Pain Flashcards
(140 cards)
1
Q
Types of pain (2 categories)
A
Nociceptive
Pathophysiologic
2
Q
What is nociceptive pain?
A
Pain that occurs when sensory nerves (nociceptors) identify tissue damage because injured tissue (visceral-organ, skin, muscle, joint, bone, etc) releases
PGs
substance P
histamine
and other substances
which stimulate nocireceptors to send impulses to the brain signaling pain=feeling pain
3
Q
What is pathophysiologic pain
A
Pain due to damage or malfunctioning of the nervous system.
AKA neuropathic pain
Includes: fibromyalgia, diabetic neuropathy, chronic headaches, drug induced toxicities, and others
4
Q
Acute vs chronic pain
A
Acute pain is typically nociceptive, and the pain typically goes away when the cause has been resolved
Chronic pain persists beyond normal healing time (usually 3 months) and sometimes without acute/visible injury (eg. OA, crushed lumbar, diabetic neuropathy, etc)
Chronic pain is divided into:
cancer pain
non-cancer pain
5
Q
Treating pain
A
Pain is subjective-pain scales are useful to assess pain severity
Mild 0-3:
non-opioid
+/- adjuvant
Moderate 4-6
opioid for mild-moderate
+/- non-opioid
+/- adjuvant
Severe 7-10
opioid for moderate-severe
+/- non-opioid
+/- adjuvant
6
Q
non-opioid analgesics
A
acetaminophen
NSAIDs
7
Q
Adjuvants for pain management
A
Commonly used for neuropathic pain
- anti-epileptic drugs (gabapentin, pregabalin, carbamazepine)
- analgesic antispasmodics (Backofen, cyclobenzaprine, tizanidine)
- sedating antispasmodics (carisoprodol, methocarbamol)
- SNRIs and TCAs (milnacipran, amitriptyline, desipramine, duloxetine)
- topicals (lidocaine, capsaicin, methyl salicylate)
8
Q
ACetaminophen MOA
A
Reduces pain and fever BUT is NOT anti-inflammatory
MOA not well defined but is thought to inhibit PG synthesis
9
Q
Name agents for mild pain (rx and OTC)?
A
Acetaminophen (Tylenol, Ofirmev, FeverALL)
+ Hydrocodone (Vicodin, Norco, Lortab)
+ Oxycodone (Percocet, Endocet, Primlev)
+ codeine (Tylenol #2, 3, 4)
+ tramadol (Ultracet)
+butalbital/Caffiene (Fioricet)
+benadryl (Tylenol PM)
10
Q
Brand name of Acetaminophen?
A
Tylenol, Ofirmev, FeverALL
11
Q
Brand name of Acetaminophen + Hydrocodone?
A
Vicodin
Norco
Lortab
12
Q
Brand name of Acetaminophen + Oxycodone?
A
Percocet
Endocet
Primlev
13
Q
Brand name of Acetaminophen + Codeine?
A
Tylenol #2, 3, 4
14
Q
Brand name of Acetaminophen + Tramadol?
A
Ultracet
15
Q
What’s the max daily dose of Acetaminophen in adults?
A
Box: Keep below 4,000 mg/day (4g/day)
To prevent hepatoxicity
Doses >2g/day can increase INR in warfarin patients
16
Q
Children’s dosing of Acetaminophen? Max daily dose?
A
10-15 mg/kg Q4-6H
Max 5 doses/day
17
Q
What’s the conc of Acetaminophen in infants and children’s suspension?
A
160mg/5mL
18
Q
SEs of Acetaminophen use?
A
Hepatoxicity (with overdose), SJS/TEN, nephrotoxic-rare but seen in chronic overdose (safer than NSAIDs)
19
Q
What’s the DOC in pregnancy for pain?
A
Acetaminophen
20
Q
Antidote for Acetaminophen overdose?
A
N-acetylcysteine (NAC, Mucomyst, Cetylev, Acetadote)
comes oral and IV
21
Q
Moa of N-acetylcysteine (Antidote for Acetaminophen overdose)?
A
Restores intracellular glutathione (acts as a glutathione substitute)
Rumack-Matthew nomogram uses serum acetaminophen level vs time since ingestion to determine if hepatotoxicity is likely and the need for NAC
22
Q
MOA of Aspirin and other NSAIDs (not acetaminophen)?
