Acute Pain & Opioid-Free Analgesia (Cornelius) Exam II Flashcards
(238 cards)
1
Q
Which of the following best describes the function of acute pain?
A) A long-lasting pain meant to promote healing.
B) A direct stimulation of pain fibers that precedes potential tissue damage as a warning.
C) A direct response triggered by psychological factors only.
D) A type of chronic pain without a specific stimulus.
A
B) A direct stimulation of pain fibers that precedes potential tissue damage as a warning.
There is a close relationship between the intensity of the stimulus, the discharges in the primary afferents, and the subjective expression of pain.
Slide 3
2
Q
Acute pain has been shown to affect which of the following systems? (Select 3)
A) Cardiac
B) Pulmonary
C) Immune
D) Integumentary
A
A) Cardiac - heart rate goes up.
B) Pulmonary -they may breathe faster.
C) Immune
Slide 3
3
Q
Acute pain may lead to alterations in which of the following systems? (Select 3)
A) Endocrine
B) GI/GU
C) Coagulation pathways
D) Skeletal muscle function
A
A) Endocrine - things kind of get out of whack from a glycemic standpoint. Blood sugar may go up or go down.
B) GI/GU
C) Coagulation pathways
Slide 3
4
Q
Which of the following is an example of somatic superficial pain?
A) Expanding bowel gas
B) Accidental knife cut to the finger
C) Pain radiating to the left shoulder due to cardiac ischemia
D) Acute appendicitis
A
B) Accidental knife cut to the finger
slide 4
5
Q
Somatic acute pain that originates from skin, subcutaneous tissues, or mucous membranes is known as __________ pain.
A) Deep
B) Superficial
C) Parietal
D) Referred
A
B) Superficial
6
Q
Which of the following is an example of parietal pain?
A) Pain due to appendicitis
B) Pain due to muscle strain
C) Pain from a skin abrasion
D) Pain in tendons
A
A) Pain due to appendicitis
Localized around an organ; Sharp and stabby ⚡️⚡️⚡️⚡️⚡️
slide 4
7
Q
Which of the following are types of somatic pain? (Select 2)
A) Pain from a skin abrasion
B) Pain from a tendon injury
C) Pain from myocardial ischemia
D) Pain from peritoneal irritation
A
A) Superficial pain from a skin abrasion
B) Deep pain from a tendon injury - can also be from muscles, joints and bone
Slide 4
8
Q
Visceral pain can include which of the following characteristics? (Select 3)
A) Referred pain to cutaneous areas
B) Localized parietal pain
C) Deep pain from muscles and joints
D) Pain due to expanding bowel gas
A
A) Referred pain to cutaneous areas
B) Localized parietal pain,
D) Pain due to expanding bowel gas
slide 4
9
Q
Which of the following best defines referred pain ?
A) Pain localized to the area directly affected by tissue damage.
B) Pain that originates from the skin, muscles, or joints and is easily localized.
C) Pain that is felt in a location distant from the actual source of the pain
D) Pain that results only from organ damage and is sharp and well-defined.
A
C) Pain that is felt in a location distant from the actual source of the pain due to the convergence of visceral and somatic afferent input in the central nervous system (CNS).
Slide 4
10
Q
One of the key goals in pain management, especially for an intubated patient is:
A) Reducing the need for oxygen therapy
B) Controlling anxiety and agitation
C) Enhancing motor function
D) Improving gastrointestinal motility
A
B) Controlling anxiety and agitation
slide 5
11
Q
Which of the following are goals of pain control? (Select 2)
A) Attenuation of adverse physiologic responses
B) Prevention of chronic pain syndromes
C) Increased blood glucose regulation
D) Allowing anxiety and agitation
A
A) Attenuation of adverse physiologic responses
B) Prevention of chronic pain syndromes,
Overall Patient Comfort 🩵
Overall Patient Comfort 🩵
slide 5
12
Q
Which of the following is a key component of achieving optimal pain control goals according to the slide?
A) Reactive analgesia
B) Preemptive and preventative analgesia
C) Postoperative analgesia only
D) Single-modality approach
A
B) Preemptive and preventative analgesia
C - if we’re able to control the pain before it happens, you don’t have quite the same risk of the agitation, the sympathetic responses, the development of chronic pain syndromes.
slide 6
13
Q
Which of the following strategies is becoming more common in modern pain management?
A) Increasing opioid usage
B) Reducing all analgesic usage
C) Opioid-free anesthesia
D) Solely using NSAIDs for pain management
A
C) Opioid-free anesthesia
Slide 6
14
Q
The multimodal approach to pain control involves:
A) Using a single analgesic to target all receptors
B) Utilizing various analgesics to target multiple pain pathways
C) Decrease number of receptors
D) Administering pain medications only after surgery
A
B) Utilizing various analgesics to target multiple pain pathways
Corny - multimodal approach to do that and hitting as many receptors as possible, but with that in mind, you really have to target your analgesic plan to the patient.
Slide 6
15
Q
Which of the following correctly describes the progression of pain phases?
A) Neuropathic pain → Acute pain → Chronic nociceptive pain
B) Acute pain → Chronic nociceptive pain → Neuropathic pain
C) Chronic nociceptive pain → Acute pain → Neuropathic pain
D) Acute pain → Neuropathic pain → Chronic nociceptive pain
A
B) *Transient *Acute pain → Chronic nociceptive pain → Neuropathic pain
C - Now you can have patients that start off with essentially neuropathic pain. Think about somebody with diabetic neuropathy.
They may never really have an acute pain phase because they don’t have adequate sensation.
So with those patients, neuropathic pain may be their start.
Slide7
16
Q
True or False
Pain is not exclusive - at anytime, several of the underlying mechanisms may coexist in the same individual
A
True
Slide 7
17
Q
Which of the following disease states are commonly associated with pain?
A) Degenerative joint disease
B) Diabetes mellitus
C) Polymyalgia rheumatica
D) Wounds
E) End of Life
F) All of the above
G) None of the Above
H) A, B, & C
I) C, D, and E
A
F) All of the above
Slide 8
18
Q
Which of the following can cause pain related to immobility? (Select 4)
A) Surgery
B) Dementia
C) Fractures
D) Finger cut
E) PVD
A
A) Surgery
B) Dementia
C) Fractures
E) PVD - Peripheral vascular disease
slide 9
19
Q
Which of the following strategies can help alleviate pain caused by immobility? (Select 2)
A) Mobilizing the patient early post-surgery
B) Using opioid-free anesthesia
C) Encouraging physical therapy and movement
D) Increasing bed rest to prevent pain
A
A) Mobilizing the patient early post-surgery,
C) Encouraging physical therapy and movement
Slide 9
20
Q
Which of the following is NOT considered a red flag in pain management?
A) Pain that wakes the patient up
B) Severe or progressive neurologic deficit
C) Pain relieved by rest
D) Constitutional symptoms
A
C) Pain relieved by rest
Slide 10
21
Q
Which of the following signs in a patient with pain would indicate a potential Red Flag?
Select 3
A) Severe pain with immunosuppression
B) Pain accompanied by a cold, pale limb
C) Pain that gradually decreases over time
D) Severe abdominal pain with hypotension and fever
A
A) Severe pain with immunosuppression
B) Pain accompanied by a cold, pale limb
D) Severe abdominal pain with hypotension and fever
Cornelius - Pain to the point where it’s causing immunosuppression, oftentimes with malignancy will see that patients develop severe pain as their presentation and then they go in and they’ve got something like osteosarcoma.
slide 10
22
Q
Which of the following describes a constitutional symptom that would be considered a red flag in pain management?
A) Back pain that resolves with rest
B) Chronic back pain that improves with NSAIDs
C) Acute back pain followed by loss of balance and new onset of incontinence
D) Pain localized to the joints after activity
A
C) Acute back pain followed by loss of balance and new onset of incontinence
Corn - Constitutional symptoms - So maybe they have back pain and it’s a chronic condition, maybe it’s acute back pain. You fall and you’re doing OK, but the next day you wake up in your incontinence.
That’s a huge red flag.
Slide 10
23
Q
Matching!
Match the system with the consequences of poorly managed acute pain
A
Cardiovascular → Tachycardia, hypertension, and increase in cardiac workload
Pulmonary → Respiratory muscle spasm (splinting), decrease in vital capacity, atelectasis, hypoxia, and increased risk of pulmonary infection
Gastrointestinal → Postoperative ileus
Renal → Increased risk of oliguria and urinary retention
Coagulation → Increased risk of thromboemboli
Immunologic → Impaired immune function
Muscular → Muscle weakness and fatigue; limited mobility can increase the risk of thromboembolism
Psychological → Anxiety, fear, and frustration resulting in poor patient satisfaction
Slide 11
24
Q
In a patient with a history of coronary artery disease (CAD) and uncontrolled pain, which of the following could result from tachycardia and increased cardiac workload?
A) Arrhythmias
B) Demand ischemia
C) Pulmonary edema
D) Stroke
A
B) Demand ischemia
Slide 11
25
What complication may develop in a patient with rib fractures and inadequate pain control due to decreased respiratory effort?
A) Pneumonia
B) Pleural effusion
C) Cardiac tamponade
D) Hemothorax
A) Pneumonia
## Footnote
Slide 11
26
In a post-abdominal surgery patient receiving large doses of opioids for pain management, what complication might arise due to slowed gastrointestinal function?
A) Bowel perforation
B) Intestinal obstruction
C) Postoperative ileus
D) Gastric ulcer
C) Postoperative ileus
## Footnote
Slide 11
27
Who proposed the Specificity Theory of Pain?
A) Sigmund Freud
B) Charles Darwin
C) Rene Descartes
D) Immanuel Kant
C) Rene Descartes
| This guy
## Footnote
Slide 12
28
According to the Specificity Theory, the intensity of pain is directly related to:
A) The emotional response to pain
B) The amount and degree of tissue injury
C) The duration of the painful stimulus
D) The individual's pain threshold
B) The amount and degree of tissue injury
C - *if you hit your finger with a hammer versus a small needle, the pain you experience will be different in its intensity and is probably indicative of potential tissue damage*
*it doesn't include other senses, you have to involve other senses like see feeling and those may impact things*
## Footnote
Slide 12
29
One criticism of the Specificity Theory is that it *overreacts to pain* in cases where there is little tissue damage but the injury appears __________.
A) Insignificant
B) Severe
C) Superficial
D) Psychological
B) Severe
## Footnote
Slide 12
30
According to the Intensity Theory of Pain, which philosopher first conceptualized pain as an emotional experience rather than a sensory one?
