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Pharm Exam 4 Ch29

Pain Management in Patients with Cancer

define neuropathic pain pain that results from injury to peripheral nerves
define nociceptive pain pain from injury to tissues
forms of nociceptive pain x2 somatic visceral
define somatic pain pain that results from injury to somatic tissues (bone, joints, muscles)
define visceral pain pain from injury to visceral organs (eg, small intestines)
drug class(es) effective for nociceptive pain opioid analgesics may respond to nonopioids
drug class(es) effective for neuropathic pain adjuvant analgesics: certain antidepressants anticonvulsants local anesthetics/antidysrhythmics
drug class not effective for neuropathic pain opioids
define pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage
most reliable pain assessment method patient description
causes of pain in cancer patients x2 the cancer itself therapeutic interventions (chemo)
adverse effects from chemotherapy mucositis diffuse neuropathies aseptic necrosis of joints
adverse effects from radiation osteonecrosis chronic visceral pain peripheral neuropathy
adverse effects of surgery pain syndromes: phantom limb syndrome postmastectomy syndrome
'A' of pain management strategy ASK/assess pain regularly ASSESS pain systematically
'B' of pain management strategy BELIEVE the patient's reports of pain
'C' of pain management strategy CHOOSE pain control options appropriate for patient
'D' of pain management strategy DELIVER interventions in a timely, logical, and coordinated fashion
'E' of pain management strategy EMPOWER patients and families by ENABLING them to control as much of treatment as possible
Components of Comprehensive Initial [pain] Assessment x5 Intensity/character (patient report) Physical and Neurological exams Diagnostic tests Psychosocial assessment Pain intensity scales
frequent reassessment of pain after implementation of treatment plan "Ongoing Evaluation" to determine efficacy of treatment early diagnosis and treatment of new pain
barriers to pain assessment x4 inaccurate report of pain (under/exaggerated) language/culture inaccurate reading of behavior/facial expressions young children/nonverbal patients
Steps to Drug therapy 1: mild-mod; non-opioid/NSAIDS/APAP 2: more severe; add opioid analgesic 3: severe; replace w/ powerful opioid
nonopioid analgesic drugs NSAIDS Acetaminophen
Opioid analgesic drug selection pure opioid agonists preferred
opioid rotation to minimize adverse effects while maintaining good analgesia stop old abrupt; replace immidiately
use of codeine (relief vs. safety) degree of pain relief achieved safely is low because side effects limit the dose
opioids to avoid Meperidine (toxic metabolites) agonist-antagonists: prevents opioid agonist from working in pts with physical dependence to opioids (block analgesia and precipitate withdrawal)
therapeutic effects of NSAIDs pain relief suppression of inflammation reduction of fever
adverse effects of NSAIDs gastric ulceration acute renal failure bleeding thrombotic events (except aspirin)
therapeutic effects of acetaminophen pain relief reduction of fever
drug interactions of acetaminophen alcohol: potentially fatal liver damage warfarin: increased risk of bleeding
what is a equianalgesia table it indicates equivalent analgesic doses for different opioids and their different routes
7.5 mg of oral hydromorphone parenteral equivalent (specific example from book, know just in case) 10 mg parenteral morphine
preferred route for chronic pain oral: cheap, convenient, noninvasive
preferred route for pts who cannot take drugs by mouth rectal
preferred alternative to oral route; allows for steady analgesia transdermal
acceptable alternatives when oral, rectal, and transdermal cannot be used IV and SubQ: onset quick permit rapid dose escalation
conditions to use IV or SubQ administration x5 nausea and vomiting (preclude oral) not able to swallow (preclude oral) delirium or stupor (preclude oral) pain requires large number of pills (makes oral inconvenient) unstable pain: requires rapid escalation of dosage
Brainthrough pain: onset duration frequency precipitated by random pain episodes even medicated develops quickly minutes to hours typically 1-4 times a day coughing or other movements
rescue medication strong opioids with rapid onset and short duration to treat breakthrough pain
respiratory depression vs. pain relief (end of life) opioids should be given to pts who are near death even with the risk of respiratory depression because when death is imminent comfort is more important than prolonging life
managing constipation increase dietary fiber and fluid stool softeners (docusate) laxatives (senna, sodium phosphate) methylnaltrexone (op antagonist selective for op rec in intestine)
managing sedation Tolerance develops quickly, but can give lower dose more frequently. If needed, CNS stimulant: caffeine, methylphenidate, dextroamphetamine, modafinil
managing nausea and vomiting pretreatment with antiemetic
managing itching diphenhydramine
managing orthostatic hypotension moving slowly when changing position
managing neurotoxicity hydration dose reduction opioid rotation
adjuvant analgesics use used to complement effects of opioids
antidepressants as adjuvant tricyclic antidepressant (Amitriptyline) can reduce neuropathic pain
antiseizure drugs as adjuvant (carbamazepine) to relieve neuropathic pain
Local anesthetics/antidysrhythmics as adjuvant (lidocaine/mexiletine) appropriate for rapidly escalating neuropathic pain
CNS stimulants as adjuvant enhance analgesia counteract sedation
Antihistaine as adjuvant (hydroxyzine) promotes drowsiness reduces anxiety
Glucocorticoids as adjuvant emergency management of intracranial pressure and epidural spinal cord compression can improve appetite can impart general sense of well-being
Bisphosphonates as adjuvant (etidronate/pamidronate) can reduce bone pain by inhibiting bone resorption
neurolytic nerve block destroys neurons that transmit pain from limited areas
neurosurgery nerve block opioid infusion systems neuroaugmentation (electrodes to stimulate neurons that release opioid peptides
tumor surgery debulk tumor to relieve pain
radiation therapy relieves pain by causing tumor regression
risks of pain management in the elderly patient x3 heightened drug sensitivity undertreatment of pain increased risk of side effects and adverse interactions
assessment of pre- and non-verbal children behavioral observation (observing pain cues)
pain treatment risk for neonates and infants heightened drug sensitivity underdeveloped BBB underdeveloped kidneys and liver (slow drug elimination)
Created by: tmbobe11