Flashcards in Pain Deck (137):
T/F? It's preferable to treat severe pain at initial onset?
Is physiological adaptation and addiction the same?
All pts become physiologically adapted to opioid after repeated exposure
Involves a strong desire or compulsion to take the drug despite harm and is manifested by drug-seeking behaviors
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
Tolerance to opioids develops over time and necessitates a higher dose to produce the same analgesic response
What's opioid hyperalgesia?
Chronic opioid use that actually worsens pain sensitivity
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
Whats an essential component of chronic opioid regimen?
What must inpatients on IV opioids be monitored for?
Sedation - most imp predictor of respiratory depression (usual cause of fatality with an opioid overdose)
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)
Brand name of Acetaminophen?
Brand name of Acetaminophen + Hydrocodone?
Brand name of Acetaminophen + Oxycodone?
Brand name of Acetaminophen + Codeine?
Tylenol #2, 3, 4
Brand name of Acetaminophen + Tramadol?
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
Children's dosing of Acetaminophen? Max daily dose?
10-15 mg/kg Q4-6H
Max 5 doses/D
What's the conc of Acetaminophen in infants and children's suspension?
SEs of Acetaminophen use?
Hepatoxicity (with overdose)
What's the DOC in pregnancy for pain?
Antidote for Acetaminophen overdose?
N-acetylcysteine (NAC, oral and IV)
Moa of N-acetylcysteine (Antidote for Acetaminophen overdose)?
Restores intracellular glutathione (acts as a glutathione substitute)
NAC should be admin IMMEDIATELY
MOA of Aspirin and other NSAIDs (not acetaminophen)?
Aspirin - irreversibly
Other NSAIDs - reversibly
Block the activity of thromboxane and prostaglandins
While cox-2 selective agents have lower bleeding risk, but what risk increases with their use?
List NSAIDs, Salicylates agents
Aspirin (Acetylsalicylic acid) - Bayer, Bayer "Advanced" aspirin, Ascriptin, Bufferin, Ecotrin, Excedrin
Choline Mg Trisalicylate
Risk that increases with NSAIDs use. Grp with highest risk?
Chronic or high dose use
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
SE to Aspirin (NSAIDs, Salicylates) use? And Ibuprofen (NSAIDs, others)?
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)
List agents under NSAIDs, others
Ibuprofen (Motrin, Advil)
Brand name of Ibuprofen (NSAIDs, others)?
Brand name of Naproxen-Esomeprazole?
PPI used to protect gut from damage caused by NSAID
Howz all forms of Naproxen dosed?
All given BID
Advantage of Naproxen formulations?
Relatively lower cardiac risk
Agents under other non-selective NSAIDs?
Diclofenac (Cataflam, Voltaren XR)
Indomethacin (Indocin IR, CR)
Brand name of Diclofenac (non-selective NSAIDs)?
Brand name of Indomethacin (non-selective NSAIDs)?
Brand name of Piroxicam (non-selective NSAIDs)?
Brand name of Ketorolac (non-selective NSAIDs)?
SEs unique to indomethacin (Indocin)?
High risk for CNS SEs (avoid in psych conditions)
SEs unique to Piroxicam (Feldene)?
High risk for GI toxicity and severe skin rxns (including SJS/TEN)
SEs unique to Ketotolac (Toradol)?
GI bleeding and perforation
Acute renal failure
Max duration of Ketorolac (Toradol) use?
Max 5 days in adults
COX-2 selective agents?
Brand name of Celecoxib (COX-2 selective agents)?
Brand name of Meloxicam (COX-2 selective agents)?
Brand name of Etodolac (COX-2 selective agents)?
Brand name of Nabumetone (COX-2 selective agents)?
Which COX-2 selective agent has highest COX-2 selectivity and is CI with Sulfonamide allergy?
How do u mitigate upset stomach from NSAID use?
Take with food
Which meds shouldn't NSAIDs be used with (to reduce ulcers and bleeding in stomach)?
When should NSAIDs be avoided?
If you've experienced breathing problems or allergic-type rxns after taking aspirin or other NSAIDs
Effect of NSAIDs on BP?
NSAIDs can raise BP
NSAIDs and photosensitivity?
Limit sun exposure; use broad spectrum sunscreen (blocks both UVA and UVB)
Which opioids are classified as pure opioid receptor agonists?
What's the primary receptor for pain relief?
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
Brand name of morphine (long-acting brands)?
How should long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol) be used?
Don't crush or chew any of these
Avinza and alcohol use?
No alcohol - can shorten long-acting duration
Can sprinkle on applesauce, soft food (Kadian too)
SEs of long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol)?
Tolerance develops to all SEs except?
What's used for constipation from opioids?
Stimulant laxatives (senna, bisacodyl)
Osmotic laxatives (MOM)
Methylnaltrexone (Relistor) - last line
Brand name of Fentanyl patch?
Brand name of Fentanyl pills?
How's Duragesic (fentanyl patch) used?