A) Aristotle
B) Descartes
C) Plato
D) Socrates
C) Plato
| The dude
## Footnote
Slide 13
31
The Intensity Theory of Pain views pain primarily as a(n) __________ experience, rather than a sensory one.
A) Physical
B) Emotional
C) Mechanical
D) Psychological
B) Emotional
## Footnote
Slide 13
32
Who proposed the Gate Control Theory of Pain in 1965?
A) Rene Descartes and Sigmund Freud
B) Ronald Melzack and Patrick Wall
C) Charles Darwin and Immanuel Kant
D) Plato and Aristotle
B) Ronald Melzack and Patrick Wall
*this theory is the best one we have right now. it was the first cohesive explanation for the emerging complexities of pain phenomena, particularly chronic pain.*
| These old guys
## Footnote
Slide 14
33
According to the Gate Control Theory, pain transmission is modulated by *impulses transmitted to the spinal cord* and regulated by ________ .
A) Chemical neurotransmitters
B) Gate mechanisms
C) Electrical impulses
D) Hormonal signals
B) Gate mechanisms
## Footnote
Slide 14
34
According to the Gate Control Theory, where are the "gates" that regulate pain transmission located?
A) Cerebral cortex
B) Brainstem
C) Substantia gelatinosa of the spinal cord
D) Peripheral nerves
C) Substantia gelatinosa of the spinal cord
*The cells in this area functions as a gate regulating transmission of impulses to the central nervous system. *
## Footnote
slide 14
35
According to the Gate Control Theory, pain perception can be influenced by psychological factors such as __________, which may amplify or diminish the pain experience.
A) Hormones
B) Nutrient intake
C) Immune response
D) Past experiences
D) Past experiences
## Footnote
Slide 14
36
What types of tissue damage activate nociceptors in the body?
Select 3
A) Thermal
B) Mechanical
C) Electrical
D) Chemical
A) Thermal
B) Mechanical
D) Chemical
## Footnote
Slide 15
37
Which of the following fibers are responsible for transmitting pain signals from nociceptors?
Select 2
A) Myelinated Alpha-β
B) Myelinated Alpha-δ
C) Unmyelinated Delta fibers
D) Unmyelinated Gamma fibers
E) Unmyelinated C fibers
B) Myelinated Alpha-δ
E) Unmyelinated C fibers
**free afferent nerve endings **
## Footnote
Slide 15
38
Which of the following are inflammatory mediators released with **histamine** during tissue injury?
Select 3
A) Bradykinin
B) Prostaglandins
C) Acetylcholine
D) Serotonin
A) Bradykinin (peptides)
B) Prostaglandins (lipids)
D) Serotonin (neurotransmitters)
## Footnote
Slide 15
39
First-order neurons transmit pain signals from which location to the spinal cord?
A) The thalamus
B) The periphery
C) The brainstem
D) The somatosensory cortex
B) The periphery
## Footnote
Slide 16
40
Second-order neurons transmit pain signals from the spinal cord to the:
A) Somatosensory cortex
B) Brainstem
C) Thalamus
D) Cerebellum
C) Thalamus
## Footnote
Slide 16
41
Third-order neurons transmit pain signals from the thalamus to the __________, where the *final processing of pain occurs*.
A) Brainstem
B) Cerebellum
C) Somatosensory cortex
D) Spinal cord
C) Somatosensory cortex
42
First-order neurons receive pain signals in the periphery tissue receptors of the skin and the proprioceptors which are located in:
Select 3
A) Muscles
B) Joints
C) Thalamus
D) Tendons
E) Fascia
A) Muscles
B) Joints
D) Tendons
## Footnote
Slide 17
43
Where do the first-order neurons synapse with the second-order neurons in the pain pathway?
A. Thalamus
B. Somatosensory cortex
C. Dorsal horn of the spinal cord
D. Brainstem
C. Dorsal horn of the spinal cord
## Footnote
Side 18
44
After synapsing with the first-order neurons, where do the second-order neurons cross to in the pain pathway?
A. Ipsilateral side of the spinal cord
B. Contralateral side of the spinal cord
C. Anterior side of the spinal cord
D. Ventral side of the spinal cord
B. Contralateral side of the spinal cord
## Footnote
Slide 18
45
The second-order neurons ascend to the thalamus via which of the following tracts?
A. Spinothalamic tracts
B. Corticospinal tracts
C. Dorsal column tracts
D. Reticulospinal tracts
B. Spinothalamic tracts
## Footnote
Slide 18
46
Through which structure do third-order neurons project to the **postcentral gyrus** of the cerebral cortex?
A. Corpus callosum
B. Internal capsule
C. Spinal tract
D. Limbic system
B. Internal capsule
## Footnote
Slide 19
47
The ________ fibers are small, unmyelinated and conduct pain signals at a slow velocity, while the _______ fibers are large, myelinated and transmit pain signals rapidly.
A) C fibers; A-delta fibers
B) A-beta fibers; A-delta fibers
C) C fibers; A-beta fibers
D) A-beta fibers; Delta Fibers
A) C fibers; A-delta fibers
## Footnote
Slide 20
48
# Matching
Match the Four elements of Pain Processing to their definitions
Transduction: 1
Transmission: 3
Modulation: 4
Perception: 2
## Footnote
Slide 21
49
What is the definition of Allodynia?
A. Exaggerated response to a painful stimulus
B. Pain caused by a stimulus that normally provokes pain
C. Numbness or no pain from an affected area
D. Dull, aching pain
E. Pain caused by a stimulus that does not normally provoke pain
E. Pain caused by a stimulus that does not normally provoke pain
## Footnote
Slide 22
50
Which of the following describes Hyperalgesia?
A. Pain caused by a light touch
B. Exaggerated response to a painful stimulus
C. No pain response from the affected area
D. Numbness in the affected area
B. Exaggerated response to a painful stimulus
## Footnote
Slide 22
51
What is the **primary** mechanism of hyperalgesia?
A. Decreased sensitivity to painful stimuli
B. Augmented sensitivity to painful stimuli
C. Allodynia misinterpretation of non-painful stimuli as painful
D. Both B and C
E. Both A and C
F. All of the above
G. None of the above
D. Both B and C
Tissue trauma releases local inflammatory mediators that can produce augmented sensitivity to stimuli.
## Footnote
Slide 23
52
Which neurotransmitter is involved in **secondary** hyperalgesia by increasing excitablility of neurons and activating NMDA receptors?
A. Dopamine
B. Glutamate
C. Serotonin
D. Acetylcholine
B. Glutamate
## Footnote
Slide 23
53
What medication is commonly associated with causing hyperalgesia?
A. Fentanyl
B. Oxycodone
C. Morphine
D. Ketamine
E. Remifentanil
E. Remifentanil
## Footnote
Slide 23
54
Which medication is recommended to be used alongside remifentanil to prevent hyperalgesia?
A. Acetaminophen
B. Midazolam
C. Ketamine
D. Propofol
C. Ketamine
## Footnote
Slide 23
55
What is **central hypersensitivity** most associated with?
A) Increased tissue damage
B) Exaggerated pain responses
C) Reduced pain sensitivity
D) Increased nerve regeneration
B) Exaggerated pain responses
## Footnote
Slide 24
56
In the context of pain sensitization, which condition follows hyperalgesia on the stimulus intensity-pain intensity curve?
A) Normal pain response
B) Hyperesthesia
C) Neuropathy
D) Allodynia
D) Allodynia
C - *if you've got a patient with a normal pain response, look at how they shift to hyperlgesia and then to allodyni and a chronic pain state.*
## Footnote
Slide 24
57
Central hypersensitivity can cause pain in response to what type of stimuli?
A) Normal and minimal sensory stimuli
B) Only severe nociceptive stimuli
C) Deep tissue injury only
D) Minimal only sensory stimuli
A) Normal and minimal sensory stimuli
## Footnote
Slide 24
58
What is a hallmark 'negative' symptom of neuropathy resulting from complete denervation of a body part?
A) Burning sensation
B) Shooting pain
C) Numbness
D) Tingling sensation
C) Numbness
C -* it may also result in pain depending on how severe the denervation is for those patients. *
## Footnote
Slide 25
59
In addition to 'negative' symptoms, nerve trauma and disease are also associated with what type of symptoms?
A) Positive symptoms
B) Increased mobility
C) Loss of sensation only
D) Decreased pain perception
A) Positive symptoms
## Footnote
Slide 25
60
What effect does aging have on gastric acid secretion in the elderly?
a) Increases gastric acid secretion, decreased gastric pH
b) Decreases gastric acid secretion, elevating gastric pH
c) Has minimal effect on gastric acid secretion
d) Increases gastric acid, increases gastric pH
b) Decreases gastric acid secretion, elevating gastric pH
*Increased use of medications alter pH*
## Footnote
Slide 27
61
# Absorption
What is the overall effect of aging on drug absorption?
a) Significant reduction in absorption
b) Increased absorption due to slower metabolism
c) Minimal effect on drug absorption
d) Complete inhibition of absorption
c) Minimal effect on drug absorption
## Footnote
Slide 27
62
# Absorption
______ refers to the process where drugs are metabolized in the liver before reaching systemic circulation, which can be reduced in the elderly.
a) First-pass metabolism
b) Bioavailability
c) Active transport
d) Passive diffusion
a) First-pass metabolism
## Footnote
Slide 27
63
# Distribution
Which of the following statements are true regarding protein binding in elderly patients?
Select 2
a) Low albumin levels can lead to more free drug in circulation.
b) Highly protein-bound drugs are less affected by first-pass metabolism.
c) Malnourished patients may require albumin administration to improve drug effectiveness.
d) Changes in albumin levels do not affect wound healing.
a) Low albumin levels can lead to more free drug in circulation
c) Malnourished patients may require albumin administration to improve drug effectiveness
## Footnote
Slide 28
64
# Distribution
Whic factor does **not** affect drug binding and distribution in elderly patients?
a) Molecular size
b) Protein binding
c) pH levels
d) Lipid solubility
e) Enzyme activity
e) Enzyme activity
*Proportion relates the amount of drug in the body to the concentration measured in biological fluid*
* Protein binding
* pH
* Molecular size
* **Water**
* Lipid solubility
## Footnote
Slie 28
65
# Distribution
As patients age, their ____ mass decreases, which affects drug distribution.
a) Fat
b) Muscle
c) Bone
d) Liver
b) Muscle
## Footnote
Slide 29
66
# Distribution
Which factors influence the distribution of drugs in elderly patients?
