Analgesia Flashcards
(176 cards)
1
Q
principles of pain therapy (pre-opioid crisis)
A
give scheduled
verify effectiveness
allow for dose titration
not “1-2 tabs” without indicating when to use 2 vs 1
2
Q
for severe pain, provide ___
A
long acting analgesics ATC
short acting analgesics PRN for break through pain
3
Q
non-opioids
A
NSAIDs
Acetaminophen
4
Q
adjuvant therapy
A
anticonvulsants (gabapentin)
TCAs
SSRI
SNRI
5
Q
opiates
A
codeine
morphine
6
Q
opioids
A
propxyphene tramaodl hydromorphone oxycodone fentanyl meperidine methadone
7
Q
MOA of NSAIDs
A
inhibition of cylooxygenase (COX)
8
Q
most NSAIDs are ___
A
nonselective for COX1 and COX2
9
Q
COX1 is ___
A
cyto-protective
10
Q
COX 2 is ___
A
inflammatory
11
Q
use NSAIDs for ____ pain
A
mild-moderate
12
Q
ceiling effects
A
additional drug gives no additional analgesia; only increases SE (NSAIDs)
13
Q
class side effects
A
GI upset
GI irritation/ulceratio
edema
renal impairment
14
Q
after one class of drug fails, ___
A
try another
15
Q
Dual MOA work in ___
A
synergy
16
Q
With combo NSAIDs, efficacy > ___
A
sum of the individual components
17
Q
In NSAID combos, dose titration is often limited by ___
A
non-opioid
18
Q
NSAID combos being limited by non-opioid is often the cause of ___
A
unintended overdose
19
Q
most hepatic failures with NSAIDs are from ___
A
excessive opioid/APAP use
20
Q
usual max of acetaminophen
A
4g/d (soon to be 3g/d per FDA)
21
Q
usual max for Aspirin
A
4g/d (higher for anti-inflammatory)
22
Q
usual max for ibuprofen
A
3.2g/d
23
Q
salicylic acids (aspirin) is a ___
A
weak anti-inflammatory agent
24
Q
aspirin is contraindicated if ___
A
<16 years (risk of Reye’s Syndrome0
25
low dose aspirin
81mg
26
anti-inflammatory dose of aspirin
3.6-5.4 g/d
27
propionic acids (ibuprofen) are ___
anti-inflammatory, antipyretic, analgesic
28
max inflammatory dose of ibuprofen
3.2g/d
29
max pain/fever/dysnemorrhea dose of ibuprofen
1.2 g/d
30
only commonly injectable NSAID
ketorolac (toradol)
31
ketorolac is used for ___
mod-severe pain
32
NSAID useful for post-op pain
ketorolac
33
ketorolac is only used for___
5 days due to increased risk of GI bleed
34
ketorolac usual dose
30mg IVP q6
35
max dose of ketoroalc
120mg/d
36
dise reduction of ketorolac:
patients >65
body weight <50 kg
"moderately elevated" serum creatinine
37
mefenamic acid is used for ___
mild-mod pain
38
avoid ___ when using mefenamic acid
alcohol (enhances mucosal irritation)
39
this NSAID is little used
mefenamic acid
40
NSAIDs mainly used for acute and chronic RA and OA
piroxicam
41
advantage of piroxicam is
long half life
42
piroxicam allows for ___
daily dosing
43
reduce dose of piroxicam with ___
hepatic dysfunction
44
only remaining selective COX2 inhibitor
celecoxib
45
Rofecoxib increased number of ___
cardiac events (AMIS)
46
CoX2 inhibitors are very useful in
non-cardiac patients (orthopedics)
47
Acetaminophen is an effective ___
analgesic, antipyretic
48
APAP has little ___
anti-inflammatory activity
49
many ____ following overdose on APAP
hepatic failures
50
recommended max dose of APAP
4g/d (3g/d soon?)
