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Flashcards in Pain Deck (137):
0

T/F? It's preferable to treat severe pain at initial onset?

T

1

Is physiological adaptation and addiction the same?

No!

All pts become physiologically adapted to opioid after repeated exposure

2

What's addiction?

Involves a strong desire or compulsion to take the drug despite harm and is manifested by drug-seeking behaviors

3

What's pseudo-addiction?

Pt may be anxious about running out of drug and may have used up the med too quickly - signs which can be mistaken for addiction, but may actually be due to poorly treated pain

4

Whats Tolerance?

Tolerance to opioids develops over time and necessitates a higher dose to produce the same analgesic response

5

What's opioid hyperalgesia?

Chronic opioid use that actually worsens pain sensitivity

6

What's breakthrough pain (BTP)?

Acute pain that occurs despite use of long-acting or scheduled opioid

It's best treated with fast relief agent - such as immediate release opioid

7

Whats an essential component of chronic opioid regimen?

Constipation prophylaxis

8

What must inpatients on IV opioids be monitored for?

Sedation - most imp predictor of respiratory depression (usual cause of fatality with an opioid overdose)

9

Name agents for mild pain (rx and OTC)?

Acetaminophen (Tylenol, "non-Aspirin" pain relievers)

Acetaminophen + Hydrocodone (Vicodin, Norco, Lortab)

Acetaminophen + Oxycodone (Percocet, Endocet)

Acetaminophen + codeine (Tylenol #2, 3, 4)

Acetaminophen + tramadol (Ultracet)

10

Brand name of Acetaminophen?

Tylenol

11

Brand name of Acetaminophen + Hydrocodone?

Vicodin

Norco

Lortab

12

Brand name of Acetaminophen + Oxycodone?

Percocet

Endocet

13

Brand name of Acetaminophen + Codeine?

Tylenol #2, 3, 4

14

Brand name of Acetaminophen + Tramadol?

Ultracet

15

What's the max daily dose of Acetaminophen in adults?

Keep below 4,000 mg/day (3,000-3,900 mg/day)

To prevent hepatoxicity

16

Children's dosing of Acetaminophen? Max daily dose?

10-15 mg/kg Q4-6H

Max 5 doses/D

17

What's the conc of Acetaminophen in infants and children's suspension?

160mg/5mL

18

SEs of Acetaminophen use?

Hepatoxicity (with overdose)

19

What's the DOC in pregnancy for pain?

Acetaminophen

20

Antidote for Acetaminophen overdose?

N-acetylcysteine (NAC, oral and IV)

21

Moa of N-acetylcysteine (Antidote for Acetaminophen overdose)?

Restores intracellular glutathione (acts as a glutathione substitute)

NAC should be admin IMMEDIATELY

22

MOA of Aspirin and other NSAIDs (not acetaminophen)?

Aspirin - irreversibly

Other NSAIDs - reversibly

Block the activity of thromboxane and prostaglandins

23

While cox-2 selective agents have lower bleeding risk, but what risk increases with their use?

Cardiovascular risk

24

List NSAIDs, Salicylates agents

Aspirin (Acetylsalicylic acid) - Bayer, Bayer "Advanced" aspirin, Ascriptin, Bufferin, Ecotrin, Excedrin

Salsalate

Mg Salicylate

Choline Mg Trisalicylate

Diflunisal

Salicylate salts

Topical ?Salicylates

25

Risk that increases with NSAIDs use. Grp with highest risk?

GI bleeding

Elderly
Previous bleed
Chronic or high dose use

26

CI to Aspirin (NSAIDs, Salicylates use)? And Ibuprofen (NSAIDs, others)?

Avoid with NSAID hypersensitivity

Avoid Aspirin (not other NSAIDs) in children < 16 y/o with any viral inf

27

SE to Aspirin (NSAIDs, Salicylates) use? And Ibuprofen (NSAIDs, others)?

Dyspepsia

Heartburn (more common with Aspirin - EC or buffered pdt can reduce dx) - take NSAIDs, salicylate with food to reduce nausea

BP may increase (monitor)

GI irritation/bleeding, renal

Severe skin rash (SJS/TEN) - rare (stop drug, seek immediate medical help)

28

List agents under NSAIDs, others

Ibuprofen (Motrin, Advil)

Naproxen Na

29

Brand name of Ibuprofen (NSAIDs, others)?

Motrin

Advil

30

Brand name of Naproxen-Esomeprazole?

