Resources:

Text:

Katzung, chapters 27, 31, 32, 36
Kuhn, chapters 18, 22, 57, 67

LSUMC videotapes

Web-based resources:

From Stanford University available at:

http://www-med.stanford.edu

Primary care teaching module: Knee and hip pain.

The Migraine Treatment Center of the American Medical Association is
available at:

http://www.ama-assn.org/special/migraine/
treatmnt/guidecan.htm

From the American Academy of Family Practice at z:

http://www.aafp.org

Carpenter, R. (1997). Optimizing Postoperative Pain Management.
AmericanFamily Physician 56 (3):

Siwek, J. (1997). Twelve pitfalls of adequate pain control. American
Family Physician 56(3):

From MEDSCAPE : http://www.medscape.com

No Author listed (1998) The management of chronic pain in older persons:
New guidelines from the American Geriatrics Society. Clinician Reviews 8
(9): 69-72, 75-78, 81-82, 87-89, 94, 99, 103-104.

Campbell, S. (1998). Rheumatoid arthritis: Current strategies. Hospital
Medicine 34(8):29-32, 39-40.

Cohen, J. (1996), Migraine headache and the managed care formulary.
Drug Benefit Trends 8(8): 28-30, 33-34, 41.

Smith, T. (1998). Migraine prevention need no longer be a headache. Hospital
Medicine 34 (10): 13-14, 19-21, 25.

From the Agency on Health Care Policy and Review:

http://text.nlm.nih.gov

choose AHCPR supported guidelines on Acute Pain Management in Adults:
Operative Procedures

Acute Low Back Problems In Adults: Assessment and Treatment Managing
Cancer Pain

Study Guide:

1.  Differentiate between acute and chronic pain in terms of function, characteristics and nerve pain pathways.

2.  Identify and describe nonopoid analgesics in terms of drug classification, mechanisms of action, indications, contraindications, adverse effects and drug interactions.

A. Acetominophen

B.  Salicylates

C.  NSAIDS

a.  Propionic acid derivatives

b.  Indole analogs

c.  Oxicam drugs

d.  Pyrazolone derivatives

e. Fenamate drugs

3. Visit a local pharmacy and complete the following information regarding  commonly used OTC pain relievers.

A.  Acetominophen

    (1) Trade names (2) Cost/dose (3) Cost/24 hr
    pain relief

B.  Ibuprofen

     (1) Trade names (2) Cost/dose (3) Cost/24 hr
     pain relief

C.  Naproxyn Sodium

     (1) Trade names (2) Cost/dose (3) Cost/24 hr
      pain relief

D.  Ketoprofen

     (1) Trade names (2) Cost/dose (3) Cost/24 hr
      pain relief

E.  Aspirin

    (1) Trade names (2) Cost/dose (3) Cost/24 hr
    pain relief

F.  Choline Salicylate

     (1) Trade names (2) Cost/dose (3) Cost/24 hr
      pain relief

G.  Choline Magnesium Trisalicylate

     (1) Trade names (2) Cost/dose (3) Cost/24 hr
     pain relief

4.  List the major therapeutic indications for use of NSAIDs
    (other than pain relief) in clinical practice and indicate the
    intended effect of NSAIDs in each instance.

5.  Describe the WHO stepped approach to pain relief.

6.  Differentiate among the ways that opiate and nonopiate pain
     relievers, ergot derivatives and selective serotonin agonists
     influence pain relief.

7.  Define the following terms:

a. agonist

b. antagonist

c. agonist-antagonist

d. endorphin

e. enkephalin

8.  Differentiate between opiate tolerance and opiate
    dependence.

9.  Describe nonpharmacologic mechanisms by which
     endogenous endorphins and enkephalin production can be
     enhanced as an adjunct to pain relief.

10.  Describe the effects of various opiates on receptor sites
       found in the central nervous system.

Receptor type          Physiologic Effect      Opiate/Endogenous Peptide-
                                                                     Type of Activity

mu

kappa

sigma

delta

epsilon

11. Morphine is considered the gold standard for calculation of
      equianalgesic effects of other opiates. Because the effects of opiate
      analgesics vary considerably between drugs as well as between dosage
     forms, it is essential to understand the concept of equivalent dosing.

Complete the following table for practice in determining equianalgesic dosing: (Assume adult patients weighing > 50 kg with no opiate tolerance)

Combination opioid/NSAID preparations

12. Identify and describe at least two opiate antagonists according to
      mechanism of action, indications. contraindications, adverse effects
      and interactions.

#1 Headache

Katie Lincoln is a 25 year old white female who is seen in the clinic with complaints of recurrent severe headaches. She describes these headaches
as throbbing, usually on the left side in the temple area, and are typically accompanied by nausea and photophobia.. Pain is typically an 8 or 9 on a
10 point scale. Intensity and frequency of headaches have increased over
the last several months, and usually occur during her menses. Katie states that her headache today is "terrible; I took two ibuprofen tablets about
1 1/2 hrs ago, and they haven't even touched it."

PMH: Previous workups for aneurysm, tumor and infection have been negative, Otherwise, noncontributory

FH: Father 56, with NIDDM and HTN. Mother died 3 years ago in MVA.

Social: Teaches first grade. Smokes 1 ppd. Admits to occasional glass of wine, 2-3 times/month. Denies illegal drug use. 1-2 cups of coffee daily;
4-5 diet cokes daily. No routine exercise program. Frequently skips
breakfast. NKDA

Meds: Desogen, 1 tablet daily, began 6 months ago. Multivitamin daily, Ibuprofen prn

PE: Day 2 of menses, otherwise all parameters, including vs and neuro are normal.

Lab: BS 98, UA negative.

1. Develop a differential diagnosis list for Katie.

2. Assuming your most likely diagnosis is correct, what data in
   the H &P support your diagnosis?

3. Describe the options for abortive therapy for migraine
   headaches.

4. Prescribe a therapeutic regimen for Katie, including patient
    education and life style changes as well as pharmacologic
   interventions.

5. After following your prescribed regimen for several months,
    Katie tells you that she is somewhat better, but that she still
    gets headaches for several days each month. She states she
    had a friend with migraines who took a shot to prevent
    them. She wants to know what she can do to prevent hers.
    Describe the options for preventive therapy for migraine
    headaches. Which of these options would be most
   appropriate for Katie?