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Multi-morbid > Pain Management > Flashcards

Pain Management Flashcards

1
Q

What class of drug is Morphine

A

Opioids

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2
Q

Is Morphine syrup a controlled drug in Singapore?

A

No

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3
Q

How is active morphine-6-glucuronide eliminated?

A

Renal

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4
Q

Caution when using morphine

A

Patients with end organ damage of kidneys – risk of respiratory depression and extreme somnolence from renal accumulation of active metabolite

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5
Q

Conversion of morphine to fentanyl patches

A

2mg (or 3.6mg) PO morphine = 1mcg/hr fentanyl patches

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6
Q

How to transit from SA to LA for chronic pain?

A

Add 50-100% of total amount of SA used as prn to scheduled dose of LA

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7
Q

Rescue prn doses are ________ of daily opioid requirements

A

10-20%

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8
Q

How is opioid use disorder defined in CDC?

A

In the DSM-5 as a problematic pattern of opioid use leading to clinically significant impairment or distress

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9
Q

For chronic pain, ____ doses are superior to ____ doses.

A

scheduled
PRN

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10
Q

Onset of fentanyl

A

Fast onset

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11
Q

Half life of Fentanyl

A

Short t1/2

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12
Q

FDA definition of opioid tolerant

A

≥60mg Morphine or equivalent

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13
Q

When to use fentanyl patches?

A

Patient is opioid tolerant

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14
Q

Absorption in Fentanyl patches

A

Erratic; heat can increase absorption

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15
Q

Onset of Fentanyl patches

A

Slower as compared to other routes
~8-12 hours
~2-3 days for full effect
SQ will form depot to diffuse Fentanyl slowly into bloodstream

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16
Q

Duration for Fentanyl patches

A

q72 hours for most patients
for patients with wearing off effect, may require SA opioid for breakthrough pain moments

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17
Q

Conversion of PO Morphine to Fentanyl Patch

A
  1. 2mg PO Morphine = 1mcg/hr Fentanyl Patch
  2. 3.6mg PO Morphine = 1mcg/hr Fentanyl Patch
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18
Q

Consideration of patient factors when switching from PO Morphine to Fentanyl patches

A
  • Patient’s ability to remove the patch
  • Presence of cognitive impairment
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19
Q

Methadone’s benefit

A

Can reverse potential tolerance to other opioids

20
Q

Half life of Methadone

A

Very long t1/2, counsel patients on potential variations on how they may feel day to day

21
Q

How is Methadone different from other opioids?

A

Does not produce euphoric effect → patients might be initially unwilling to switch from other opioids to Methadone

22
Q

Ketamine

A
  • Inhibits NMDA receptor
  • Works together with opioids to make them ‘supercharged’
  • Difficult to use, many ADR and questionable efficacy in literature
23
Q

Opioid tolerance

A

Reduced response
Requiring more opioids (to experience same effect)

24
Q

Opioid dependence

A

Unpleasant physical symptoms when medication stopped

25
Q

Opioid addiction/OUD

A

Physically challenged to stop opioid use and increasing risk of withdrawal

26
Q

CDC guidelines not applicable for?

A
  • Management of pain related to sickle cell disease
  • Management of cancer-related pain
  • Palliative care or end-of-life care
27
Q

Main CDC principle

A

opioids should be used only when benefits for pain and function are expected to outweigh risks

28
Q

When initiating opioid therapy, prescribe _____ opioids.

A

Immediate release

29
Q

Opioid - use caution when combining opioids with___________.

A

Benzodiazepines and other CNS depressants

30
Q

Step 1 of WHO’s pain ladder

A

Non-opioid +/- adjuvants

31
Q

Step 2 of WHO’s pain ladder

A

Opioid for mild-moderate pain
+/- non-opioid
+/- adjuvants

32
Q

Step 3 of WHO’s pain ladder

A

Opioid for moderate-severe pain
+/- non-opioid
+/- adjuvants

33
Q

Mild to moderate pain

A

Weak opioids (codeine, tramadol)
+ non-opioids

34
Q

Moderate to severe pain

A

Discontinue weak opioids
Consider starting strong opioids (morphine, fentanyl, oxycodone)

35
Q

Which opioid is a safer option in patients with moderate to severe renal and liver impairment?

A

Fentanyl

36
Q

Codeine is a prodrug of ______.

A

Morphine

37
Q

Caution use of Tramadol in ____?

A

Avoid use in severe H impairment
Low dose required for R/H impairment and/or older persons

38
Q

Caution in Oxycodone

A

Increased risk of respiratory depression

39
Q

Caution in IM/IV tramadol

A

Patients with history of seizures

40
Q

Adjuvants for pain management

A

I. GABA Acting Anticonvulsants
II. SNRIs
III. Tramadol
IV. Lidocaine Patches

41
Q

MOA of tramadol

A
  1. serotonin reuptake inhibitor
  2. norepinephrine reuptake inhibitor
42
Q

Which SNRI can be used as an adjuvant?

A

Duloxetine

43
Q

Which anticonvulsants can be used as an adjuvant?

A
  • Gabapentin
  • Pregabalin
44
Q

End of Life Syndromes

A

a. Dyspnea
b. Secretions
c. Agitation/Delirium

45
Q

Management of dyspnea

A

Non-pharmacological
- optimal breathing techniques, ensure airy environment, oxygen therapy for hypoxic patients
Pharmacological
- Morphine most commonly prescribed

46
Q

Management of secretions

A
  1. Glycopyrrolate (anticholinergic) - not in SG
  2. Hyoscine butylbromide (anticholinergic) - dry mouth, constipation and urinary retention

Multi-morbid (5 decks)

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