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Naplex 2025 > Pain > Flashcards

Pain Flashcards

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1
Q

What is Nociceptive Pain?

A
  • When tissue damage causes stimulation of nerves that releases prostaglandins, substance P, Histamine that send impluses to the brain = Pain
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2
Q

What are the two main categories of Pain?

A
  • Nociceptive Pain
  • Neuropathic Pain
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3
Q

What is Neuropathic Pain?

A
  • From damage or maldunction of the nervous system [i.e.; Fibromyalgia, Diabetic Neurophaty, Chronic Headaches]
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4
Q

What is the difference between Acute and Chronic Pain?

A
  • Acute: sudden and sharp
  • Chronic: Pain that lasts 3 months or more
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5
Q

What is a way to assess pain?

A
  • Pain scales or Face thing (0 - 10 pain)
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6
Q

What analgesic regimen is used for Mild Pain Intensity?

A
  • Non-Opioid +/- Adjuvant
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7
Q

What analgesic regimen is used for Moderate Pain Intensity?

A
  • Opioid for Mild-Mod pain +/- non-opioids +/- Adjuvant
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8
Q

What analgesic regimen is used for Severe Pain Intensity?

A
  • Opioid for Mod-severe pain +/- non-opioids +/- adjuvant
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9
Q

What is the MOA for Aceteminophen?

A
  • Inhibits prostangladin synthesis in the CNS causing reduce pain and fever but NO anti-inflammatory
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10
Q

What are some the different forms of acetaminophen [Tylenol}?

A
  • FeverAll = Rectal Supps
    • Hydocodone [Norco]
    • Oxycodone [Percocet]
    • Codiene [Tylenol # 3 or # 4]
    • Caffeine [Excedrin]
    • Aspirin/Caffeine [Excedrin Migraine]
      + Caffeine/Pyrilamine [Midol] (painful periods)

MAX 4000 mg/day*

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11
Q

What are some boxed warnings for acetaminophen used for pain?

A
  • Hepatotoxicity when taking more that 4 g/day or using multiple acetaminophen products at once
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12
Q

What are some additional notes for acetaminophen used for pain?

A
  • Avoid using APAP?
  • Overdose: NAC with the Rumack-Matthew Scale (to see if needed or not)
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13
Q

What are the difference subclasses of NSAIDs and how do they work?

A
  • Non-selective NSAIDs: blocking synthesis of BOTH COX 1 & 2
  • COX 2 Selective NSAIDs: ONLY block COX 2 = less GI Issues (GI is COX 1)
  • Aspirin: Irreversibly blocks COX 1 & 2 and is an antiplatelet

ALL will decrease Prostanglandin formation = decrease in inflammation, pain, fever

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14
Q

What are the Boxed Warnings for the Non-Aspirin NSAIDs?

A
  • GI Risk: increasd risk of GI issues (Bleeding or Uclers) [Also aspirin too]
  • CV Risk: increase risk of MI or Stroke
  • CABG Surgery: Contraindicated after but Aspirin is ok
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15
Q

What are some of the Side effects that ALL NSAIDS carry?

A
  • Decreased Renal function (Avoid in renal failure)
  • Increased Blood Pressure (Avoid in uncontrolled HTN)
  • Premature clousre of the ductus srteriosus during pregnacy = HF (DO NOT use NSAIDS during 3rd tri)
  • Nausea so take with food or use EC
  • Photosensitivity
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16
Q

What are the COX 1 & 2 Non-selective NSAIDs that are used for pain?

A
  • Ibprofen [Advil, Mortin]
  • Indomethacin [Indocin}
  • Naproxen [Aleve]
  • Ketorolac [Torodol]
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17
Q

What are some additional notes for Ibprofen used for pain?

A
  • OTC: Limit self treatment to < 10 days
  • Adults:OTC 200 - 400 mg Q4-6H (MAX 1.2 mg/day)/RX 400 - 800 mg Q6-8H (MAX 3.2 mg/day)
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18
Q

What are some additional notes for Indomethacin used for pain?

A
  • Higher risk for CNS side effects so avoid in Psych conditions
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19
Q

What are some additional notes for Naproxen used for pain?

A
  • Better since its BID (200 mg Q8-12H)
  • + Esomeprazole [Vimovo]
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20
Q

What are some boxed warnings for Ketorolac used for pain?

