Pain management

Question 1

Indications for rotating opioids

Answer 1

• dose-limiting side effects (sedation, nausea, pruritis, myoclonus)
• Need for new dosing route
• Cost/insurance changes
• Inadequate analgesia despite dose escalation of current opioid

Question 2

Brief pain inventory

Answer 2

assesses pain influence and mood and function

Question 3

McGill Pain Questionnaire

Answer 3

Evaluates pain qualities

Question 4

Methylnatrexone MOA

Answer 4

mu-opioid receptor antagonist
Reversed opioid induced constipation and urinary retention and pruritis.

Question 5

MOA and use clonidine

Answer 5

alpha 2 adrenergic agonist

Used as neuraxial adjuvant – reduces concentration of local anesthetic need
increases duration of sensory block
decreased adrenal stress response

SE: hypotension, sedation, bradycardia

Question 6

CYP450 inhibitors

Answer 6

Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole

Question 7

CYP450 inducers

Answer 7

Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas

Question 8

CYP2D6 inhibitors

Answer 8

Bupropion
Dacomitinib
Fluoxetine
Paroxetine
Quinidine
Tipranavir

Question 9

Medications metabolized by CYP2D6

Answer 9

Amitriptyline, clozapine, desipramine, flecainide, haloperidol, nortriptyline, risperidone, and valbenazine

Question 10

Neuraxial conversions

Answer 10

Morphine
PO 300
IV 100
epidural 10
intrathecal 1

(fentanyl IV 15:1 intrathecal, 3:1 epidural)

Question 11

Use of Behavioral pain scale

Answer 11

For critically ill pts

Question 12

which opioids have no phase one metabolism with CYP450

Answer 12

Oxy, morphine, hydromorphone

Question 13

Metabolism of gabapentin

Answer 13

Renally excreted
peak concentration 2-3 hr

Question 14

Pathophys of hyperalgesia caused by chronic opioid use

Answer 14

Increased neuronal activity in dorsal horn
Sensitization of afferent neurons
Increased expression of substance P

Question 15

Nerve block for pancreatic cancer, distal 2/3 esophagus to transverse colon

Answer 15

Celiac plexus block (T12-L1)

or splanchnic nerve block (for visceral pain; T5-T12)

Question 16

Nerve block for descending colon to rectum and urogenital

Answer 16

Superior hypogastric plexus block

Question 17

Nerve block for distal pelvic structures, anus, rectum

Answer 17

Ganglion impar block

Question 18

Metabolites of morphine

Answer 18

Morphine-3-glucuronide (acts as a convulsant)
Morphine- 6- glucuronide (responisble for the pain relief effect)

Question 19

signs of morphine build up

Answer 19

convulsions, agitation, hallucinations, hyperalgesia, coma

Question 20

Opioid side effects that do not resolve with tolerance

Answer 20

Constipation
Miosis

Question 21

Rate to taper opioids

Answer 21

10% of original dose per week.

Question 22

Signs that opioid is being tapered too quickly

Answer 22

hyperactive bowel sounds
temp instability
pain
sense of impending doom

peak sx 2-3 days (resolve in 5-10; cravings insomnia and dysphoria can last wks to mos)

Question 23

Most potent opioid

Answer 23

Sufentanil

(Sufentanil>fentanyl>hydromorphone>oxymorphone>morphine>hydrocodone)

Question 24

Mechanism of neuropathic pain

Answer 24

1. ectopy from injured nerves (increased NA channels)
2. up reg receptors around C-fibers (heat sensing)
3. phenotype switch to wide dynamic range neurons
4. Loss of K channels
5. decreased expression of opioid receptions
6. new collateral peripheral afferents to sympathetic fibers

Question 25

Chemo meds that cause neuropathic pain

Answer 25

Acute: oxaliplatin and paclitaxel Chronic: carboplatin, cisplatin, bortezomib, lenalidomide, thalidomide

Question 26

Methadone conversion: OME<60

Answer 26

2.5mg PO q8h max

Question 27

Methadone conversion: 60-199 OME

Answer 27

10:1 ratio (<30mg/d max)

Question 28

Methadone conversion: >200 OME

Answer 28

20:1 ratio (<30mg/d max)

Question 29

Starting dose of morphine PO

Answer 29

5-10mg

Question 30

Starting dose of hydromorphone PO

Answer 30

1-2mg

Question 31

Starting dose of oxycodone

Answer 31

2.5-5mg

Question 32

Timing of dose adjustment for long acting medications

Answer 32

2-3 days

Question 33

Timing of dose adjustment for transdermals

Answer 33

3-6 days

Question 34

Timing of dose adjustment of methadone

Answer 34

5-7days

Question 35

For which pain syndrome is acupuncture most effective

Answer 35

Migraine headache

Question 36

First line treatment fir patient with mild opioid use disorder

Answer 36

Naltrexone 3-6 days after last short acting dose

Question 37

First generation antipsychotics

Answer 37

fluphenazine, haloperidol, loxapine, perphenazine, pimozide, thiothixene, and trifluoperazine Lower potency: chlorpromazine and thioridazine

Question 38

What life expectancy needed to get intrathecal pain pump

Answer 38

>3mo

Question 39

Which drugs are opiates?

Answer 39

morphine, codine and thebaine

Question 40

Timing of pain relief from XRT

Answer 40

with in first few tx. peak 4weeks

Question 41

timing of pain relief from radionuclide therapy

Answer 41

(used for multiple sites of bone mets) peak effect 3-6weeks

Question 42

Indications for XRT

Answer 42

localized bone mets Epidural mets spinal cord compression Brain mets (whole brain) -- Gamma Knife for small lesions in brain obstruction: SVC, esophagus, airway, rectum, biliary tract Pain: adrenal mets w/ flank pain, tumors causing nerve impingement Bleeding: Stomach, esophagus, H/N CA, bladder, cervix Ulceration/fungation