Select 3
a) Total body water decreases
b) Muscle mass increases
c) Proportion of body fat increases
d) Albumin levels decrease
e) Total body water increases
a) Total body water decreases, *affecting water-soluble drugs,*
c) Proportion of body fat increases, *affecting lipid-soluble drugs*
d) Albumin levels decrease, *affecting protein-bound drugs*
## Footnote
Slide 29
67
# Metabolism
The ______ is the primary organ responsible for converting substances that are potentially harmful into forms that can easily be eliminated by the body.
a) Kidney
b) Heart
c) Liver
d) Lungs
c) Liver
## Footnote
Slide 30
68
# Metabolism
As patients age, **hepatic blood flow** ______, which affects the metabolism of drugs.
a) Increases
b) Decreases
c) Stays the same
d) Does not affect drug metabolism
b) Decreases
## Footnote
Slide 30
69
# Metabolism
Aging is associated with a ____ in **liver mass** and **intrinsic metabolic activity**, impacting drug metabolism.
a) Increase
b) Decrease
c) No change
d) Fluctuation
b) Decrease
## Footnote
Slide 30
70
# Excretion/Elimination
The ______ is the primary organ responsible for the excretion and elimination of substances from the body.
a) Liver
b) Heart
c) Kidney
d) Lungs
c) Kidney
## Footnote
S - 31
71
# Excretion/Elimination
A significant change in kidney function with aging is a reduction in ______, which impacts the body's ability to eliminate substances. Select 2 that apply.
a) Blood pressure
b) Blood flow
c) Glomerular filtration rate
d) Heart rate
b) blood flow
c) Glomerular filtration rate (**considered one of the most important changes with aging**)
## Footnote
Slide 31
72
# Excretion/Elimination
Aging results in a decrease in kidney **blood flow, mass** and ______, which are essential for filtration and excretion.
a) Number of blood platelets
b) Muscle fibers
c) Number of red blood cells
d) Number of functioning nephrons
d) Number of functioning nephrons
## Footnote
S - 31
73
The first step on the WHO Pain Relief Ladder recommends the use of _____ for pain persisting or increasing.
A. Opioids
B. Non-opioids
C. Corticosteroids
D. Neuromodulators
B. Non-opioids
C - *first is non opioid medications.
So we use lots of NSAIDs at this point, and you can also think about kind of adjuvant therapy for these people, things like physical therapy braces, Heat, cold, movement.*
## Footnote
Slide 32
74
When pain persists after non-opioid treatment, the second step of the WHO Pain Relief Ladder involves the addition of _____.
A. Mild to moderate opioids
B. Surgery
C. Non-pharmacological therapy only
D. Strong opioids
A. Mild to moderate opioids
C - *we may then consider opioid therapy, but we usually go ahead and consider whatever non opioid therapy we're using as well as the adjuvant therapy.*
## Footnote
Slide 32
75
At the final step of the WHO Pain Relief Ladder, opioids for _____ pain are recommended alongside non-opioid therapies.
A. Mild
B. Moderate to severe
C. Minimal
D. Chronic only
B. Moderate to severe
## Footnote
Slide 32
76
Which of the following statements apply to non-opioid analgesics?
Select 2
A. They have anti-inflammatory effects.
B. They act centrally.
C. They are not controlled drugs.
D. They cause sedation and respiratory depression.
A. They have anti-inflammatory effects.
C. They are not controlled drugs.
## Footnote
Slide 33
77
What are some characteristics of opioid analgesics?
select 2
A. No ceiling effects
B. Anti-inflammatory effects
C. No adverse effects
D. Schedule II or III controlled drugs
A. No ceiling effects
D. Schedule II or III controlled drugs
## Footnote
Slide 33
78
Opioid (narcotic) analgesics:
A. Act peripherally
B. Are not habit-forming
C. Act centrally
D. Have ceiling effects
C. Act centrally
## Footnote
Slide 33
79
Non-opioid (non-narcotic) analgesics:
A. Have no anti-inflammatory effects
B. Are controlled substances
C. Act centrally
D. Act peripherally
D. Act peripherally
## Footnote
Slide 33
80
Which of the following are adverse effects of opioid analgesics?
Select 3
A. Sedation
B. Respiratory depression
C. Gastric irritation
D. Constipation
E. Bleeding
A. Sedation
B. Respiratory depression
D. Constipation
## Footnote
Slide 33
81
Which of the following adverse effects are associated with non-opioid analgesics?
Select 3
A. Renal toxicity
B. Sedation
C. Gastric irritation
D. Bleeding
E. Respiratory depression
A. Renal toxicity
C. Gastric irritation
D. Bleeding
## Footnote
Slide 33
82
# True or False
For non-opioids, increasing the dose increases the analgesia but also increases side effects
FALSE
**Ceiling effects:**
For non-opiods, increasing the dose **doesn’t increase the analgesia** but it does increases side effects
## Footnote
Slide 33
83
# Matching!
Match the receptor with its effects
## Footnote
Slide 34
84
# True or False
The Mu (μ) receptor is the most common one we see with it's effects, especially that kinda high feeling
TRUE
Cornelius - *Mu is probably one of the most common ones that we see, and that's really what results in the analgesia, but it also results in a lot of our complications. That's where the respiratory depression comes from, the decrease in GI motility. That kinda high feeling.*
## Footnote
Slide 34
85
Which of the following is **NOT** a function of opioids?
a) Reducing the perception of pain
b) Acting directly on the CNS
c) Treating the underlying cause of pain
d) Binding to opioid receptors
c) Treating the underlying cause of pain
## Footnote
Slide 35
86
What is the alternate name for codeine?
a) 3-Hydroxycodeine
b) 3-Methoxymorphine
c) 3-Methylcodeine
d) 3-Ethoxymorphine
b) 3-Methoxymorphine
*derived from opium poppy the substitution for a methyl group for a hydroxyl group on the #3 carbon of morphine molecule*
## Footnote
Slide 39
87
Which of the following is a benefit of codeine compared to morphine?
a) Codeine is more potent when given orally
b) Codeine is less addictive when absorbed orally
c) Codeine is more reliably absorbed orally
d) Codeine has fewer side effects when given IV
c) Codeine is more reliably absorbed orally
## Footnote
Slide 39
88
Codeine is commonly co-administered with which of the following medications?
a) Aspirin
b) Ibuprofen
c) Acetaminophen
d) Naproxen
c) Acetaminophen
*dosing really varies between the Tylenol #3 and the Tylenol #4.*
## Footnote
Slide 39
89
Codeine is metabolized by the P450 enzyme ________ which demethylates **10%** of it into morphine in the liver?
a) CYP2C9
b) CYP3A4
c) CYP2D6
d) CYP1A2
c) CYP2D6
## Footnote
Slide 40
90
What happens to the remainder of the codeine dose that is not metabolized to morphine?
a) It is excreted unchanged
b) It is demethylated to inactive norcodeine by CYP3A4
c) It is metabolized into another active opioid
d) It is metabolized into an active analgesic
b) It is demethylated to **inactive norcodeine** by CYP3A4
## Footnote
Slide 40
91
Which of the following are true regarding codeine metabolism?
Select 2
a) 10% of the population is resistant to codeine’s analgesic effect
b) Children under 12 have mature CYP2D6 enzyme activity
c) Codeine metabolism involves more than 50 polymorphisms leading to variability in analgesia
d) All administered codeine is converted into morphine
a) 10% of the population is resistant to codeine’s analgesic effect
c) Codeine metabolism involves more than 50 polymorphisms leading to variability in analgesia
## Footnote
Slide 40
92
Which population is at risk of experiencing side effects from codeine without receiving adequate analgesia?
a) Adults over 65
b) Children under 12
c) Patients with liver disease
d) Pregnant women
b) Children under 12
## Footnote
slide 40
93
What is the typical adult dosing range for codeine?
a) 5-30 mg every 2 hours
b) 10-40 mg every 6 hours
c) 15-60 mg every 4 hours
d) 20-80 mg every 8 hours
c) 15-60 mg every 4 hours
Cornelius - *If its Tylenol #3, it's 30mg. For Tylenol #4, it's 60mg*
***60mg is equivalent to 650mg of Aspirin***
## Footnote
Slide 41
94
What is the maximum daily dose of codeine for adults?
a) 300 mg/day
b) 200 mg/day
c) 360 mg/day
d) 400 mg/day
c) 360 mg/day
## Footnote
Slide 41
95
What is the pediatric dosing range for codeine?
a) 1-2 mg/kg/dose
b) 0.5-1 mg/kg/dose
c) 2-4 mg/kg/dose
d) 0.2-0.4 mg/kg/dose
b) 0.5-1 mg/kg/dose
**60mg max per day**
## Footnote
Slide 41
96
What is the half-life of codeine?
a) 1-1.5 hours
b) 3-3.5 hours
c) 4-5 hours
d) 2-2.5 hours
b) 3-3.5 hours
## Footnote
Slide 41
97
Which of the following are common drug interactions with codeine?
a) Antihistamines, alcohol, anticholinergics
b) Opioids, alcohol, anticholinergics
c) Antihistamines, caffeine, alcohol
d) Antibiotics, NSAIDs, alcohol
b) Opioids, alcohol, anticholinergics
## Footnote
Slide 42
98
Which of the following is **NOT** a common side effect of codeine?
a) Hypotension
b) Urinary retention
c) Bradycardia
d) Hyperactivity
d) Hyperactivity
**Other side effects - N/V, respiratory depression, dizziness and *miosis***
C - *Something people don't think about from opioids, a lot of the time is the increased incidence of urinary GI symptoms. So you'll have patients that have **constipation and urinary retention,** just directly related to taking PO opioids.*
## Footnote
Slide 42
99
Select all contraindications for the use of codeine:
Select 4
a) Hypersensitivity
b) Acute/severe asthma
c) Respiratory depression
d) Paralytic ileus
e) Renal impairment
f) Hypertension
a) Hypersensitivity
b) Acute/severe asthma
c) Respiratory depression
d) Paralytic ileus
## Footnote
Slide 42
100
Tramadol is a synthetic opioid that acts on which of the following receptors?
a) Mu, Kappa, and Delta
b) Alpha 2 and Beta 1
c) NMDA and serotonin
d) GABA and nicotinic receptors
a) Mu, Kappa, and Delta
*Synthetic 4 -phenylpiperdine analogue of morphine*
| the - enantiomer stimulates alpha-2 receptors
## Footnote
Slide 43
101
Which enantiomer of Tramadol is responsible for **inhibiting norepinephrine** reuptake and stimulating **alpha-2 receptors**?
a) The + enantiomer
b) The – enantiomer
c) Both enantiomers
d) Neither enantiomer
b) The – enantiomer
The Great Cornholio - *A caution is that it opposes serotonin reuptake and norepinephine uptake, while it stimulates the A2 receptors, so if you're trying to treat somebody's blood pressure.