A
  • MAX combined duration (IV/IM/PO/NS) is 5 days
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21
Q

What are some warnings for Ketorolac used for pain?

A
  • Increased Bleeding
  • Acute Renal Failure
  • Liver Failure
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22
Q

What are some additional notes for Ketorolac used for pain?

A
  • Nasal Spray: Prime it 5 times before using
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23
Q

What are the COX 2 Selective NSAIDS that are used for Pain?

A
  • Celecoxib (Celebrex)
  • Diclofenac (Voltarin)
  • Meloxicam (Mobic)
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24
Q

What are some contraindications for celecoxib used for pain?

A
  • Sulfonamide allergy
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25
What are some **additional notes** for **celebrex** used for **pain**?
- Highest COX 2 selectivity
26
What are some **Boxed warnings** for **Diclofenac** used for **pain**?
- **Arthotec**: avoid in females of childbearing potential (+ Misoprostol)
27
What are some **additional notes** for **Diclofenac** used for **pain**?
- Some COX 2 selectivity - **Misoprostol** can replace gut-protective Prostaglandins **BUT** will increase utrine contractions (possibly terminating pregnancy)
28
What are some **additional notes** for **Melcoxicam** used for **pain**?
- Some COX 2 selectivity
29
What are the **Salicylate NSAIDs** that are used for **Pain**?
- Aspirin/Acetulsalicyclic Acid [Ascriptin, Bufferin, Ecotrin]
30
What are some **Warnings** for **Aspirin** used for **pain**?
- Avoid in childern and teenagers with **viral infections** as it can lead to **Reyes Syndrome**
31
What are some **side effects** for **Aspirin** used for **pain**?
- Dyspepsia, Heartburn, Bleeding
32
What are some **additional notes** for **aspirin** used for **pain**?
- PPIs can help protection GI (watch out tho for long time use) - Overdose --> Tinnitus - Methyl Salicylate is a popular OTC Topical (BenGay, IcyHot, SalonPas) - **Cardio Protection**: 81 - 162 mg daily
33
What are the ways that **Opioids** work within the body for **pain**?
- Work on Mu, Kappa, Delta receptors - **Mu** receptors agonist (their main action) will cause the **pain relief** with the feeling of **euphoria and respiratory depression** [REMS]
34
What is the **definition** of **physical dependence**?
- Start to had **physical withdrawel symtpoms** when a opioid is **stopped or missed** (anxeity, tachycardiam shakiness, SOB)
35
What is the **definition** of **addiction**?
- complusion or desire to take drug despite harm; involves **seeking out drug**
36
What is the **definition** of **Opioid Use Disorder (OUD)**?
- Problematic **pattern** of **opioid use** that causes **impairment or distress** (failure to do things at home, work, or school)
37
What is the **definition** of **tolerance**?
- Needing **higher opioid doses** to have the **same effect**
38
What is the **Definition** of **opioid hyperalgesia**?
- When a opioid **dose increasees** to help with pain the **pain worsens**
39
what is the **definition** of **Break-through pain (BTP), End of dose pain**?
- **Sharp spikes of severe pain** that happen even though **using an ER opioid**
40
What is the **definition** of **Centrally-Acting Opoid Antagonist**?
- Blocks the **opioids form binding** (Narcan)
41
What are some some **important things** to note about **ALL OPIOIDS** used for **pain**?
- C-II - SE: Constipation, Nausea/Vomiting (espically with high doses), Somnolence, Dizziness/Lightheadedness, Seizures, Respiratory Depression
42
What are the **opioids** that are used for **pain**?
- Codeine (+ tylenonl = C-III & oral solution = C-V) - Fentanyl (Sublimaze) - Buprenorphine C-III - Hydrocodone - Hydromorphone (Dilaudid) - Methadone - Meperidine (Demerol) - Morphine - Oxycodone
43
What are some **Boxed warnings** for **codeine** used for **pain**?
- Respiratory Depression and Death have occured in childern that are **ultrarapid metabolizers** after a **tonsillectomy and/or adenoidctomy**
44
What are some **contraindications** for **codeine** used for **pain**?
- DO NOT use in childern < 12 yo (for anything) or < 18 yo (after that tonsellectomy and/or adenoidectomy)
45
What are some **other side effects** for **codeine** used for **pain**?
