SULINDAC
Chemically related to Indomethacin
Lidocaine patch 5% in _______________ patch
Pliable
Lidocaine patch 5%

Up to ___________ applied once daily directly over painful site
3 patches
Lidocaine patch 5%

Time patches remain on
12 h on, 12 h off (FDA approved label)
Lidocaine patch 5%

Efficacy demonstrated in 3 randomized controlled trials on _________________
Post-herpetic neuralgia
Lidocaine patch 5%

Drug interactions and systemic side effects _______________

Most common side effect:
Unlikely

Application-site sensitivity
Lidocaine patch 5%

Clinically insignificant _______________ levels
Serum lidocaine
Lidocaine patch 5%

Mechanical barrier decreases __________
Allodynia
Topical vs. Transdermal

Topical (lidocaine patch 5%)
Peripheral tissue activity

Applied directly over painful site

Insignificant serum levels

Systemic side effects unlikely
Topical vs. Transdermal

Transdermal (Fentanyl patch)
Systemic activity

Applied away from painful site

Serum levels necessary

Systemic side effects
Anticonvulsant drugs for neuropathic pain disorders
Postherpetic neuralgia

Diabetic neuropathy
Anticonvulsant drugs for neuropathic pain disorders

Postherpetic neuralgia
Gabapentin

Pregabalin
Anticonvulsant drugs for neuropathic pain disorders

Diabetic neuropathy
Carbamazepine

Phenytoin

Gabapentin

Lamotrigine

Pregabalin
Anticonvulsant drugs for neuropathic pain disorders

Use in HIV
Gabapentin

Pregabalin
Gabapentin

FDA approved for ______________
Post-herpetic neuralgia
Gabapentin

MOA
Anticonvulsant: GABA receptor modulator
Gabapentin

Limited ______________ absorption
Intestinal
Gabapentin

Side effects
Usually well tolerated; serious adverse effects rare

Dizziness and sedation can occur
Gabapentin

Drug interactions
No significant drug interactions
Gabapentin

Peak time / Elimination half life
2-3 h

5-7 h
Gabapentin

Usual dosage range for neuropathic pain
Up to 1 g tid
What other drugs act on GABA receptor?
Benzodiazepines

Alcohol

Propofol
Antidepressants in pain - MOA
Multiple
Antidepressants in pain

Randomized controlled trials and meta-analyses demonstrate
Benefit of tricyclic antidepressants (especially amitriptyline, nortriptyline, desipramine) for postherpetic neuralgia and diabetic neuropathy
Antidepressants in pain

Analgesic effects independent of _____________
Antidepressant activity
Antidepressants in pain


Improvements in...
Insomnia, anxiety, depression
Antidepressants in pain


___________ have fewer adverse effects
Desipramine and nortriptyline
Principles of Opioid Therapy for Neuropathic Pain

Opiods should be ______________ for therapeutic efficacy
Titrated
Principles of Opioid Therapy for Neuropathic Pain

_____________ generally preferred over _____________
Fixed-dose regimens

Prn regimens
Principles of Opioid Therapy for Neuropathic Pain

Document _____________
Treatment plan and outcomes
Principles of Opioid Therapy for Neuropathic Pain

Consider use of ______________
Opioid written care agreement
Principles of Opioid Therapy for Neuropathic Pain

Most opioid adverse effects controlled with _____________
Appropriate specific management
Principles of Opioid Therapy for Neuropathic Pain

Understand distinction between
Addiction, tolerance, physical dependence, and pseudo-addiction
Summary of Advances in Treatments for Neuropathic Pain

Botulinum toxin
Facial nerve pain, low back pain, migraine
Summary of Advances in Treatments for Neuropathic Pain

Lidocaine patch 5%
Low back pain, osteoarthritis, diabetic and HIV-related neuropathy, with gabapentin
Summary of Advances in Treatments for Neuropathic Pain

Oxycodone
Diabetic neuropathy
Summary of Advances in Treatments for Neuropathic Pain

Gabapentin
HIV-related neuropathy, diabetic peripheral neuropathy
Summary of Advances in Treatments for Neuropathic Pain

Levetiracetam
Neuropathic pain and migraine
Summary of Advances in Treatments for Neuropathic Pain

Oxcarbamazepine
Neuropathic pain; diabetic neuropathy
Summary of Advances in Treatments for Neuropathic Pain

Buproprion
Neuropathic pain
Summary of Advances in Treatments for Neuropathic Pain

Transdermal fentanyl
Low back pain
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