Pain management

Question 1

Prior to surgery what NSAID type drug must be stopped 7 days in advanced? Why?

What other drugs can be given instead?

Answer 1

Stop (Acetylsalicylic acid) Aspirin 7 days prior to prevent anti-platelet functions

Replace with Acetaminophen (Tylenol) instead

Question 2

What NSAID class does ibuprofen fall under

Answer 2

Propionic acids

Question 3

Ketorolac (Toradol) falls under which class of drugs?
How long do they last?

Answer 3

Pyrrolacetic Acids

Max of 5 days

Question 4

How is Ketorolac (Toradol) normally administered?

Answer 4

Parenterally

Question 5

Celecoxib falls under what drug class?

Answer 5

COX-2 inhibitor

Question 6

What apecial instructions do you ned to give to cardiace patients taking Celecoxib

Answer 6

A before C

aspirin should be given before celecoxib

Question 7

ADE with NSAIDS?

Answer 7

Upper GI bleeding
Acute Renal failure

**ask if patient is taking any meds that might cause these

Question 8

ADE with Acetaminophen?

What needs to be monitored?

Answer 8

ADE: Hepatotoxicity

Monitor: 
ALT/AST
Liver synthesis tests
   -PT/INR or Albumin
Acetaminophen serum concentration

Question 9

What needs to be monitored while taking NSAIDS

Answer 9

Complete blood count, stool guaiac (if symptoms such as black tarry stools, warrant)

Question 10

What benefits does taking NSAIDS like acetaminophen/aspirin provide while taking with opoids

Answer 10

Boosts the effects of opioids, therefore reducing the dosage needed

Question 11

What opioid class does Morphine fall under?

Is it naturally made or synthetic?

Answer 11

Phenanthrenes

Naturally occuring

Question 12

What response does injecting morphine naturally cause in the body?

Answer 12

Histamine release

Question 13

What is the dosing equivalents between IM and PO morphine?

Why is IM dosing lower than PO dosing

Answer 13

IM: 10
PO: 30

IM avoids the first pass effect so is more potent

Question 14

What is the drug of choice usually for severe pain?

Answer 14

Morphine

Question 15

Drug of choice for mild/moderate pain

Answer 15

NSAIDS

Question 16

Codeine, Hydrocodone, Oxycodone falls under which opioid drug class

Which is naturally occurring?

Answer 16

Phenanthrenes

Codeine = natural

Question 17

What is codeine used to treat?

Which enzyme is codeine dependent on for metabolism in the body?

Answer 17

Mild to moderate pain and cough suppression

CYP 450 2D6

Question 18

What opioid class do Meperidine and Fentanyl fall under?

Answer 18

Phenylpiperidines

Question 19

What is the drug dose equivalent between Meperidine and Fentanyl?

Answer 19

Meperidine 100

Fentanyl 0.1

Question 20

Which drug produces an active metabolite known as Normeperidine?

What effects does this cause on the body

Answer 20

Meperidine

tremors, myoclonus, and seizures
and Mydriasis

Question 21

Should Fentanyl be used as a transdermal patch in acute pain?

Answer 21

No, designed to give a dose for a longer duration

Question 22

When taking Fentanyl as a trasnmucosal, intranasal and sublingual dose what instructions ned to be followed?

Answer 22

Start with lowest dose despite daily opioid intake

Question 23

What opioid class does methadone fall under

Answer 23

Diphenylheptanes

Question 24

What complications or side effects can Mehtadone cause

Answer 24

Sedation

QT Prolongation

Question 25

How often are you allowed to titrate dosing with methadone?

Answer 25

Avoid dose titrations more frequently than every 2 weeks

Question 26

What drug class does Pentazocine (Talwin) fall under? What other medications is added with these drugs to avoid abuse potential?

Answer 26

Agonist-Antagonist or Partial Agonists Narcan

Question 27

What drug class does Buprenorphine fall under?

Answer 27

Agonist-Antagonist or Partial Agonists

Question 28

When taking Pentazocine or Buprenorphine what effect does it have on Naloxene

Answer 28

Naloxone may not be effective in reversing respiratory depression

Question 29

What opioid drug class does Tramadol fall under Decreasing dosage is necessary for which population?

Answer 29

Central analgesics Renal impairment and the elderly

Question 30

What adverse effect are we most worried about with opioid use?

Answer 30

``` Respiratory depression (slowing things down) Constipation ``` Sleep apnea or COPD

Question 31

Which adverse drug effects will decrease over time while taking opioids?

Answer 31

Sedation | Nausea and vomiting

Question 32

High dose opioid use will cause what to occur in males?

Answer 32

Hypo-testosterone/Hypogonadism

Question 33

Who should avoid taking Codeine?

Answer 33

Children and breastfeeding women

Question 34

What drug class does Naloxone (Narcan) fall under?

Answer 34

Opioid Antagonist

Question 35

What is the downfall with given Naloxene to treat opioid abuse/overdose

Answer 35

Requires repeat dosing since some opioids can outlast duration of Naloxene

Question 36

What two drugs are most effective for Neuropathic pain

Answer 36

Tremedol | Methadone

Question 37

MOA of Gabapentin (Anticonvulsant drug)

Answer 37

may decrease neuronal excitatory neurotransmitters and nociception through voltage-gated calcium channels specifically possessing the alpha-2-delta-1 subunit

Question 38

slide 62

Answer 38

slide 62

Question 39

What adjunctive therapy can be used to treat Chronic pain? What is their method of action

Answer 39

Tricyclic antidepressants Serotonin Norepinephrine reuptake inhibitor antidepressants block the reuptake of serotonin and norepinephrine enhancing pain inhibition

Question 40

MOA of Duloxetine for chronic pain?

Answer 40

Potent inhibitor of neuronal serotonin and norepinephrine reuptake

Question 41

Regional Analgesias and their ADE?

Answer 41

High plasma concentrations Cardiovascular effects - myocardial depression, hypotension, decreased cardiac output, heart block, bradycardia, arrhythmias, and cardiac arrest.

Question 42

What is the MOA of Ziconotide?

Answer 42

Selectively binds to N-type voltage-sensitive calcium channels located on the nociceptive afferent nerves of the dorsal horn in the spinal cord Blocks the excitatory neurotransmitter release and reduces sensitivity to painful stimuli

Question 43

ADE of Ziconotide?

Answer 43

Confusion, dizziness, hallucinations | Urinary retention

Question 44

What medication is used to treat Fibromyalgia? Which is not recommended?

Answer 44

Acetaminophen Opioids

Question 45

What is a Pseudoallergy when taking opiods?

Answer 45

Histamine released from mast cells but NOT an immunologic response Itching, flushing, sweating

Question 46

If a patient is experiencing a possible psedoallergy what can be done to reduce these side effects?

Answer 46

1. Use of non-opiod analgesic 2. Avoid codeine, morphine and merepiridine, drugs associated with pseduoallergies 3. Use a more potent opioid to reduce histamine release 4. Use an antihistamine (H1/H2 blocker) 5. Dose reduction

Question 47

If a patient is actually experiencing an allergy from opioids what can be done to reduce these side effects

Answer 47

A non-opioid analgesic An opioid in a chemical class different from the one to which the patient reacted, with close monitoring

Question 48

What the difference in location between Somatic and Visceral pain? How do these types of pain differ when they occur?

Answer 48

Somatic- arising from skin, bone, joint, muscle, or connective tissue Present as throbbing pain and localized Visceral - internal organs. Pain feeling as if it is coming from other structures (referred) or as a more localized phenomenon