51
avoid APAP in patients with ___
alcoholic liver disease
52
MOA Of APAP
inhibits both COX isozymes
53
COX inhibition may be more pronounced in the ___
brain
54
APAP inhibits ____
hypothalamic heat-regulating center
55
when adjusting APAP for renal impairment, ___
metabolites accumulate
56
CrCl 10-50 give APAP ___
q6h
57
CrCL <10 give APAP ___
q8h
58
infant drop dose of APAP
100mg/mL
59
injection dose of APAP
Afirmed: 1000mg/100mL (post op x 4 doses, $$$)
60
dose of injection APAP adults / adolescents >50kg
1000mg q6h
| MAX 4G/D
61
Injection (Afirmed) adults adolescents <50 kg dose
15mg/kg q6 OR 5mg/kg Q4
| MAX 75 mg/kg/d
62
child dosing for APAP
10-15mg/kg/d
63
APAP toxicity tx
oral therapy: Mac (Mucomyst)
| IV therapy: (Acetadote)
64
long term acetaminophen use during pregnancy resulted in ___
2 fold increased risk of offspring having ADHD
65
APAP used for <8d during pregnancy was assc w/ ___
decreased risk in ADHD
66
remeasured pain score 2 hr post dose most reduction to least reduction
oxycodone
hydrocodone
codeine
67
MOA of Opioid receptors
mu-classical analgesic receptor
68
opioid receptors are the basis of ___
mixed agonist-antagonist agents
69
opiates = ___
natural agents from opium (codeine, morphine)
70
opioids = ___
modifications of natural opiates (synthetics)
71
mixed opioid agonists-antagonists
buprenorphine
butorphanol
pentazocine
nalbuphine
72
mixed agents are __
little used
73
exception ot mixed opioid agonists not being used is __
nalbuphine
74
nalbuphine is more effective in ___
females
75
nalbuphine has a ceiling effect on ___
respiratory depression
76
napbuphine is used in ___
labor/delivery
77
endorphins are derived from __
small endogenous peptide hormones
78
endorphins account for ___
variability of response to pain
79
opiate/opioid side/adverse effects
```
nausea
itching
sedation/cognitive impairment
respiratory depression
meiosis
decreased GI peristalsis
```
80
tolerance does not develop to
opioid AEs
81
opioids for mild-moderate pain
tramadol
codeine
hydrocodone
82
tramadol is a ___
weak opioid analgesic -- useful for chronic pain
83
ultram is ___
immediate release
84
ultracet is __
tramadol 37.5mg/acetaminophen 325mg
85
ultram
ER tabs
86
increase dosage of tramadol over ___
weeks -- high incidence of N/V (limits usefulness for acute pain)
87
tarmadol has a ___ MOA
dual
88
tramadol is useful for __
neuropathic pain
89
tramadol is now a ___
controlled substance
| 2014--CIII
90
codeine is a ___
weak alagesic, antitussive
91
60mg codeine produces less analgesia than ___
aspirin 650mg
92
codeine is metabolized by __
CYP2D6 to morphine
93
cyp2d6 inhibitors ___
decrease codeine's effect
94
antiemetic phenothaizenes
thorazine, compazine, phenergan)
95
cyp2d6 inhibitors
haloperidol, fluoxetine, paroxetine
96
10% of the population lack the ___ enzyme
cyp2d6
97
codeine is available alone or in combination w/
acetaminophen
98
hydrocodone is only available ___ w/ ___
PO with acetaminophen
99
Norco dose of acetaminophen
325mg
100
hydrocodone:
norco
lortab
vicoden
101
hydrocodone allows better ___
pain relief and longer duration than codeine
102
hydrocodone is metabolized by __
cyp2d6 to hydromorphone (dilaudid)
103
63% of unintentional overdoses involve combination products, most commonly ___
hydrocodone
104
opioids for moderate to severe pain
```
morphine
hydromorphone
oxycodone
meperidine
methadone
fentanyl
```
105
morphine prototype pure ___
mu receptor agonist
106
morphine has 2 active metabolites, both __ eliminated
renally
107
morphine-3-glucuronide is a ___
neurotoxin
108
morphine-6-glucuronide provides ___
analgesia 2-4x that of morphine
109
morphine induces ___
histamine release (hypotension, pruritus)
110
morphine has a significant _____
first-pass effect
111
morphine has a parenteral-to-oral dose ratio of:
1:3
112
dose of morphine sulfate injection
2mg/mL
113
dosage forms of morphine sulfate
```
injection
immediate release tabs
SR capsules (Kadian)
CR tabs (MS Contin)
Oral solution (Roxanol)
```
114
5-7x more potent than morphin
hydromorphone (dilaudid)
115
hydromorphone (dilaudid) often results in ___
iatrogenic overdoses
116
hydromorphone's imported SE profile:
less histamine erelease
| no active opioid metabolites
117
sustained released form of hydromorphone