12 (delivers 12.5 mcg/hr), 25, 50, 75, 100 mcg/hr
Change transdermal patch Q3 days
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
Role of Fentanyl, in any form, in therapy?
Chronic pain management only
How do adjust oral opioid when starting fentanyl?
Reduce dose by 50% at first of oral opioid
Which form of fentanyl is a REMS drug?
How do u dispose of Duragesic (fentanyl patch)?
Dispose in toilet
Cut up and put in coffee grounds
Brand name of Hydromorphone?
Brand name of Oxycodone CR?
Brand name of Oxycodone + Acetaminophen?
BBWs of Oxycodone (OxyContin; OP - CR Oxycodone) +
Oxycodone + Acetaminophen (Percocet, Endocet, Roxicet)?
Avoid with 3A4 inhibitors (eg Amiodarone, Fluconazole, Grapefruit, Verapamil etc)
Brand name of Oxymorphone?
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
Brand name of Methadone?
Methadose - liquid
Concern with using Methadone (Dolophine, Methadose) and Meperidine (Demerol)?
Serotonergic, when used in combo with other drugs
Brand name of Meperidine?
Role of Meperidine (Demerol) in therapy?
Short duration so action (pain control for max 3 hrs)
Avoid as agent for chronic pain management
Brand name of Hydrocodone + Acetaminophen?
Brand name of Hydrocodone + Acetaminophen - referred to as safer combo?
Norco (325mg APAP)
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)
Brand name of Codeine + Acetaminophen?
Tylenol #2, 3, 4
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)
Brand name of Tramadol + Acetaminophen?
Brand name of Tramadol?
Brand name of Tapentadol?
Whats warning associated with Tramadol use?
Increased seizure risk (serotonin syndrome)
SEs of Tapentadol (Nucynta, Nucynta ER)?
But lower GI than stronger opioids
What should be avoided with Tapentadol (Nucynta, Nucynta ER)?
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)
Which opioid has a take on empty stomach direction (almost all others are use with food)?
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)
When converting from 1 opioid to another, what should always be considered?
Always Use breakthrough med, as-needed, when converting
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
When converting 1 opioid to another, do u round up?
Round down (use breakthrough doses for compensation)
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)
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)
Role of Naloxone (as a single agent) in therapy?
Used for Opioid overdose
Whys repeat dosing of Naloxone required?
Opioid may last longer than blocking agent
Effect of Naloxone in pts physically dependent on opioids?
Will cause acute withdrawal syndrome (pain, anxiety, tachypnea)
Acute overdose s/sx to watch out for when using Naloxone?
Respiratory depression with shallow breathing
Cold and clammy skin
Constricted (pinpoint, miosis) pupils
Can lead to coma and death
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
SEs of Buprenorphine + Naloxone (Suboxone)?
Buprenorphine and QT interval?
Prolongs QT interval (avoid in pts at risk of arrhythmia)
List Antispasmodics with analgesic effects
Brand name of Baclofen (Antispasmodics with analgesic effects)?
Brand name of Cyclobenzaprine (Antispasmodics with analgesic effects)?
Brand name of Tizanide (Antispasmodics with analgesic effects)?
SEs of all skeletal muscle relaxants?
Excessive sedation, dizziness, confusion
SEs of Cyclobenzaprine (Flexmid)?
Xerostomia (may have efficacy with fibromyalgia)
SEs of Tizanidine (Zanaflex)?
Central alpha-1-agonist => Hypotension, dizziness, xerostomia,
List drugs that exert their effects by sedation
Methocarbamol (Robaxin, Robaxin-750)
Brand name of Carisoprodol (drugs that exert effects by sedation)?
C IV (due to dependence, withdrawal sx and diversion and abuse)
Brand name of Metaxalone (drugs that exert effects by sedation)?
Poor CYP 2C19 metabolizes and Carisoprodol (Soma)?
Poor CYP 2C19 metabolizes will have higher Carisoprodol (Soma) conc (up to 4-fold)
What meds is Tizanidine (Zanaflex) CI with?
Ciprofloxacin & Fluvoxamine (due to elevated Tizanidine levels)
List common neuropathic pain agents
Brand name of Pregabalin (Neuropathic pain agents)?
Brand name of Duloxetine (Neuropathic pain agents)?
Brand name of Gabapentin (Neuropathic pain agents)?
Brand name of Amitriptyline (Neuropathic pain agents)?
SEs of Pregabalin (Lyrica) and Gabapentin (Neurontin)?
SE of Amitriptyline (Elavil) - mostly uncommon with low doses used for neuropathic pain
List Fibromyalgia agents
Brand name of Milnacipran (Fibromyalgia agent)?
SEs of Milnacipran (Savella)?
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)
Brand name of Lidocaine 5% patch?
Brand name of Capsaicin 0.025% and 0.075%?
What's Lidoderm (Lidocaine 5% patch) approved for?
Postherpetic neuralgia (shingles)
Can Lidoderm (Lidocaine 5% patch) be cut into smaller pieces?
Yes! B4 removing backing
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
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)
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