Chapter 58: Pain Flashcards by Emily Jansen

____ pain occurs when sensory nerves identify tissue namage

Nociceptive

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Which drug classes can be given for mild pain (score 1-3)

Non-opioid +/- adjuvant

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Which drug classes can be given for moderate pain (score 4-6)

Opioid for mild-moderate pain
+/- non-opioid
+/- adjuvant

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Which drug classes can be given for severe pain (score 7-10)

Opioid for moderate-severe pain
+/- non-opioid
+/- adjuvant

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Acetaminophen does not provide ____ effect

anti-inflammatory

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Mechanism of APAP

inhibits PG synthesis in the CNS

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APAP brand names

Tylenol, FeverAll, Ofirmev

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FeverAll drug formulation

rectal suppository

APAP

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Ofirmev drug formulation

Injection

APAP

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APAP + hydrocodone brand names

Lorcet, Lortab, Norco, Vicodin

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APAP + oxycodone brand names

Endocet, Percocet

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APAP + codeine brand names

Tylenol #2, #3, #4

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APAP + caffeine brand name

Excedrin Tension Headache

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APAP + ASA + Caffeine brand names

Excedrin Extra Strength, Excedrin Migraine

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APAP + caffeine + pyrilamine brand name

Midol Complete

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Max APAP per day for adults

< 4000 mg/day

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APAP dosing for children < 12 yrs

10-15 mg/kg Q4-6H

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APAP infants and childrens suspension concentration

160 mg/5 ml

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APAP BW

Severe hepatotoxicity with doses > 4 g/day or use of multiple APAP-containing products

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Antidote for APAP overdose

NAC, Acetadote

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How is NAC administered for APAP overdose

IV or PO (using the solution for inhalation or injectable formulation)

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How does NAC help with APAP overdose

restores hepatic glutathione

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Non-selective NSAIDs block the synthesis of

both COX enzymes

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COX-2 selective NSAIDs block the synthesis of

COX-2 only, which decreases GI risk (b/c COX-1 protects the gastric mucosa)

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Aspirin MOA

irreversible COX-1 & 2 inhibitor | makes it an effective antiplatelet

All Rx, non-aspirin NSAIDs require a MedGuide with the following info

- GI risk including bleeding and ulceration - CV risk (MI and stroke) - CABG surgery: NSAID use is CI after surgery. Antiplatelet therapy is recommended (commonly ASA)

NSAID side effects

- Caution in renal failure - Can increase BP - Can cause premature closure of the ductus arteriosus (do not use in 3rd trimester) - Nausea (take with food) - Photosensitivity

If the ductus arteriosus does not close after birth, which NSAIDs can be used

IV NSAIDs (indomethacin, ibuprofen) can be used within 14 days of birth | to close a patent ductus arteriosus

Ibuprofen brand name

Advil, Caldolor, Motrin

Which NSAIDs are COX-1 & COX-2 non-selective

Ibuprofen, indomethacin, Naproxen, Ketorolac (NIKI)

Adult OTC dosing for Ibuprofen

200-400 mg Q4-6H

Max Rx dose of ibuprofen

3.2 g/day | OTC: 1.2 g/day

Pediatric dosing for Ibuprofen

5-10 mg/kg/dose Q6-8H

OTC self-treatment with ibuprofen should be limited to

< 10 days

Indomethacin brand name

Indocin

Indomethacin has a high risk for which side effects

CNS (avoid in psych conditions)

Naproxen brand name

Aleve

Naproxen + esomeprazole brand name

Vimovo

Ketorolac brand name

Toradol

How often is naproxen dosed

BID

How is Ketorolac nasal spray administered in patients < 65 years

1 spray in each nostril

How is Ketorolac nasal spray administered in patients 65+ years

1 spray in one nostril

Max combined duration IV/IM and PO/nasal for ketorolac is __ days in adults

Ketorolac warnings

acute renal failure, liver failure

How should ketorolac nasal spray be used

Prime 5x before use

Which NSAIDs have increased COX-2 selectivity

Celecoxib, diclofenac, meloxicam, nabumetone, etodolac (C, D, E....M, N)

Benefit of COX-2 selective NSAIDs

lower risk for GI complications (but increased risk of MI/stroke), same renal risk