Vimovo

PPI used to protect gut from damage caused by NSAID

31

Howz all forms of Naproxen dosed?

All given BID

32

Advantage of Naproxen formulations?

Relatively lower cardiac risk

33

Agents under other non-selective NSAIDs?

Diclofenac (Cataflam, Voltaren XR)

Indomethacin (Indocin IR, CR)

Piroxicam (Feldene)

Ketorolac (Toradol)

34

Brand name of Diclofenac (non-selective NSAIDs)?

Cataflam

Voltaren XR

35

Brand name of Indomethacin (non-selective NSAIDs)?

Indocin

36

Brand name of Piroxicam (non-selective NSAIDs)?

Feldene

37

Brand name of Ketorolac (non-selective NSAIDs)?

Toradol

Sprix NS

38

SEs unique to indomethacin (Indocin)?

High risk for CNS SEs (avoid in psych conditions)

GI toxicity

39

SEs unique to Piroxicam (Feldene)?

High risk for GI toxicity and severe skin rxns (including SJS/TEN)

40

SEs unique to Ketotolac (Toradol)?

GI bleeding and perforation

Acute renal failure

Liver failure

41

Max duration of Ketorolac (Toradol) use?

Max 5 days in adults

42

COX-2 selective agents?

Celecoxib (Celebrex)

Meloxicam (Mobic)

Etodolac (Lodine)

Nabumetone (Relafen)

43

Brand name of Celecoxib (COX-2 selective agents)?

Celebrex

44

Brand name of Meloxicam (COX-2 selective agents)?

Mobic

45

Brand name of Etodolac (COX-2 selective agents)?

Lodine

46

Brand name of Nabumetone (COX-2 selective agents)?

Relafen

47

Which COX-2 selective agent has highest COX-2 selectivity and is CI with Sulfonamide allergy?

Celecoxib (Celebrex)

48

How do u mitigate upset stomach from NSAID use?

Take with food

49

Which meds shouldn't NSAIDs be used with (to reduce ulcers and bleeding in stomach)?

Steroids

Anticoagulant

Antidepressant, including
Fluoxetine
Paroxetine
Sertraline
Citalopram
Venlafaxine
Others

50

When should NSAIDs be avoided?

If you've experienced breathing problems or allergic-type rxns after taking aspirin or other NSAIDs

51

Effect of NSAIDs on BP?

NSAIDs can raise BP

52

NSAIDs and photosensitivity?

Limit sun exposure; use broad spectrum sunscreen (blocks both UVA and UVB)

53

Which opioids are classified as pure opioid receptor agonists?

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Methadone

Morphine

Oxycodone

Oxymorphone

54

What's the primary receptor for pain relief?

Mu receptor

55

While full agonists don't have a true ceiling effect, how should high doses be used!

Rotated with other opioids to reduce risk of tolerance

56

Brand name of morphine (long-acting brands)?

MS Contin

Avinza

Kadian

Oramorph SR

Roxanol

57

How should long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol) be used?

Don't crush or chew any of these

58

Avinza and alcohol use?

No alcohol - can shorten long-acting duration

Can sprinkle on applesauce, soft food (Kadian too)

59

SEs of long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol)?

Constipation

N/V

60

Tolerance develops to all SEs except?

Constipation

61

What's used for constipation from opioids?

Stimulant laxatives (senna, bisacodyl)

Osmotic laxatives (MOM)

Methylnaltrexone (Relistor) - last line

62

Brand name of Fentanyl patch?

Duragesic

63

Brand name of Fentanyl pills?

Abstral

Fentora SL

64

How's Duragesic (fentanyl patch) used?

12 (delivers 12.5 mcg/hr), 25, 50, 75, 100 mcg/hr

Change transdermal patch Q3 days

65

If pain is controlled, but short-lived with Duragesic (Fentanyl patch), how should they be treated? (As u would do with any long-acting opioid)?

Don't increase dose, reduce freq

From Q72h => Q48h

66

Role of Fentanyl, in any form, in therapy?

Chronic pain management only

67

How do adjust oral opioid when starting fentanyl?

Reduce dose by 50% at first of oral opioid

68

Which form of fentanyl is a REMS drug?

Onsolis

69

How do u dispose of Duragesic (fentanyl patch)?

Dispose in toilet

Or

Cut up and put in coffee grounds

70

Brand name of Hydromorphone?