A
Aspirin - irreversibly blocks COX 1=decrease TxA2 (which is required for platelet activation & aggregation)
Other NSAIDs - reversibly block cox 1 &2 (non-selective) or COX-2 only (selective)
COX1 protects the gastric mucosa so selective (only cox2) NSAIDs decrease GI risk
23
Q
While cox-2 selective agents have lower GI bleeding risk, but what risk increases with their use?
A
Cardiovascular risk- MI and stroke
24
Q
List NSAIDs, Salicylates agents
A
Aspirin (Acetylsalicylic acid) - Bayer, Ascriptin, Bufferin, Ecotrin, Durlaza
Non-Acetylated Salicylates:
Salsalate
Mg Salicylate (Doans)
Choline Mg Trisalicylate
Diflunisal
Salicylate salts
25
Risk that increases with NSAIDs use. Groups with highest risk?
GI bleeding
Elderly
Hx of GI bleed
Taking systemic steroids
On SSRIs or SNRIs
26
NSAID SE (all NSAIDs)
1. decrease renal clearance-ALL should be used cautiously or avoided in renal failure
2. increase blood pressure-caution in controlled HTN, avoid in uncontrolled HTN
3. premature closure of ductus arteriosus=HF in baby-Don't use in 3rd trimester of pregnancy
4. nausea-salicylates are worse than other NSAIDs. To minimize, take w/ food, enteric coated, or buffered products
27
Salicylate SEs?
```
Avoid with NSAID hypersensitivity, nasal polyps, asthma
Avoid in children/teens -Reye's
SJS/TEN
Increases bleeding risk
GI ulceration & bleeding can occur
```
```
Dyspepsia
Heartburn
Bleeding
Nausea
BP may increase (monitor)
CNS effects
Photosensitivity
Edema
Hyperkalemia
Blurred Vision
```
OVERDOSE: tinnitus
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
How are all forms of Naproxen dosed?
All given BID
32
Advantage of Naproxen formulations?
Relatively lower cardiac risk
33
Agents under non-selective NSAIDs?
IN SKIP- block Cox1 and Cox2
GI risk, CV risk, Post CABG risk
Ibuprofen (Motrin, Advil, Caldolor, NeoProfen)
Naproxen (Aleve, Naprelan, Naprosyn)
Sulindac
Ketorolac (Toradol, Sprix)
Indomethacin (Indocin, Tivorbex)
Piroxicam (Feldene)
34
Brand name of Diclofenac?
Box-Avoid in women of child bearing potential
```
Voltaren
Cambia
Cataflam
Enova
many others
```
+misoprostol (Arthrotec)
misoprostol is used to replace gut protective PG to decrease GI risk. CAN cause uterine contarctions-abort pregnancy. Also causes cramping & diarrhea
35
Brand name of Indomethacin
Indocin
Tivorbex
High risk for CNS side effects- avoid in psych pts
36
Brand name of Piroxicam
Feldene
37
Brand name of Ketorolac
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)?
Increase bleeding
Acute renal failure
Liver failure
Anaphylactic shock
Box-only for short term mod-severe pain as continuation of IV or IM Tx (MAX COMBINED duration IV+IM+PO+Nasal 5 DAYS) NOT for intrathecal or epidural use
41
Max duration of Ketorolac (Toradol) use?
Max 5 days in adults of all combined delivery methods (IV, IM, PO, nasal)
42
COX-2 selective agents?
```
Celecoxib (Celebrex)
Diclofenac (Volateren)
Meloxicam (Mobic)
Etodolac (Lodine)
Nabumetone (Relafen)
```
43
Brand name of Celecoxib (COX-2 selective agents)?
Celebrex
highest cox 2 selectivity
Contraindicated in sulfa allergy
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 or use enteric coated or buffered forms
49
Which meds shouldn't NSAIDs be used with?
Multiple NSAIDs shouldn't be used together. If taking aspirin + NSAID take aspirin 1 hr before OR 8 hours after
NSAIDs increase levels of lithium and methotrexate
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 opioid 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
Kadian
MorphaBond
Duramorph
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)
137
T/F? It's preferable to treat severe pain at initial onset?
T
138
Best NSAID for renal pts or lithium users
Sulindac
139
Ibuprofen Adult dosing
OTC
200-400 mg Q4-6H
MAX: 1.2g/day
RX
400-800 mg Q6-8H
Max 3.2g/day
140
Pediatric Ibuprofen dosing
5-10mg/kg/dose Q6-8H
| Max: 40mg/kg/day