Diclofenac brand name

Voltaren

Voltaren gel total body max dose

32 g/day

Celecoxib CI

sulfonamide allergy

Which COX-2 selective NSAID has the most COX-2 selectivity

celecoxib

Diclofenac + misoprostol (Arthrotec) boxed warning

Avoid in women of childbearing potential

Why is misoprostol used with diclofenac

Used to replace the gut-protective PG to decrease GI risk

Meloxicam brand name

Mobic

ASA + omeprazole brand name

Yosprala

ASA dose for cardioprotection

81-162 mg once daily

ASA side effects

Dyspepsia, heartburn, bleeding

What may be used to protect the gut with chronic NSAID use

PPIs

Salicylate overdose can cause

tinnitus

What ingredient is found in Bengay, Icy Hot and Salonpas

Methyl salicylate

How should ASA and ibuprofen be used if taken together

Take ASA one hour before or 8 hours after ibuprofen

NSAIDs can increase the levels of which drug

Lithium | and methotrexate

Aspirin/acetylsalicylic acid brand names

Ascriptin, Bufferin, Ecotrin | all EC/buffered

Opioid MOA

Mu receptor agonists

What components of REMS do opioids have?

prescriber education and counseling requirements

Which opioids cannot be taken with alcohol

Kadian, Nucynta ER, Oxymorphone ER & Zohydro | can increase plasma levels and cause fatal overdose

What drug class (DEA) is codeine solution combination products (e.g, cough syrups)

C-V

Respiratory depression and death have occurred in children following tonsillectomy and/or adeoidectomy found to have evidence of being ultra-rapid metabolizers of codeine due to what polymorphism

2D6

Codeine should be avoided in children < __ years for any indication & < __ years following tonsillectomy/adenoidectomy surgery

12 | 18

Brand name of fentanyl oral transmucosal lozenge ("lollipop on a stick")

Actiq

How often is fentanyl patch applied

Q72H

Fentanyl should be avoided with CYP450 ____

3A4 inhibitors

A patient who has been using morphine ___ mg/day or equivalent for at least ___ days can be converted to fentanyl patch

60 | 7

Similar drug (IV) to fentanyl

remifentanil

Fentanyl patch can be covered with

Only the permitted adhesive film dressings: Bioclusive or Tegaderm

How should fentanyl patch be disposed

In toilet

Hydrocodone should be avoided with CYP450 ____

3A4 inhibitors

Hydromorphone oral dose

2-4 mg Q4-6H PRN

Hydromorphone IV dose

0.2-1 mg Q2-3H PRN

Hydromorphone should only be used in:

Opioid-tolerant patients only | high potency

Hydromorphone has a high risk for

overdose | very potent

Methadone brand name

Dolophine

Methadone BW

QT prolongation (life-threatening)

Which C2 opioid has a variable half-life and is hard to dose safely

Methadone

Which C2 opioid can decrease testosterone levels and lead to sexual dysfunction

Methadone

Methadone is a major ____ substrate

3A4

Meperidine brand name

Demerol

Meperidine warning

Renal impairment/elderly at risk for CNS toxicity

Which C2 opioid is no longer recommended as an analgesic

Meperidine

Which C2 opioid has a short duration of action

Meperidine | controls pain for max 3 hours

What is the metabolite of Meperidine and how is it cleared

Normeperidine | Renally (can accumulate and cause seizures)

Whch opioid, when combined with other drugs, can be serotonergic

Meperidine

Morphine ER brand name

MS Contin, Kadian

Morphine injection brand name

Duramorph, Infumorph

Morphine SE

pruritis

What can be given to block histamine-induced pruritis with morphine

Diphenhydramine

Oxycodone IR brand name

Roxicodone

Oxycodone CR brand name

OxyContin

Oxycodone initiation with CYP450 ____ can cause fatal overdose | (Boxed warning)

3A4

Oxycodone side effect

Pruritis

How should oxymorphone be taken

On empty stomach

Which opioids are 3A4 substrates

Hydrocodone, fentanyl, methadone, and oxycodone

How should opioid conversions be rounded

Round down to reduce risk of OD

opioid conversions (morphine, hydromorphone, oxycodone)

Morphine: 10 mg (IV); 30 mg (PO) Hydromorphone: 1.5 mg (IV); 7.5 mg (PO) Oxycodone: 20 mg (PO)

If an exam question says to reduce the dose of an equivalent opioid, how much do you reduce it by

25% | don't.do this if question does not say to reduce dose

If using opioids, which formulation should be started first

What should be done in a true opioid allergy

Use an agent in a different chemical class

Conversions to and from fentanyl and methadone

fentanyl: dosing table in PI methadone: highly variable due to patient tolerance methadone t1/2 varies

The common drugs in the same chemical class that cross-react with each other have which words in their names

cod or morph (or norph)

T/F: Opioids are first line for chronic pain

False | goal might be low pain rather than no pain

What is the first line laxative for OIC

Stimulant laxatives (like Senna)

All opioids should be taken (with or without) food except ____

with (to lessen nausea) oxymorphone

If laxatives are not sufficient for OIC, what can be used

PAMORAs

If PAMORAs are not effective for OIC, what can be used

Lubiprostone

PAMORA MOA

block opioid receptors in the gut to reduce constipation without affecting analgesia