You may have issues. Likewise, if you're administering dexmedatomidine, you may say that it's potentiated*
## Footnote
Slide 43
102
The + enantiomer of tramadol acts as a __________ with moderate affinity at __________ receptors, contributing to its analgesic effects.
a. opioid agonist, mu
b. serotonin antagonist, kappa
c. norepinephrine reuptake inhibitor, delta
d. acetylcholine antagonist, sigma
a. opioid agonist, mu
## Footnote
Slide 43
103
In addition to binding at mu receptors, the + enantiomer of tramadol opposes the reuptake of __________ and has weak affinity at __________ receptors.
a. dopamine, delta and sigma
b. norepinephrine, alpha-2
c. serotonin, kappa and delta
d. acetylcholine, mu and sigma
c. serotonin, kappa and delta
## Footnote
Slide 43
104
Tramadol is metabolized by the hepatic P-450 enzymes __________ and __________ to O-desmethyltramadol, which is **2-4 times more potent** than the original compound.
a. CYP 2D6, CYP 3A4
b. CYP 1A2, CYP 2C9
c. CYP 3A5, CYP 2B6
d. CYP 2C19, CYP 2E1
a. CYP 2D6, CYP 3A4
## Footnote
Slide 44
105
Tramadol is __________ the potency of morphine.
a. 1/3 to 1/10
b. 1/2 to 1/5
c. 1/5 to 1/15
d. 1/5 to 1/10
d. 1/5 to 1/10
## Footnote
Slide 45
106
The onset of action of oral tramadol is __________.
a. 30 minutes
b. 1-2 hours
c. 2-4 hours
d. 4-6 hours
b. 1-2 hours (oral)
## Footnote
Slide 45
107
The volume of distribution of tramadol is __________.
a. 1.5-2.5 L/kg
b. 2.6-2.9 L/kg
c. 3.0-3.5 L/kg
d. 4.0-4.5 L/kg
b. 2.6-2.9 L/kg
## Footnote
Slide 45
108
The half-life (T₁/₂) of tramadol is __________ hours, while its metabolite has a half-life of __________ hours.
a. 5.3, 6.0
b. 4.5, 6.5
c. 6.3, 7.4
d. 7.4, 9.0
c. 6.3, 7.4
## Footnote
Slide 45
109
What is the percentage of protein binding of tramadol?
a. 10%
b. 20%
c. 30%
d. 40%
b. 20%
## Footnote
Slide 45
110
Which of the following patients would tramadol be contraindicated for?
a. Patients with seizure disorders
b. Patients with hypertension
c. Patients with asthma
d. Patients with diabetes
a. Patients with seizure disorders
## Footnote
slide 46
111
Which of the following are **NOT** associated with tramadol use?
a. High incidence of nausea and vomiting
b. Minimal incidence of constipation
c. Associated with dependence and addiction
d. Minimal respiratory depressant effects
c. Associated with dependence and addiction
*or tolerance*
## Footnote
Slide 46
112
Who originally isolated morphine in 1804?
A) Albert Hofmann
B) Friedrich Serturner
C) Louis Pasteur
D) Alexander Fleming
B) Friedrich Serturner
## Footnote
Slide 47
113
Morphine was named after which Greek God?
A) Zeus
B) Apollo
C) Morpheus
D) Hermes
C) Morpheus
## Footnote
Slide 47
114
The oral dose requirement of morphine is about _____ times the intramuscular (IM) or intravenous (IV) dose.
A) Two
B) Three
C) Four
D) Five
B) Three
## Footnote
Slide 47
115
Morphine affects primarily which receptors?
A) Kappa and Delta
B) Alpha-1 and Alpha-2
C) Mu-1 and Mu-2
D) Beta-1 and Beta-2
C) Mu-1 and Mu-2
## Footnote
Slide 47
116
In which year was morphine first marketed for distribution?
A) 1787
B) 1804
C) 1827
D) 1853
C) 1827
## Footnote
Slide 47
117
What is the principal pathway of morphine metabolism?
A) Sulfation in the liver
B) Conjugation with oxidation
C) Oxidation via CYP450 enzymes
D) Reduction in the kidneys
E) Conjugation with glucuronic acid
E) Conjugation with glucuronic acid
*in hepatic AND extrahepatic sites **especially the kidneys***
## Footnote
slide 48
118
Which active metabolite of morphine contributes to analgesia?
A) Morphine-3-glucuronide
B) Morphine-6-glucuronide
C) Morphine sulfate
D) Normorphine
B) Morphine-6-glucuronide
## Footnote
Slide 48
119
Which of the following morphine metabolites is associated with neurotoxicity and hyperalgesia?
A) Morphine-6-glucuronide
B) Morphine-3-glucuronide
C) Morphine sulfate
D) Normorphine
B) Morphine-3-glucuronide
## Footnote
Slide 48
120
Which of the following factors contribute to the minimal absorption of morphine into the CNS? (Select 3)
A) Poor lipid solubility
B) High degree of protein binding
C) Extensive first-pass effect
D) Low ionization at physiologic pH
E) High degree of metabolism via CYP450 enzymes
F) High degree of ionization at physiologic pH
A) Poor lipid solubility
B) High degree of protein binding
F) High degree of ionization at physiologic pH
## Footnote
Slide 48
121
What is the typical onset of effect for morphine after intramuscular administration?
A) 5-10 minutes
B) 15-30 minutes
C) 30-45 minutes
D) 45-60 minutes
B) 15-30 minutes
## Footnote
Slide 49
122
Which of the following are characteristics of morphine's pharmacokinetics? (Select 2)
A) 35% protein binding
B) Well absorbed after intramuscular administration
C) Peak effect occurs within 15 minutes of administration
D) Elimination half-life ranges from 1.5 to 3.7 hours
E) Volume of distribution is 100 liters
A) 35% protein binding,
B) Well absorbed after intramuscular administration,
## Footnote
Slide 49
123
Morphine exhibits greater analgesic potency and slower speed of offset in _____.
A) Men compared to women
B) Women compared to men
C) Patients under 40 years of age
D) Patients with renal impairment
B) Women compared to men
## Footnote
Slide 49
124
The volume of distribution of morphine is approximately _____.
A) 50 liters
B) 100 liters
C) 224 liters
D) 300 liters
C) 224 liters
## Footnote
Slide 49
125
What is the elimination half-life range of morphine?
A) 0.5 to 1 hour
B) 1.7 to 3.3 hours
C) 5 to 6 hours
D) 10 to 12 hours
B) 1.7 to 3.3 hours
## Footnote
Slide 49
126
In patients with renal impairment, morphine-6-glucuronide can accumulate and lead to which of the following *serious* side effects?
A) Respiratory depression
B) Hypertension
C) Seizures
D) Tachycardia
B) Respiratory depression
## Footnote
Slide 50
127
Which of the following is associated with morphine use? (Select 4)
A) Histamine release
B) Tolerance and dependence
C) Tachycardia
D) Euphoria
E) Excitability
F) Sedation
A) Histamine release
B) Tolerance and dependence
D) Euphoria
F) Sedation
## Footnote
Slide 50
128
Which of the following is **NOT** a common side effect of morphine?
A) Euphoria
B) Sedation
C) Constipation
D) Diarrhea
D) Diarrhea
## Footnote
Slide 50
129
Which of the following drugs is a synthetic derivative of thebaine?
A) Morphine
B) Codeine
C) Oxycodone
D) Fentanyl
C) Oxycodone
*recently replaced Morphine as the most opioid used worldwide*
## Footnote
Slide 51
130
Oxycodone is often combined with medications such as __ , __ , and __ , and is widely used in the treatment of __ pain.
A) Acetaminophen, Aspirin, Ibuprofen; Neuropathic
B) Acetaminophen, Naproxen, Ibuprofen; Inflammatory
C) Aspirin, Ibuprofen, Codeine; Post-surgical
D) Acetaminophen, Aspirin, Morphine; Musculoskeletal
**A) Acetaminophen, Aspirin, Ibuprofen;**
**Neuropathic pain**
*acute and chronic pain*
## Footnote
Slide 51
131
What is the controlled-release form of oxycodone known as and what is its immediate-release counterpart?
A) Oxycontin; OxyIR
B) Percocet; Oxycontin
C) OxyIR; Vicodin
D) Oxycontin; Percocet
A)
**Oxycontin** (controlled-release)
**OxyIR** (immediate-release)
## Footnote
Slide 51
132
Oxycodone is primarily considered a prodrug and it is metabolized into ___which is active and ___ which is inactive.
A) Oxymorphone; Noroxycodone
B) Noroxycodone; Oxymorphone
C) Morphine; Codeine
D) Hydromorphone; Norcodeine
A)
Oxymorphone (active)
Noroxycodone (inactive)
## Footnote
Slide 52
133
Oxycodone primarily acts on which receptors?
A) μ and κ receptors
B) δ and κ receptors
C) σ and δ receptors
D) μ and δ receptors
A) **μ and κ receptors**
of the CNS
## Footnote
Slide 52
134
Where is oxycodone primarily metabolized, and how is it excreted from the body?
A) Metabolized in the liver by the CYP450 2D6 pathway; excreted in urine
B) Metabolized in the kidneys; excreted in bile
C) Metabolized in the liver by the CYP450 3A4 pathway; excreted in urine
D) Metabolized in the lungs; excreted in urine
A) Metabolized in the liver by the CYP450 2D6 pathway; excreted in urine
*extensive first pass effect*
## Footnote
Slide 52
135
What is the typical dose of oxycodone, and how does it compare to morphine?
A) 10-15 mg, equal to 10 mg of morphine
B) 5-10 mg, equal to 15 mg of morphine
C) 15-20 mg, equal to 5 mg of morphine
D) 20-25 mg, equal to 10 mg of morphine
A) 10-15 mg,
equal to 10 mg of morphine
## Footnote
Slide 53
136
What is the onset of action of oxycodone?