- High degree of GI issues like **constipation**
46
What are some **additional notes** for **codeine** used for **pain**?
- Prodrug, metabolized into morphine via 2D6 (deaths have occured in nuring infants = mom was UM)
47
What are some **boxed warnings** for **Fentanyl** used for **pain**?
- Potential medication errors when changing between dosage forms, using with **strong 3A4 inhibitors**
48
What are some **other side effects** for **Fentanyl** used for **pain**?
- Increased sweating, Dry mouth, decreased appeitite - Application site redness/erythmia with the patch
49
What are some **additional notes** for **Fentanyl** used for **pain**?
- Patch and Lozenge: DO NOT use in those that are Opioid Naive
50
What are some **important notes** for **Fentanyl patches** used for **pain**?
- Apply to hairless area - ONLY covered with **Bioclusive or Tegaderm**; not heating pads or regular bandages - Dispose down the toilet; keep away from pets and kids
51
What are some **boxed warnings** for **Methadone** used for **pain**?
- Life threatening **QT prolongation**
52
What are some **additional notes** for **methadone** used for **pain**?
- Hard to does, **due to variable half-life** - Can **decrease testosterone**' - Major **3A4** substrate
53
What are some **warnings** for **meperidine** used for **pain**?
- Renal Impairment/elderly at risk for **CNS toxicity**
54
What are some **additional notes** for **meperidine** used for **pain**?
- NO LONGER RECOMMENDED for pain - Short duration (max 3H) - Serontonergic = Serotonin Syndrome
55
What are some **other side effects** for **Morphine** used for **pain**?
- Pruritus
56
What are some **additional notes** for **Morphine** used for **pain**?
- Benadryl can help prevent the pruritus
57
What is the **dosing conversion** for **Morphine, Hydromorphone, Oxycodone**?
- ......................................**IV/IM**....................**ORAL** - **Morphine**....................**10**...........................**30** - **Hydromorphone**......**1.5**.........................**7.5** - **Oxycodone**..................**---**...........................**20**
58
What is the **step to convert opioids**
- Calculate the total **24 hour dose** - Do the **ratio conversion** - Calculate the **24 hour dose** of **new drug** and **reduce by ~25%** (unless told differently)
59
# Case Scenario of Coverting Opioids A Hospice patient has been receiving **12 mg/day** of **IV Hydromorphone**. The Pharmacist will conver the **hydromorphone to morphine ER** to be given Q12H. The hospice policy for opioid conversion is to **reduce** the new dose by **50%** and to use **5 - 17%** of the total daily dose for BTP.
- 60 mg BID Morphine ER - 15 mg IR Morphine Q1-2H for BTP
60
What are the **symptoms** of a **true opioid allergy** and what should you do if this happens?
- Difficulty breathing, severe drop in BP, Serious rash, swelling of the face, lips, tonguem larynx - **Switch chemical classes** ("cod" & "morph" are the same chemical class)
61
What **populations** are at a **higher risk** of experiencing **opioid-induced resporatory depression (OIRD)**?
- Hx of overdoses - Substance used disorder - Using large doses - Using with Benzos, Gabapentin, Pregabalin - Have respiratory disesases or psych issues
62
What is **opioid induced constipation (OIC)**?
- Opioids reduce GI tract peristalsis = making it difficult to make bowel movements (must be anticipated and treateed)
63
What is considered **first line for OIC**?
- Stimulant (senna, bisacodyl) or Osmotic Laxatives (PEG) [if this doesn't work then try **PAMORAs**]
64
What is the **MOA** for the **Peripherally-acting mu-opioids antagonists (PAMORAs)**?
- blocks opioid receptors int he gut to **reduce constipation** within affecting pain
65
What are the **PAMORAs** that are used for **OIC**?
- Methylnaltrexone (Relistor) - Neloxegol (Movantik)
66
What are some **warnings** for **PAMORAs** used for **OIC**?
- Risk of **GI perforaiton**
67
What are some **side effects** for **PAMORAs** used for **OIC**?
- Abdominal Pain, Flatulence, N/D, Dizziness
68
What are some **additional notes** for **PAMORAs** used for **OIC**?
- Failed OTC laxatives (senna, biscodyl, PEG)
69
What are the **centrally acting analgesics** that are used for **pain**/
- Tramadol (Ultram) C-IV - Tapentadol (Nucynta) C-II
70