Which meds are PAMORAs

Methylnaltrexone, Naloxegol

Methylnaltrexone brand name

Relistor

Naloxegol brand name

Movantik

Methylnaltrexone & Naloxegol warning

Risk of GI perforation

Methylnaltrexone & Naloxegol SE

Abdominal pain, flatulence

Lubiprostone brand name

Amitiza

Tramadol and tapentadol MOA

mu-opioid receptor agonists - inhibit NE reuptake (tramadol also inhibits reuptake of serotonin)

Tapentadol DEA drug class

Tramadol DEA drug class

C-IV

Tramadol warnings

Seizure risk, risk of serotonin syndrome when used alone or with other serotonergic drugs or inhibitors of 2D6 or 3A4

Tramadol CI

Do not use in children < 12 years of age or in children < 18 years of age following tonsillectomy or adenoidectomy surgery Do not use with MAOi or within 14 days

Tramadol & Tapentadol side effects

dizziness, constipation, nausea, somnolence

Tramadol requires conversion to active metabolite by which CYP enzyme

2D6

Tapentadol warnings

Can increase seizure risk | Risk of serotonin syndrome

Suboxone is formulated with which abuse deterrent medication

Naloxone

Which two opioids are manufactured using specific technology designed to deter crushing, dissolving or other modifications

OxyContin & Hysingla ER (hydrocodone)

Buprenorphine MOA

partial mu-opioid agonist (agonist at low doses and antagonist at high doses)

Given by itself, naloxone is used for

opioid overdose

Buprenorphine/naloxone combination products are used as alternatives to

methadone (buprenorphine suppresses withdrawal symptoms and naloxone helps prevent misuse)

Which 3 formulations does naloxone come in

IM/IV/SC Narcan (nasal spray) Naloxone (injection)

Naloxone SE

acute withdrawal symptoms (pain)

Buprenorphine drug schedule

buprenorphine buccal brand name

Belbuca

buprenorphine patch brand name

Butrans

Buprenorphine + naloxone brand names

sublingual film: Suboxone sublingual tabs: Zubsolv

Buprenorphine patch (Butrans) should be changed how often

weekly

How should Buprenorphine patch be disposed

fold sticky sides together and flush

side effects from Buprenorphine patch

dizziness, HA, application site reactions, nausea

To prescribe for opioid dependence, prescribers need a ____ waiver

Drug Addiction Treatment Act (DATA 2000)

If a prescriber has authorization from the DEA to prescribe for opioid dependence, what will the DEA number start with

Butrans patch can be covered with:

permitted adhesive film dressings: Bioclusive or Tegaderm

Gabapentin ER brand name for post herpetic neuralgia and RLS

Horizant

Gabapentin SE

Dizziness, somnolence, peripheral edema/weight gain

Pregabalin DEA drug class

C-V

Pregabalin SE

Dizziness, somnolence, peripheral edema, weight gain, mild anxiolytic

Pregabalin is approved for which conditions

fibromyalgia, post herpatic neuralgia, and neuropathic pain

What is the only FDA-approved medication for trigeminal neuralgia

Carbamazepine (tegretol)

Baclofen brand name

Lioresal

common adjuvants for pain management

gabapentin, pregabalin, carbamazepine, amitriptyline, duloxetine | milnacipran, desipramine

SE for all muscle relaxants

excessive sedation, dizziness, confusion, asthenia (muscle weakness)

Cyclobenzaprine brand names

Amrix, Fexmid, Flexeril

which muscle relaxant has serotonergic properties

cyclobenzaprine

Cyclobenzaprine side effect

dry mouth | Serotonergic

Tizanidine SE

Hypotension, dry mouth

tizanadine brand name

Zanaflex

Carisoprodol brand name

Soma

Carisoprodol DEA class

C-IV

Poor ____ metabilizers will have increased Carisoprodol concentrations

2C19

methocarbamol brand name

Robaxin

Which muscle relaxant is used for malignant hyperthermia

Dantrolene (Dantrium)

How long can lidoderm patches be used per day

12 hours/day

Which topical patch is approved for PHN (shingles) pain

Lidoderm

Which topical patch can be cut into smaller pieces

Lidoderm

Do not apply more than __ patches of Lidoderm at a time

How often can Capsaicin be used

TID-QID

Capsaicin brand names

Zotrix, Zostrix HP

Capsaicin counseling

Do not touch genitals, nasal area, mouth or eyes after application & wash hands after applying

how does capsaicin cream work?

decreasing substance P

Trolamine brand name

Aspercreme

Chapter 58: Pain Flashcards

(174 cards)