A) Less than 1 hour
B) 1-2 hours
C) 2-3 hours
D) 3-4 hours
A) Less than 1 hour
## Footnote
Slide 53
137
What is the typical duration of effect for immediate-release (IR) and controlled-release (CR) formulations of oxycodone?
A) IR: 3-4 hours, CR: 12 hours
B) IR: 2-3 hours, CR: 10 hours
C) IR: 4-5 hours, CR: 14 hours
D) IR: 1-2 hours, CR: 8 hours
A) IR: 3-4 hours, CR: 12 hours
## Footnote
Slide 53
138
Oxycodone has ___ effects when combined with other central nervous system depressants.
A) Additive
B) Synergistic
C) Antagonistic
D) Neutral
A) Additive
## Footnote
Slide 54
139
# Hope the question format isn't too complicated
Select all the side effects of oxycodone based on their respective body systems:
A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity
B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate
C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea
D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence
A) Central Nervous System:
* Sedation
* Euphoria
B) Respiratory System:
* Respiratory depression
C) Gastrointestinal System:
* Constipation
* Nausea and vomiting
D) Miscellaneous:
* Histamine release
* Tolerance and dependence
Corn: *As I mentioned, there is less risk, but you do still have a risk of tolerance and dependence in these patients*
## Footnote
Slide 54
140
Methadone is a synthetic broad-spectrum opioid primarily used for:
A) Acute pain management
B) Maintenance therapy for opioid addiction
C) Neuropathic pain relief
D) Anesthetic induction
**B) Maintenance therapy for opioid addiction**
- 60-90% oral bioavailability
- High potency
- Long duration of action
Corn: *So methadone is a mixed agonist antagonist and as a result of that we see that it's used for weaning patients off of more opioids*
## Footnote
Slide 55
141
What should be known about methadone’s half-life? (Select 2 that apply)
A) It is very long and unpredictable, up to 36 hours
B) It is short and predictable, less than 12 hours
C) Can accumulate with repeated doses
D) It does not accumulate with repeated doses
E) It has a half-life similar to other opioids such as morphine
A) It is very long and unpredictable, up to **36 hours**
C) Can accumulate with repeated doses
## Footnote
Slide 55
142
Methadone has affinities for which of the following receptors and actions? (Select 4 that apply)
A) Weak noncompetitive NMDA receptor antagonist
B) Serotonin reuptake inhibitor
C) Monoamine reuptake inhibitor
D) Alpha-adrenergic receptor agonist
E) μ receptor affinity
A) Weak noncompetitive NMDA receptor antagonist
B) Serotonin reuptake inhibitor
C) Monoamine reuptake inhibitor
E) μ receptor affinity
## Footnote
Slide 55
143
What would occur if methadone is used concurrently with carbamazepine?
A) Methadone levels will increase due to slower metabolism
B) Methadone will be metabolized faster
C) Methadone levels will remain unchanged
D) Methadone’s half-life will be extended
B) Methadone will be metabolized faster
*Carbamazepine is a CYP450 inducer*
*Methadone is Metabolized in the liver by CYP450 system (primarily by CYP3A4, out also cYP1A2 and cYP2D6. Into Inachve metabolites)
## Footnote
Slide 56
144
Which of the following agents can inhibit the metabolism of methadone? (Select 2 that apply)
A) Antiretrovirals
B) Carbamazepine
C) Grapefruit juice
D) Rifampin
A) Antiretrovirals
C) Grapefruit juice
*CYP450 Inhibitors*
## Footnote
Slide 56
145
How is methadone excreted from the body?
A) Primarily in urine with no unchanged drug
B) Primarily in bile, with significant amounts of unchanged drug
C) Excreted in both urine and bile, with small amounts of unchanged drug
D) Primarily through feces
C) Excreted in both urine and bile, with small amounts of unchanged drug
*Hepatic and renal impairment do not influence clearance of Methadone significantly*
SAFE FOR OLDER PATIENTS
## Footnote
Slide 56
146
What is the typical dose of methadone for pain management?
A) 2.5-10 mg PO/IM/SC every 4-12 hours
B) 5-20 mg PO/IM/SC every 8-24 hours
C) 10-30 mg PO/IM/SC every 2-6 hours
D) 1-5 mg PO/IM/SC every 12-24 hours
**A) 2.5-10 mg PO/IM/SC
every 4-12 hours**
*Steady state concentrations may take up to 10 days to achieve due to extensive restribution of the drug. Can accumulate and result in high plasma concentrations*
## Footnote
Slide 57
147
Why are standardized simple dosing guidelines unachievable for methadone?
A) It has a low bioavailability
B) It has a highly variable half-life ranging from 8 to 80 hours
C) It is primarily metabolized by the kidneys
D) It is rapidly eliminated from the body
B) It has a highly variable half-life ranging from 8 to 80 hours
## Footnote
Slide 57
148
What is the most dangerous medication interaction associated with methadone?
A) Carbamazepine
B) Antiretrovirals
C) Monoamine oxidase inhibitors (MAOIs)
D) Grapefruit juice
C) Monoamine oxidase inhibitors (MAOIs)
*can cause severe, unpredictable reactions with these drugs*
*effects similar to other opioids: hypotensiton, respiratory depression, confusion, sedation*
## Footnote
Slide 58
149
Which of the following drugs are known to increase the concentration or effects of methadone? (Select 3 that apply)
A) Ciprofloxacin
B) Diazepam
C) Carbamazepine
D) Acute alcohol consumption
E) Rifampin
A) Ciprofloxacin
B) Diazepam
D) Acute alcohol consumption
## Footnote
Slide 58
150
Which of the following drugs are known to decrease the concentration or effects of methadone? (Select 5 that apply)
A) Amprenavir
B) Phenobarbital
C) Phenytoin
D) Rifampin
E) Monoamine oxidase inhibitors (MAOIs)
F) Ciprofloxacin
A) Amprenavir
B) Phenobarbital
C) Phenytoin
D) Rifampin
E) Monoamine oxidase inhibitors (MAOIs)
## Footnote
Slide 58
151
Which of the following are cardiac complications that can rarely occur with methadone usage? (Select 3 that apply)
A) Pause-dependent dysrhythmia (associated with bradycardia)
B) QT prolongation
C) Torsades de pointes
D) Atrial fibrillation
A) Pause-dependent dysrhythmia (associated with bradycardia)
B) QT prolongation
C) Torsades de pointes
## Footnote
Slide 58
152
Fentanyl is structurally similar to which of the following drugs?
A) Morphine
B) Meperidine
C) Codeine
D) Hydromorphone
B) Meperidine
## Footnote
Slide 59
153
Fentanyl has ___ potency, ___ onset of action, and ___ duration of action.
A) Low; slow; long
B) High; rapid; short
C) Moderate; slow; long
D) High; slow; short
B) High; rapid; short
Fentanyl has **high potency,** **rapid onset** of action, and **short duration** of action.
*Onset: 30 - 60 sec; Duration of action: 1 - 1.5 hr*
## Footnote
Slide 59
154
# True or False
Fentanyl was initially developed for intravenous anesthetic use but later gained additional roles in cancer and chronic pain management through transdermal and transmucosal preparations.
True
## Footnote
Slide 59
155
What is the principal metabolite of fentanyl?
A) Norfentanyl
B) Normeperidine
C) Morphine-6-glucuronide
D) Codeine
A) Norfentanyl
*Detectable in urine up to 72 hours after single dose*.
## Footnote
Slide 60
156
Why is the elimination of fentanyl slightly prolonged despite its very short duration of action?
A) It is metabolized by the kidneys
B) It binds strongly to plasma proteins
C) The lungs serve as a large inactive reservoir
D) It undergoes extensive hepatic metabolism
C) The lungs serve as a large inactive reservoir
*up to 75% of initial dose undergoes first pass pulmonary uptake)*
## Footnote
Slide 60
157
Why is fentanyl more potent and has a more rapid onset of action compared to morphine?
A) Greater water solubility
B) Lower protein binding
C) Greater lipid solubility
D) Higher molecular weight
C) Greater lipid solubility
## Footnote
Slide 61
158
The short duration of action of fentanyl is mainly due to:
A) Liver metabolism
B) Slow movement into fat and muscle
C) rapid distribution into inactive tissues like fat and muscle
D) Long time in the liver
C) rapid distribution into inactive tissues like fat and muscle
## Footnote
Slide 61
159
Which of the following is true about fentanyl’s pharmacokinetics? (Select 3 that apply)
A) It has a protein binding of 84%
B) Its volume of distribution is 335 liters
C) Its elimination half-time is between 3.1 and 6.6 hours
D) Its initial dose is not subject to first-pass metabolism
A) It has a protein binding of 84%
B) Its volume of distribution is 335 liters
C) Its elimination half-time is between 3.1 and 6.6 hours
## Footnote
Slide 61
160
Fentanyl dosing is highly dependent on which of the following factors?
A) Patient's weight
B) Route of administration
C) Patient's age
D) Kidney function
**B) Route of administration**
Corn: *So your dose really depends on how you're administering. So say for instance. somebody's having their lap, Chole, I may give them 50 to 100 mcg of it now,. On the other hand, if I'm putting it in a spinal injection, I may only use 10 mcg. So quite a bit of variability as far as how you dose it.*
## Footnote
Slide 61
161
What percentage of an initial fentanyl dose undergoes first-pass pulmonary uptake, limiting the initial amount that reaches systemic circulation?
A) 50%
B) 75%
C) 25%
D) 90%
B) 75%
*lungs also serve as a large inactive storage*
## Footnote
Slide 61
162
What type of drug interaction occurs when fentanyl is used with other central nervous system depressants?
A) Antagonistic effects
B) Additive effects
C) Synergistic effects
D) No significant interaction
B) Additive effects
## Footnote
Slide 62
163
Select all the side effects of Fentanyl based on their respective body systems:
A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity
B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate
C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea
D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence
A) Central Nervous System:
* Sedation
* Euphoria
B) Respiratory System:
* Respiratory depression
C) Gastrointestinal System:
* Constipation
* Nausea and vomiting
D) Miscellaneous:
* Histamine release
* Tolerance and dependence
| Yes, it's a repeated question :)
## Footnote
Slide 62
164
Hydromorphone (Dilaudid) is a semisynthetic drug and can be formed by which of the following processes? (Select 2 that apply)
A) N-demethylation of hydrocodone
B) Hydrogenation of the ketone group in morphine
C) Oxidation of the ketone group in morphine
D) N-demethylation of morphine
E) Reduction of the ketone group in morphine
A) N-demethylation of hydrocodone
B) Hydrogenation of the ketone group in morphine
*Similar to morphine in that it is hydrophilic and has a comparable duration of analgesia ten times more lipophilic than morphine*
## Footnote
Slide 63
165
How much more potent is hydromorphone than morphine when administered orally?