What are some **Boxed warnings** for the **centrally acting analgescis** used for **pain**?
- Respiratory depression and death with childern following tonsillectomy and/or adenoidectomy who are UMs
71
What are some **warnings** for the **centrally acting analgesics** used for **pain**?
- Serizure risk - Risk of Serotonin Syndrome (when taking with other serotoneric drugs or inhibitors of 2D6 or 3A4) - Hypoglycemia
72
What are some **contraindications** for the **centrally acting analgesics** used for **pain**?
- DO NOT use in childern < 12 yo (for anything) or < 18 yo (for the tonsillectomy and/or adenoidectomy)
73
What are some **side effect** for the **centrally acting analgesics** used for **pain**?
- Dizziness, Constipation, Nausea, Somnolence
74
What is the proper **opioid overdose management**? ## Footnote Signs and symptoms, what do to, drugs?
- S/Sx: extreme sleepness, slow or shallow breathing, fingernails or lips turing blue or purple, extremely pinpoint pupils - Give Naloxone (repeat x 2-3 mins if needed) and call 911
75
What are the **treamtent options** for **opioids overdoses**?
- **Naloxone [Narcan, RiVive]**
76
What are some **side effects** of the **drugs used for Opioid Overdose**?
- Acute withdrawl symptoms (Pain, Anxeitym Tachypenia)
77
What **medications** are used to help with **opioid use disorders**?
- Buprenorphine + Nalaxone (Suboxone - sublingual flim & Zubsoluv - sublingual tabs) - Methadone
78
What is the **MOA** for **Buprenorphine + Nalaxone**?
- Buprenorphine acts as a mu antagonist (at high doses) helping suppress withdrawal symptoms - Nalaxone helps with preventing any misuse (also for Opioid overdoses)
79
What are some **side effects** for **Buprenorphine + Nalaxone** used for **Opioid use disorder**?
- **Dizziness**, Sedationm headache, confusion, mental and physical impairment, QT prolongation
80
What are some of the **common adjuvants** for **Pain managment**?
- Gabapentin (Neurontin), Pregabalin (Lyrica) & Carbamazepine [Antiseizure meds] - Amitriptyline & Duloxetine (Cymbalta) [SNRIs and TCAs]
81
What are some **side effects** for **Gabapentin & Pregabalin** used for **pain**?
- Dizziness, Somnolence, Peripheral edema/weight gain
82
What are some **additional notes** for **Pregabalin** used for **pain**?
- Approved for the use in **fibromyalgia, PHN and Neuropathic pain**
83
What are some **additional notes** for **Carbamazepine** used for **pain**?
- FDA approved for **trigeminal neuralgia** (sudden pain in the face)
84
What are some of the **oral adjuvants** used for **Musculoskeletal pain/spams**?
- Baclofen (lioresal), Cyclobenzaprine (Amrix, Fexmid, Flexeril * ), Tizanidine (Zanaflex) [Antispasmodics with pain relief] ## Footnote * Brand discontinued but still referred too in practice
85
What are some **side effects** for **ALL Muscle relaxants** used for **musculoskeletal pain/spasms**?
- Excessive sedation, Dizziness, confusion, asthenia (muscle weakness)
86
What are some **other side effects** for **Baclofen** used for **musculoskeletal pain/spams**?
- Nausea, Headachem Constipation, Hypotension, Seizures
87
What are some **other side effects** for **Cyclobenzaprine** used for **musculoskeletal pain/spasms**?
- Dry mouth
88
What are some **additional notes** for **cyclobenzaprine** used for **muscolosketal pain/spasms**?
- Serotonergic: do NOT combine with other serotonergic agents
89
What are some **other side effects** for **Tizanidine** used for **pain**?
- hypotension, Dry mouth
90
What are some **other antispasmodics** that exert their effects by sedation??
- Carisoprodol (soma) - Methocarbomal (robaxin)
91
What are some of the **topical adjuvant pain** medications
- Lidocaine [5% - Lidoderm; Viscous - Gel] - Capsaicin [Zostrix] - Methyl Salicylate [BenGay, IcyHot, SalonPas]
92
What are some **additional notes** for **Topical Lidocaine** used for **pain**?
- Can cut patches into smaller pieces (Before removing the backing) - Lidoderm: DO NOT apply more than 3 patches at one time - Fold patch in half then discard; can harm kids or pets
93
What are some **additional notes** for **Topical Capsaicin** used for **pain**?
- Decreases **substance P** - DO NOT touch genitals, nasal area, mouth or eyes (**burning sensation**) and be sure to wash hands after use

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