Dilaudid

71

Brand name of Oxycodone CR?

OxyContin

OxyContin OP

72

Brand name of Oxycodone + Acetaminophen?

Endocet

Percocet

Roxicet

73

BBWs of Oxycodone (OxyContin; OP - CR Oxycodone) +
Oxycodone + Acetaminophen (Percocet, Endocet, Roxicet)?

Report abuse

Avoid with 3A4 inhibitors (eg Amiodarone, Fluconazole, Grapefruit, Verapamil etc)

74

Brand name of Oxymorphone?

Opana

Opana ER

75

What's unique about use of Oxymorphone (Opana; Opana ER)?

Take on empty stomach (most others are use with food to avoid stomach upset)

No alcohol with Opana ER

76

Brand name of Methadone?

Dolophine

Methadose - liquid

77

Concern with using Methadone (Dolophine, Methadose) and Meperidine (Demerol)?

Serotonergic, when used in combo with other drugs

78

Brand name of Meperidine?

Demerol

79

Role of Meperidine (Demerol) in therapy?

Short duration so action (pain control for max 3 hrs)

Avoid as agent for chronic pain management

80

Brand name of Hydrocodone + Acetaminophen?

Lorcet

Lortab

Vicodin

Norco

81

Brand name of Hydrocodone + Acetaminophen - referred to as safer combo?

Norco (325mg APAP)

82

What's concern with Hydrocodone + Acetaminophen (Lorcet, Lortab, Vicodin, Norco)?

Watch for APAP max dosing (combo with APAP higher than 325mg is been phased out)

83

Brand name of Codeine + Acetaminophen?

Tylenol #2, 3, 4

84

List combination opioid agonists/norepinephrine uptake inhibitors and Tramadol also inhibits 5 Reuptake

Tramadol (Ultram, Ultram ER, Conzip IR/ER)

Tramadol + Acetaminophen (Ultracet)

Tapentadol (Nucynta, Nucynta ER)

85

Brand name of Tramadol + Acetaminophen?

Ultracet

86

Brand name of Tramadol?

Ultram

Ultram ER

Conzip IR/ER

87

Brand name of Tapentadol?

Nucynta

Nucynta ER

88

Whats warning associated with Tramadol use?

Increased seizure risk (serotonin syndrome)

89

SEs of Tapentadol (Nucynta, Nucynta ER)?

Dizziness

Drowsiness

Nausea

But lower GI than stronger opioids

90

What should be avoided with Tapentadol (Nucynta, Nucynta ER)?

No alcohol

91

All opioids have a no alcohol use warning, but which ones have a special warning to avoid alcohol use?

Opana ER (Oxymorphone ER)

Nucynta ER (Tapentadol ER)

Avinza

92

Which opioid has a take on empty stomach direction (almost all others are use with food)?

Opana (Oxymorphone)

93

Morphine and renal insufficiency?

If switching to morphine and pt has renal insufficiency, reduce dose by 50% of TDD

(Morphine has an active metabolite that's renally cleared)

94

When converting from 1 opioid to another, what should always be considered?

Always Use breakthrough med, as-needed, when converting

95

Converting to Fentanyl patch?

Find TDD in mg

Convert to mcg (multiple by 1,000)

Divide by 24 (to get patch dose)

Fentanyl is dosed mcg/hr

96

When converting 1 opioid to another, do u round up?

No! Never!

Round down (use breakthrough doses for compensation)

97

What changes do u make if medicine works well to control pain, but runs out too fast?

Shorten dosing interval (don't increase dose, this will cause a risk of respiratory depression)

98

How to convert from 1 opioid to another?

Calculate total 24h dose req of current drug

Use ratio-conversion to calc dose of new drug (make sure numerators & denominators match in both drug & route of admin)

Calculate 24h dose of new drug & reduce dose at least 25% (Note: if problem on exam says to find equivalent dose, the don't reduce it)

Divide to attain appropriate interval and dose for new drug

Always have breakthrough pain (BTP) med available while making changes (BTP dose ranges from 5-17% of total daily baseline opioid dose)

99

Role of Naloxone (as a single agent) in therapy?

Used for Opioid overdose

100

Whys repeat dosing of Naloxone required?

Opioid may last longer than blocking agent

101

Effect of Naloxone in pts physically dependent on opioids?

Will cause acute withdrawal syndrome (pain, anxiety, tachypnea)

102

Acute overdose s/sx to watch out for when using Naloxone?