A) 2 to 3 times
B) 5 to 7 times
C) 3 to 5 times
D) 8 to 10 times
C) 3 - 5 times
*Regarded as an effective alternative to morphine for the treatment of moderate to severe pain, available in oral, parenteral, and rectal use*
## Footnote
Slide 63
166
Hydromorphone is approximately how many times more potent than morphine when administered parenterally?
A) 3 times
B) 5 times
C) 8.5 times
D) 10 times
C) 8.5 times
## Footnote
Slide 63
167
What is the primary metabolite of hydromorphone?
A) Hydromorphone-6-glucuronide
B) Hydromorphone-3-glucuronide
C) Morphine-6-glucuronide
D) Normeperidine
B) Hydromorphone-3-glucuronide
*like its parent compound is excreted renally*
## Footnote
Slide 64
168
What should be known about hydromorphone-3-glucuronide? (Select 2 that apply)
A) It has strong analgesic effects
B) It lacks analgesic effects
C) It may potentiate neurotoxic effects
D) It is responsible for the majority of hydromorphone's pain-relieving properties
B) It lacks analgesic effects
C) It may potentiate neurotoxic effects (allodynia, myoclonus, seizures).
## Footnote
Slide 64
169
When are hydromorphone-3-glucuronide’s neurotoxic side effects an actual concern?
A) Patients with hepatic insufficiency
B) Patients with renal insufficiency
C) Patients with cardiovascular disease
D) Patients with pulmonary disease
B) Patients with renal insufficiency
## Footnote
Slide 64
170
What is the typical dose of parenteral hydromorphone for pain management?
A) 1 - 5 mg
B) 0.2 - 2 mg
C) 5 - 10 mg
D) 2 - 4 mg
**B) 0.2 - 2 mg**
*intravenously every 3 to 5 minutes which is titrated to achieve a balance between pain relief and respiratory depression*
Corn: *...repeat it over 10 or 15 minutes. Remember that your onset time is gonna be a little bit longer than something like Fentanyl, so don't rush and get too much in there because you may then have kind of a compounded effect*
## Footnote
Slide 65
171
What is the typical oral dose of hydromorphone for pain management?
A) 1 - 4 mg
B) 2 - 8 mg
C) 5 - 15 mg
D) 10 - 20 mg
B) 2 - 8 mg
## Footnote
Slide 65
172
What is the typical duration of action of hydromorphone?
A) 1 - 2 hours
B) 3 - 4 hours
C) 5 - 6 hours
D) 7 - 8 hours
B) 3 - 4 hours
*half life is 2.3 hours*
## Footnote
Slide 65
173
What type of drug interaction occurs when Hydromorphone is used with other central nervous system depressants?
A) Antagonistic effects
B) Additive effects
C) Synergistic effects
D) No significant interaction
B) Additive effects
| Same as all other opiods
## Footnote
Slide 66
174
Select all the side effects of Hydromorphone based on their respective body systems:
A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity
B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate
C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea
D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence
A) Central Nervous System:
* Sedation
* Euphoria
B) Respiratory System:
* Respiratory depression
C) Gastrointestinal System:
* Constipation
* Nausea and vomiting
D) Miscellaneous:
* Histamine release
* Tolerance and dependence
| yes, another repeated question :)
## Footnote
Slide 66
175
Hydrocodone is a semi-synthetic opioid that is a derivative of which substance?
A) Morphine
B) Codeine
C) Oxycodone
D) Hydromorphone
B) Codeine
## Footnote
Slide 67
176
How much more potent is hydrocodone compared to codeine?
A) 2 to 4 times
B) 4 to 6 times
C) 6 to 8 times
D) 8 to 10 times
C) 6 to 8 times
## Footnote
Slide 67
177
What are the two most commonly abused opioids?
A) 1st: Morphine, 2nd: Codeine
B) 1st: Hydromorphone, 2nd: Hydrocodone
C) 1st: Oxycodone, 2nd: Hydrocodone
D) 1st: Fentanyl, 2nd: Oxycodone
**C) 1st: Oxycodone,**
**2nd: Hydrocodone**
Corn: *So we were saying there was a pretty significant amount of abuse that was being done. If you go back and look 10 or 15 years ago, the pill mills in Florida and Appalachia were passing out tons of oxycodone and hydrocodone.*
## Footnote
Slide 67
178
Hydrocodone is most often combined with which of the following medications?
A) Ibuprofen
B) Aspirin
C) Acetaminophen
D) Naproxen
C) Acetaminophen
*Norco, Vicodin, and Lortab*
## Footnote
Slide 67
179
What are the two primary metabolites of hydrocodone metabolism?
A) Hydromorphone
B) Codeine
C) Morphine
D) Norhydrocodone
E) Oxycodone
**A) Hydromorphone** (via CYP2D6)
**D) Norhydrocodone** (inactive) via CYP3A4
## Footnote
Slide 68
180
What is the morphine equivalent of 30 mg of hydrocodone?
A) 10 mg of morphine
B) 15 mg of morphine
C) 20 mg of morphine
D) 30 mg of morphine
A) 10 mg of morphine
10 mg morphine = 30 mg hydrocodone
(1:3)
## Footnote
Slide 69
181
While oxycodone is often used for ___ pain management, hydrocodone is typically used for __ administration durations.
A) short-term; long-term
B) long-term; short-term
C) moderate; acute
D) chronic; extended
B) long-term; short-term
Corn: So while we were using **oxycodone for long-term** pain medications, we may use **hydrocodone for short-term** administrations.
Hydrocodone:
Peak: 1.3 + 0.3 hours
Elimination T½: 3.8 + 0.3 hours
## Footnote
Slide 69
182
What is the typical dosing range for hydrocodone when combined with acetaminophen, and what is the maximum daily dose of acetaminophen?
A) 2.5-10 mg hydrocodone with 300-750 mg acetaminophen; 4 g acetaminophen/24h
B) 5-15 mg hydrocodone with 500-1000 mg acetaminophen; 3 g acetaminophen/24h
C) 10-20 mg hydrocodone with 200-600 mg acetaminophen; 6 g acetaminophen/24h
D) 15-25 mg hydrocodone with 400-900 mg acetaminophen; 5 g acetaminophen/24h
A) 2.5-10 mg hydrocodone with 300-750 mg acetaminophen;
4 g acetaminophen/24h (max dose)
q4-6h
*Available as tablet, capsule, syrup, solution, XR suspension, XR tablet*
## Footnote
Slide 69
183
Hydrocodone is commonly combined with which of the following drugs? (Select 3 that apply)
A) Acetaminophen
B) Aspirin (ASA)
C) Guaifenesin
D) Ibuprofen
A) Acetaminophen
B) Aspirin (ASA)
C) Guaifenesin
*various antihistamines*
## Footnote
Slide 69
184
Which of the following interactions are associated with hydrocodone? (Select all that apply)
A) Increased sedation with other opioids
B) Increased sedation with benzodiazepines
C) Hypotension with barbiturates
D) Intravenous magnesium or calcium channel blockers may increase opioid effects
All of the above
## Footnote
Slide 70
185
Which of the following is NOT a known side effect of hydrocodone?
A) Meiosis
B) Histamine release
C) Pruritis
D) Increased hypercapnic drive
E) Decreased respiratory rate/airway reflexes
F) Bradycardia
G) Hypotension
H) Nausea/vomiting and Constipation
D) Increased hypercapnic drive
*decreased hypercapnic drive*
## Footnote
Slide 70
186
Which of the following should be used with caution in patients taking hydrocodone?
A) Alcoholism
B) Drug abuse
C) Drugs containing acetaminophen (Tylenol)
D) All of the above
D) All of the above
## Footnote
Slide 70
187
Buprenorphine is classified as a:
A) Full opioid agonist
B) Partial agonist-antagonist opioid
C) Pure antagonist
D) Non-opioid analgesic
**B) Partial agonist-antagonist opioid**
*derived from the opium alkaloid thenaine*
*Available in a variety of preparations to include: Cizdol, Subutex, Suboxone, Zubsolv, Bunavail*
## Footnote
Slide 71
188
Buprenorphine has affinity for which of the following receptors? (Select 3 that apply)
A) Mu receptor as a partial agonist
B) Kappa receptor as a strong antagonist
C) Delta receptor as a weak agonist
D) Sigma receptor as a strong agonist
A) Mu receptor as a partial agonist
B) Kappa receptor as a strong antagonist
C) Delta receptor as a weak agonist
## Footnote
Slide 71
189
What are the benefits provided by buprenorphine? (Select 3 that apply)
A) Less respiratory depression
B) Less immune suppression
C) Increased constipation
D) No accumulation in renal patients
E) More sedation
A) Less respiratory depression
B) Less immune suppression
*reduced constipation*
D) No accumulation in renal patients
## Footnote
Slide 71
190
What is the primary metabolite of buprenorphine?
A) Norbuprenorphine
B) Hydromorphone
C) Morphine-6-glucuronide
D) Codeine
A) Norbuprenorphine
*a full agonist at the Mu, Delta, and ORL-1 opioid receptors and a partial agonist at the Kappa receptor*
## Footnote
Slide 72
191
What should be known about norbuprenorphine? (Select 2 that apply)
A) It has 1/50th the analgesic activity of buprenorphine
B) It has equal analgesic activity to buprenorphine
C) It significantly increases respiratory depression
D) It reduces respiratory depression compared to buprenorphine
A) It has 1/50th the analgesic activity of buprenorphine
C) It significantly increases respiratory depression
## Footnote
Slide 72
192
What is the IV/IM dose equivalence of buprenorphine to morphine?
A) 0.3 mg IM buprenorphine = 5 mg IV morphine
B) 0.3 mg IM buprenorphine = 10 mg IV morphine
C) 0.3 mg IM buprenorphine = 15 mg IV morphine
D) 0.3 mg IM buprenorphine = 20 mg IV morphine
B) 0.3 mg IM buprenorphine = 10 mg IV morphine
## Footnote
Slide 73
193
Oral administration of buprenorphine results in high first-pass metabolism, which can be overcome by ___ or ___ administration.