exalgo
| 8, 12, 16, 32 mg CR tabs
118
alcohol destroyed time-release mechanism of SR Palladone causing --
overdoses
119
dose of injectable dilaudid
2mg/mL
120
oxycodone is more potent w/ fewer side effects than ___
morphine
121
oxycodone is metabolized by ___
cyp2d6 to oxymorphone (also active)
122
oxycodone is useful in patients with ___
cyp2d6 deficiency or on inhibitors
123
oxycodone is useful in nonresponders to ___
non-responders to codeine and hydrocodone
124
dosage forms of oxycodone
```
oxycodone IR
roxicodone
oxycodone CR
with acetaminophen
with aspirin
```
125
meperidine is not recommended as ___
1st line agent
126
meperidine is ___ causing more rapid onset, shorter duration (2-3h)
lipophilic
127
meperidine is metabolized to active metabolite ___
normeperidine (neurotoxic)
128
meperidine has long ___
metabolite half life
129
meperidine causes
euphoria, irritability, seizures
130
toxicity of meperidine is not reversed by ____
opiate antagonists
131
meperidine metabolites is __ eliminated
renally
132
meperidine is contraindicated in patients on ___
MAOIs (serotonin syndrome)
133
meperidine may be used in patients with serious ___
opiate allergies
134
meperidine is useful in controlling ___
post anesthesia shivering
135
methadone has unique pharacology:
racemic mix of I and D isomers.
136
I isomer of methadone -->
opioid activity
137
d isomer of methadone -->
NMDA antagonist & NE/5HT reuptake inhibitor
138
methadone is useful for __
neuropathic pain
139
methadone has the longest half life :
12-190h; usually ~24h
140
methadone is useful in treatment of
opiate addiction (dosed q24h)
141
analgesia from methadone only lasts ___
4-8h
142
dose methadone q___ for analgesia
6-8h
143
fentanyl is __x more potent than morphine and is dosed in __
100x; mcg
144
fentanyl is extremely ___
lipophilic.
145
fentanyl has __ onset and __ duration
rapid onset; short duration (30-60 minutes)
146
___ has many fewer adverse reactions than morphine or dilaudid
fentanyl
147
fentanyl has minimum ___
histamine release, hypotensive effect
148
dosage forms of fentanyl
injection
lozenge
transdermal
149
duragesic cautions are not usually used in ___
opiate naive pateints
150
monitor respiratory rate using duragesic cautions for ___
24h
151
replace duragesic cautions q __h
72h
152
look for multiple patches when ___
discharging patients (don't just continue adding additional patches.)
153
fentanyl is only used for ___
standing chronic (cancer) pain
154
naloxone is a pure ___
mu receptor antagonist
155
naloxone is used to reverse ____
sedation/respiratory depression but ALSO REVERSES ANALGESIA
156
administration of naloxone
dilute 0.4mg to >10mL saline
administer via SLOW IVP (1mL/1-2m)
monitor respiratory rate
stop when respiratory rate increasess
157
____ is used to establish useful analgesic regimens
equianalgesisc dosing
158
nonpharmalogic therapy and nonopijoid pharmacologic therapy are perferred for ___
chronic pain
159
when staring opioids for chronic pain, clinicians should ___
prescribe immediate release opioids instead of ER/long-acting
160
when prescribing opioids for acute pain, use ___
the lowest effective dose of IR opioids for 3-7d
161
evaluate benefits and harms within ___ of starting opioids for chronic pain and again every ___
1-4 wks
| every 3 mo or more frequently
162
incorporate strategies to mitigate risk of opioid addiction such as:
naloxone
163
monitor a patient's ____
controlled substance use
164
use drug urine drug screening before starting ____
opioid therapy and at least annually.
165
avoid prescribing opioids and ___ concurrently
benzodiazepines
166
offer or arrange evidence based treatment for patients with ___
opioid-use disorder (OUD)
167
buprenorphine is a partial ___
opioid agaonist
168
buprenorphine helps relieve ___
withdrawal sx
169
buprenorphine may begin with __
opioids in the patient's system
170
naltrexone is an ___
opioid antagonist
171
naltrexone may precipitate ___
withdrawal symptoms
172
naltrexone is only available in ___ and ___
PO daily and IM monthly
173
must be opioid free to start __
naltrexone
174
methadone is ___
log-acting opioid agonsit
175
methadone transfers opioid addiction to longer ___
half-life agonist, allowing taper
176
methadone requires ___
daily PO dosing