Somnolence

Respiratory depression with shallow breathing

Cold and clammy skin

Constricted (pinpoint, miosis) pupils

Can lead to coma and death

103

What's the role of Suboxone (Buprenorphine + Naloxone) in therapy?

Used as alternative for methadone (so pts can get from regular doctor and filled at any pharmacy and can get over opioids since withdrawal sx are reduced)

Used daily for addiction

104

SEs of Buprenorphine + Naloxone (Suboxone)?

Sedation

105

Buprenorphine and QT interval?

Prolongs QT interval (avoid in pts at risk of arrhythmia)

106

List Antispasmodics with analgesic effects

Baclofen (Lioresal)

Cyclobenzaprine (Flexmid)

Tizanidine (Zanaflex)

107

Brand name of Baclofen (Antispasmodics with analgesic effects)?

Lioresal

108

Brand name of Cyclobenzaprine (Antispasmodics with analgesic effects)?

Flexmid

109

Brand name of Tizanide (Antispasmodics with analgesic effects)?

Zanaflex

110

SEs of all skeletal muscle relaxants?

Excessive sedation, dizziness, confusion

111

SEs of Cyclobenzaprine (Flexmid)?

Xerostomia (may have efficacy with fibromyalgia)

112

SEs of Tizanidine (Zanaflex)?

Central alpha-1-agonist => Hypotension, dizziness, xerostomia,
weakness

113

List drugs that exert their effects by sedation

Carisoprodol (Soma)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin, Robaxin-750)

114

Brand name of Carisoprodol (drugs that exert effects by sedation)?

Soma

C IV (due to dependence, withdrawal sx and diversion and abuse)

115

Brand name of Metaxalone (drugs that exert effects by sedation)?

Skelaxin

116

Poor CYP 2C19 metabolizes and Carisoprodol (Soma)?

Poor CYP 2C19 metabolizes will have higher Carisoprodol (Soma) conc (up to 4-fold)

117

What meds is Tizanidine (Zanaflex) CI with?

Ciprofloxacin & Fluvoxamine (due to elevated Tizanidine levels)

118

List common neuropathic pain agents

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Gabapentin (Neurontin)

Amitriptyline (Elavil)

119

Brand name of Pregabalin (Neuropathic pain agents)?

Lyrica

120

Brand name of Duloxetine (Neuropathic pain agents)?

Cymbalta

121

Brand name of Gabapentin (Neuropathic pain agents)?

Neurontin

122

Brand name of Amitriptyline (Neuropathic pain agents)?

Elavil

123

SEs of Pregabalin (Lyrica) and Gabapentin (Neurontin)?

Dizziness

Somnolence

Peripheral edema

Weight gain

Ataxia

Diplopia

Blurred vision

Xerostomia

Mild euphoria

124

SE of Amitriptyline (Elavil) - mostly uncommon with low doses used for neuropathic pain

Anticholinergic

125

List Fibromyalgia agents

Milnacipran (Savella)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

126

Brand name of Milnacipran (Fibromyalgia agent)?

Savella

127

SEs of Milnacipran (Savella)?

Nausea

HA

Constipation

Dizziness

Insomnia

Hot flashes

128

Topical pain agents, for localized pain

Lidocaine 5% patches (Lidoderm)

Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)

Diclofenac topical (Voltaren gel, Flector patch)

Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)

129

Brand name of Lidocaine 5% patch?

Lidoderm

130

Brand name of Capsaicin 0.025% and 0.075%?

Zostrix

Zostrix HP

131

What's Lidoderm (Lidocaine 5% patch) approved for?

Postherpetic neuralgia (shingles)

132

Can Lidoderm (Lidocaine 5% patch) be cut into smaller pieces?

Yes! B4 removing backing

133

Max number of Lidoderm (Lidocaine 5% patch) that can be applied at one time? Duration of applied patch use?

Max of 3 Lidoderm (Lidocaine 5% patch) at one time

12 hrs on and 12 hrs off

134

SEs of Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)?

May cause 1st to 3rd degree burns (mostly in patients with neuropathic damage)

135

How do u obtain best results on Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)?

Best results typically occur after 2 to 4 wks of continuous use

Don't use PRN, since freq, long-term use is required for benefit

136

SEs of Ibuprofen?

May cause acute kidney problems

May cause increase in BP (codeine and APAP doesn't cause BP rise)

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