A) Intravenous; intramuscular
B) Sublingual; transdermal
C) Oral; rectal
D) Intranasal; inhalation
**B) Sublingual; transdermal**
*Sublingual administration has a relatively rapid onset of 30 minutes with a long duration of analgesia of 6-9 hours*
*Transdermal patches deliver 5-70 ug hr for 4-7 days*
## Footnote
Slide 73
194
What is the half-life of buprenorphine?
A) 5 - 10 hours
B) 10 - 20 hours
C) 20 - 73 hours
D) 80 - 100 hours
C) 20 - 73 hours
## Footnote
Slide 73
195
Buprenorphine is primarily eliminated through which organ, resulting in little risk of accumulation in patients with renal impairment?
A) Kidneys
B) Liver
C) Lungs
D) Intestines
B) Liver
## Footnote
Slide 73
196
Which of the following are common side effects of buprenorphine? (Select 4 that apply)
A) Drowsiness
B) Nausea
C) Vomiting
D) Depression of ventilation
E) Hypertension
A) Drowsiness
B) Nausea
C) Vomiting
D) Depression of ventilation
## Footnote
Slide 74
197
Buprenorphine’s antagonist properties can precipitate withdrawal symptoms in patients physically dependent on:
A) Methadone
B) Morphine
C) Fentanyl
D) Codeine
B) Morphine
## Footnote
Slide 74
198
How do withdrawal symptoms in patients physically dependent on buprenorphine compare to those associated with morphine?
A) They develop quickly and are more intense
B) They develop slowly and are of lesser intensity
C) They are more severe but develop at the same pace
D) They are identical to withdrawal symptoms from morphine
B) They develop slowly and are of lesser intensity
## Footnote
Slide 74
199
Which of the following are parenteral routes of delivery suitable for a person who cannot swallow? (Select all that apply)
A) Topical
B) Rectal
C) Intravenous (IV)
D) Subcutaneous
E) "Trans mucosal"
F) Transdermal
All of the above
## Footnote
Slide 75
200
Which of the following are benefits associated with the long-term use of opioids? (Select 3 that apply)
A) Pain reduction
B) Constipation
C) Increase in functionality
D) Fewer episodes of severe pain "spikes"
A) Pain reduction
C) Increase in functionality
D) Fewer episodes of severe pain "spikes"
## Footnote
Slide 76
201
Which of the following is NOT a risk associated with long-term opioid use?
A) Dependence
B) Addiction
C) Overdose
D) Withdrawal
E) Constipation
F) Delirium
G) Worsening of pain
H) Pain reduction
H) Pain reduction
## Footnote
Slide 76
202
Which of the following strategies can be used for the prevention and treatment of opioid side effects? (Select 4 that apply)
A) Choosing the "two-fer"
B) Opioid rotation
C) Pharmacologic interventions
D) Non-pharmacologic interventions
E) Decreasing education efforts
**A) Choosing the "two-fer"**
*think about medications that do more than one thing, so perhaps medications that have a nonopioid component as well. Or medications that hit multiple receptors as opposed to just hitting new receptors*
**B) Opioid rotation**
*Consider moving on to something else*
**C) Pharmacologic interventions**
**D) Non-pharmacologic interventions**
*just little things like getting up out of bed may be the best approach for the patient*
*educate the patients*
## Footnote
Slide 77
203
Which of the following is NOT a characteristic of non-opioid analgesics?
A) Analgesic, anti-inflammatory, and antipyretic properties
B) Act on peripheral tissues to inhibit formation of pain-causing substances
C) Bind directly to opioid receptors
D) Block production of cyclooxygenase (COX) enzymes
C) Bind directly to opioid receptors
*Do not bind to receptors*
## Footnote
Slide 78
204
Which of the following statements are true about acetaminophen (Tylenol®)? (Select 3 that apply)
A) It is effective for reducing pain and fever
B) It has strong anti-inflammatory properties
C) Caution is advised in patients with liver or kidney impairment
D) It can be used safely with excessive alcohol consumption
E) It has little anti-inflammatory effect
A) It is effective for reducing pain and fever
C) Caution is advised in patients with liver or kidney impairment (and alcohol use)
E) It has little anti-inflammatory effect
## Footnote
Slide 79
205
Which of the following statements are true about COX-2 inhibitors? (Select 3 that apply)
A) They decrease inflammation
B) They should be taken with food
C) They can cause abdominal side effects, such as constipation and cramps
D) They bind directly to opioid receptors
A) They decrease inflammation
B) They should be taken with food
C) They can cause abdominal side effects, such as constipation and cramps
## Footnote
Slide 79
206
Which of the following are non-opioid analgesics mentioned in the slide? (Select all that apply)
A) Acetaminophen (Tylenol®)
B) NSAIDs
C) COX-2 Inhibitors
D) Other
E) Steroids
All of the above
## Footnote
Slide 79
207
What is the typical dosing range for acetaminophen?
A) 100-200 mg every 8 hours
B) 250-500 mg every 12 hours
C) 500-1000 mg every 6 hours
D) 1000-1500 mg every 4 hours
C) 500-1000 mg every 6 hours
## Footnote
Slide 80
208
# NSAIDs
What is the recommended dose for celecoxib?
A) 50 mg daily
B) 100 mg daily
C) 200 mg daily
D) 400 mg daily
B) 100mg daily
## Footnote
Slide 80
209
# NSAIDs
What is the typical dosing regimen for diclofenac?
A) 25 mg once daily
B) 50 mg twice daily
C) 75 mg three times daily
D) 100 mg twice daily
B) 50 mg twice daily
## Footnote
Slide 80
210
# NSAIDs
What is the typical dosing regimen for ibuprofen?
A) 100 mg once daily
B) 200 mg three times daily
C) 400 mg four times daily
D) 600 mg every 8 hours
B) 200 mg three times daily
## Footnote
Slide 80
211
# NSAIDs
What is the typical dosing regimen for naproxen?
A) 100 mg once daily
B) 150 mg three times daily
C) 220 mg twice daily
D) 500 mg once daily
C) 220 mg twice daily
## Footnote
Slide 80
212
Which of the following are true regarding the use of antidepressants for nerve pain? (Select 3 that apply)
A) They increase transmission in the spinal cord to reduce pain signals
B) They provide immediate pain relief
C) They do not work right away and may take time to be effective
D) Common side effects include dizziness, drowsiness, and dry mouth
E) They increase appetite and energy levels
**A) They increase transmission in the spinal cord to reduce pain signals**
*nerve pain
**C) They *do not work right away* and may take time to be effective**
*Often times you're going to need 5 to 10 days to get really good coverage*
**D) Common side effects include dizziness, drowsiness, and dry mouth**
*Other times the issue you run into is patients don't appreciate the side effects with it*
Memory Trick: side effects when you're drunk = dizzy, drowsy, dry mouth
## Footnote
Slide 81
213
Which of the following anticonvulsants are commonly used for nerve pain? (Select 4 that apply)
A) Gabapentin (Neurontin®)
B) Phenytoin (Dilantin®)
C) Carbamazepine (Tegretol®)
D) Topiramate (Topamax®)
E) Acetaminophen (Tylenol®)
**A) Gabapentin (Neurontin®)** *most common*
**B) Phenytoin (Dilantin®)**
**C) Carbamazepine (Tegretol®)**
**D) Topiramate (Topamax®)**
Corn: *Anticonvulsants are one of the newer medications that we've really started using for acute surgical pain...all these are primarily targeted at neuropathic pain, but we may treat that neuropathic pain for becomes a problem.*
Side effects:
Drowsiness, dizziness, headache, weight gain
## Footnote
Slide 81
214
Which of the following are true regarding skeletal muscle relaxants and topical adjuvant medications? (Select 3 that apply)
A) Skeletal muscle relaxants are used for muscle pain, tension headaches, and lower back pain
B) Common side effects of skeletal muscle relaxants include drowsiness, dizziness, dry mouth, and constipation
C) Topical medications such as creams and patches provide long-term pain relief
D) Topical medications are used for a shorter period of time to relieve pain
**A) Skeletal muscle relaxants are used for muscle pain, tension headaches, and lower back pain**
Baclofen( Lioresal®),
Carisoprodol(Soma®), Cyclobenzaprine(Flexeril®) Methocarbamol(Robaxin®), Tizanidine(Zanaflex®)
**B) Common side effects of skeletal muscle relaxants include drowsiness, dizziness, dry mouth, and constipation**
**D) Topical medications are used for a shorter period of time to relieve pain**
Topical (over-the-counter):
Capsaicin Cream
Menthol‐ Methyl Salicylate Cream (Bengay®)
Lidoderm 5% Patch
## Footnote
Slide 82
215
Which of the following is a topical intervention used for pain management?
A) Menthol
B) Nerve blocks
C) Salsa
D) Accupuncture
E) Petroleum Jelly
A) Topical menthol
## Footnote
Slide 83
216
Which of the following are physical interventions used for pain management? (Select 5 that apply)
A) Massage/Range of motion
B) Hypnosis
C) Physical therapy
D) Heat/Cold therapy
E) Radiation
F) Nerve blocks
A) Massage/Range of motion
C) Physical therapy
D) Heat/Cold therapy
E) Radiation
F) Nerve blocks
## Footnote
Slide 83
217
Which of the following are mind-body interventions used for pain management? (Select 6 that apply)
A) Relaxation techniques
B) Hypnosis
C) Acupuncture/Acupressure
D) Psychotherapy
E) Yoga/Tai Chi
F) Aromatherapy
G) Nerve blocks
A) Relaxation techniques
B) Hypnosis
C) Acupuncture/Acupressure
D) Psychotherapy
E) Yoga/Tai Chi
F) Aromatherapy
## Footnote
Slide 83
218
Which of the following are barriers to the use of opioids for pain management? (Select 5 that apply)
A) Fear of addiction
B) Fear of side effects
C) Fear of death
D) Lack of effectiveness for acute pain
E) Care plan adherence due to functional limitations
F) Not being the best drug for chronic pain
**A) Fear of addiction**
*Concept of pseudo‐addiction
The patient with current or past substance abuse*
**B) Fear of side effects**
**C) Fear of death**
**E) Care plan adherence due to functional limitations**
**F) Not being the best drug for chronic pain**
## Footnote
Slide 85
219
Which of the following are key principles in opioid dosing for effective pain management? (Select 3 that apply)
A) Initial dosing
B) Up-titration
C) Maximum dose
D) Frequency of administration
E) Duration of treatment
**A) Initial dosing**
*somebody that's opioid naive that's really just getting opioids for acute pain*
**B) Up-titration**
**C) Maximum dose**
* For acute pain
* For persistent pain
* For cancer pain
* For other end of life pain
## Footnote
Slide 86
220
When considering Patient Controlled Analgesia (PCA), which of the following are key considerations? (Select 2 that apply)
A) Barriers to effective PCA use
B) Built-in safety mechanisms
C) Decreased effectiveness with prolonged use
D) Increased risk of sedation
A) Barriers to effective PCA use
B) Built-in safety mechanisms
*Negated by proxy dosing
*Consider provider administered bolus
## Footnote
Slide 87
221
In which of the following scenarios is Patient Controlled Analgesia (PCA) commonly used? (Select 2 that apply)
A) Hospital
B) End of life
C) Emergency room for minor injuries
D) Dental procedures
E) Outpatient rehabilitation
**A) Hospital**
*Post op
*Pain crisis
**B) End of life**
*Transition to home
## Footnote
Slide 87
222
Match the route of administration with its correct dosage for Morphine:
Intravenous
Intramuscular
Oral
A) 30 - 60 mg
B) 2.5 - 15 mg
C) 10 - 15 mg
Intravenous B) 2.5 - 15 mg
Intramuscular C) 10 - 15 mg
Oral A) 30 - 60 mg
## Footnote
Slide 88
223
Match the route of administration with its correct dosage for Hydromorphone:
Intravenous
Intramuscular
Oral
A) 1 - 4 mg
B) 0.2 - 1 mg
C) 1 - 4 mg
Intravenous B) 0.2 - 1 mg
Intramuscular A) 1 - 4 mg
Oral C) 1 - 4 mg
## Footnote
Slide 88
224
Match the route of administration with its correct dosage for Fentanyl:
Intravenous
Transmucosal
Transdermal
A) 200 - 1600 µg
B) 12.5 - 100 µg
C) 20 - 50 µg
Intravenous C) 20 - 50 µg
Transmucosal A) 200 - 1600 µg
Transdermal B) 12.5 - 100 µg
## Footnote
Slide 88
225
Match the route of administration with its correct dosage for Oxymorphone:
Oral
Intravenous
Subcutaneous
Intramuscular
A) 0.5 - 1 mg
B) 1 - 1.5 mg
C) 1 - 1.5 mg
D) 5 - 10 mg
Oral D) 5 - 10 mg
Intravenous A) 0.5 - 1 mg
Subcutaneous C) 1 - 1.5 mg
Intramuscular B) 1 - 1.5 mg
## Footnote
Slide 88
226
Compare the equianalgesic dose of Morphine for parenteral and oral administration:
A) 10 mg Parenteral = 30 mg Oral
B) 7.5 mg Parenteral = 30 mg Oral
C) 10 mg Parenteral = 20 mg Oral
D) 30 mg Parenteral = 100 mg Oral
A) 10 mg Parenteral = 30 mg Oral
## Footnote
Slide 89
227
Compare the equianalgesic dose of Hydromorphone for parenteral and oral administration:
A) 1.5 mg Parenteral = 30 mg Oral
B) 10 mg Parenteral = 30 mg Oral
C) 1.5 mg Parenteral = 7.5 mg Oral
D) 7.5 mg Parenteral = 15 mg Oral
C) 1.5 mg Parenteral = 7.5 mg Oral
## Footnote
Slide 89
228
Compare the equianalgesic dose of Codeine for parenteral and oral administration:
A) 130 mg Parenteral = 100 mg Oral
B) 10 mg Parenteral = 30 mg Oral
C) 130 mg Parenteral = 200 mg Oral
D) 200 mg Parenteral = 130 mg Oral
C) 130 mg Parenteral = 200 mg Oral
## Footnote
Slide 89
229
Compare the equianalgesic dose of Methadone for parenteral and oral administration:
A) 2.5 mg Parenteral = 5 mg Oral
B) 130 mg Parenteral = 200 mg Oral
C) 1.5-2.5 mg Parenteral = 3-5 mg Oral
D) 130 mg Parenteral = 150 mg Oral
C) 1.5-2.5 mg Parenteral = 3-5 mg Oral
## Footnote
Slide 89
230
# Case Study
Test Question: Mary is a 70-year-old female with a past medical history of spinal stenosis, presenting with left leg pain and weakness. Given her chronic pain and potential signs of neuropathic pain, what might be an appropriate opioid treatment option that minimizes the risk of respiratory depression, sedation, and other common opioid-related side effects? (2)
A) Oxycodone
B) Fentanyl
C) Methadone
D) Buprenorphine
**C) Methadone**
**D) Buprenorphine**
*So a lot of times with these patients, especially if they're a little bit older, we try and go to something that's a little bit more of a mixed picture...we don't have a lot of those complications and that way we can kind of get her to this steady state without the risk of sedation*
## Footnote
Slide 92-93
231
# Case Study
David is an 86-year-old nursing home resident with end-stage dementia. He is bed-bound, contracted, dependent in all activities of daily living (ADLs), and presents with a new Stage 5 sacral decubitus ulcer. Surgery is planned to debride the ulcer. Considering his condition, which of the following anesthesia and long-term care options are most appropriate? (Select 4 that apply)
A) Administer a traditional opioid like morphine or fentanyl to manage pain and behavior during surgery.
B) Consider a general anesthetic to manage positioning challenges and behavioral control due to dementia.
C) Use a sacral erector spinae plane (ESP) block or spinal anesthesia to minimize the cognitive impact of anesthesia.
D) Administer minimal sedation and have the surgeon infiltrate local anesthetic into the wound to manage pain.
E) Focus on regional anesthesia like a quadratus lumborum block for pain management, even if positioning is difficult.
F) Begin discussing palliative care or hospice options given his end-stage dementia, functional decline, and ongoing weight loss.
G) Consider transitioning David to intensive physical therapy after surgery to restore mobility and function.
H) Continue aggressive nutritional support, including enteral feeding, to reverse his weight loss and prevent further decline.
B) Consider a general anesthetic to manage positioning challenges and behavioral control due to dementia.
C) Use a sacral erector spinae plane (ESP) block or spinal anesthesia to minimize the cognitive impact of anesthesia.
D) Administer minimal sedation and have the surgeon infiltrate local anesthetic into the wound to manage pain.
F) Begin discussing palliative care or hospice options given his end-stage dementia, functional decline, and ongoing weight loss.
## Footnote
Slide 94-95
232
Jack, a 65-year-old man with squamous cell lung cancer, experiences right-sided pelvic pain rated at 8/10 in the region of known pelvic metastases. His pain limits mobility and awakens him from sleep. Positioning during his care is a concern due to the increased pain he experiences. He has been on 30 mg of morphine every four hours, but it no longer provides relief. What would be an appropriate pain management plan for Jack during surgery to control his pain, considering his history and current condition? (Select all that apply)
A) Continue administering 30 mg of morphine every four hours during surgery.
B) Switch to a longer-acting opioid, such as continuous-release oxycodone, to maintain more consistent pain relief.
C) Consider a ketamine infusion during surgery to help manage pain and potentially use ketamine nasal spray post-operatively for continued pain relief.
D) Administer a fentanyl patch for additional analgesia during surgery and post-operatively.
E) Use a patient-controlled analgesia (PCA) system with a non-opioid option to manage post-surgical pain.
All of the above
## Footnote
Slide 96-97
233
Which of the following medications have both a bolus dose and continuous infusion options? (Select 4 that apply)
A) Alfenatnil
B) Morphine
C) Methadone
D) Hydromorphone
E) Fentanyl
F) Sufentanil
G) Oxymorphone
**B) Morphine**
*Bolus: 0.5-2.5 mg
*Continuous Infusion: 1-2 mg/h
**D) Hydromorphone**
*Bolus: 20-50 µg
*Continuous Infusion: 10-100 µg/h
**E) Fentanyl**
*Bolus: 0.05-0.25 mg
*Continuous Infusion: 0.2-0.4 mg/h
**F) Sufentanil**
*Bolus: 2-5 µg
*Continuous Infusion: 2-8 µg/h
## Footnote
Slide 98
234
What is a common reference range for lockout intervals in Patient-Controlled Analgesia (PCA)?
A) 1-5 minutes
B) 10-20 minutes
C) 20-30 minutes
D) 30-40 minutes
B) 10-20 minutes
Corn: *Some will be shorter than that, but most of these medications have a duration of action that's a lot longer than that, and that'll get you enough time for onset. But it also gives you enough time that they should be comfortable. So Lockout 10 to 20 minutes is pretty common.*
## Footnote
Slide 98
235
Which of the following opioids is commonly used for its longer duration of action in epidural top-offs?
A) Fentanyl
B) Naloxone
C) Duramorph
D) Sufentanil
C) Duramorph
(Neuraxial Morphine)
Corn: *Top off an opioid before we pull it.Durhamorph is a pretty common agent that we use for that because it does provide a little bit longer duration of action than something like fentanyl*
## Footnote
Slide 99
236
What are the most common opioids used intrathecally for neuraxial analgesia?
A) Fentanyl and Morphine
B) Oxycodone and Methadone
C) Buprenorphine and Nalbuphine
D) Hydromorphone and Codeine
A) Fentanyl and Morphine
Corn: *pretty much any of our opioids can be used intrathecally. But I think the most common ones you see are fentanyl and Morphine*
## Footnote
Slide 99
237
In epidural medications, which combination is commonly seen for continuous infusion?
A) Lidocaine with Hydromorphone
B) Bupivacaine or Ropivacaine with Fentanyl
C) Ketamine with Naloxone
D) Propofol with Sufentanil
B) Bupivacaine or Ropivacaine with Fentanyl
Corn: *The other thing you'll see is that a lot of times our continuous infusion epidural medications will already have opioids added to it.
I think probably one of the most common ones we see is either bupivacaine or ropivocaine with fentanyl in it.*
## Footnote
Slide 99
238
How do spinal doses of opioids typically compare to epidural doses?
A) Spinal doses are higher than epidural doses.
B) Spinal doses are the same as epidural doses.
C) Spinal doses are lower than epidural doses.
D) Spinal doses are irrelevant to epidural doses.
C) Spinal doses are lower than epidural doses.
Corn: *Keep in mind your spinal dose is going to be significantly lower than your epidural dose.*
## Footnote
Slide 99
