Term
Which opiate-induced symptom does not abate over time (like other SEs will)?
a)Nausea/Vomiting
b)Itching
c)Constipation
d) |
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Definition
constipation.
tolerance rarely occurs. leads to decreased QOL, can be life threatending.
prevention is best treatment.
ATC: give scheduled bowel regimen
PRN: give PRN bowel regimen |
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Term
for opiate induced constipation, what is first line for outpatient? first line for inpatient?
a)increase activity, fluids and fiber
b)MUSH and PUSH! with stool softener + stimulant (Senna-S) |
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Definition
1st line outpatient-increase activity, fluids and fiber
1st line inpatient- MUSH and PUSH!
Stool softener + stimulant (NOT one or the other, docusate alone or stimulant alone is not enough!)
Senna-S (sennosides + docusate) 2 tabs PO qHS |
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Term
Which opiate SE is MORE common in elderly with codeine? and LESS common in fentanyl and hydromorphone?
How to treat it? |
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Definition
Nausea and Vomiting
I think 1st line is: Promethazine, Metoclopramide.
may also use ondasetron (commonly seen).
other options are Prochlorperazin, granisetron, and dolasetron-???
May consider other agents in cancer and palliative care |
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Term
Which SE of opioids is associated with:
Worse with ‘natural agents’ like morphine and codeine. Has to do with histamine relief. This is NOT an allergy! It is a SE. Can always change the agent.
a)Nausea/Vomiting
b)Pruritis and itching
c)Constipation
d) |
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Definition
Pruritis and itching
Usually abate within a few days of therapy
may give pt benadryl also if dont want to change to diff agent, Diphenhydramine IV or PO (mby 15min prior to opioid dose, or prn itching). May give scheduled with analgesic dose or PRN |
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Term
true or false: True opioid allergy is RARE (less than 1%).
If pt DOES have true allergy, what do u do? |
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Definition
True.
Switch to an opioid of a different analogue class. (phenanthrenes, phenylpiperidines, or diphenylheptanes).
Know that meperidine is not used often, not on formulary. Think of it as not an option. Wouldn’t choose methadone either for allergy unless pt has chronic pain. |
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Term
Whese drugs are part of which class?
1)Fentanyl, Meperidine
2)Morphine, codeine, hydromorphone, oxycodone, hydrocodone
3)Methadone
which are synthetic? which are semi-synthetic? |
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Definition
1)Phenylpiperidines: Fentanyl, Meperidine
2)Phenanthrenes: Morphine, codeine, hydromorphone, oxycodone, hydrocodone
3)Methadone: Diphenylheptanes
Synthetic: fentanyl, meperidine
Semi synthetic: hydromorphone, hydrocodone, oxycodone |
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Term
For opioid-induced hyperalgesia, what are treatment options??
a)switch to another opioid
b)consider another analogue
c)switch to another agent entirely (one that is not an opioid, such as.....there are five) |
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Definition
all are treatment options.
Another agent entirely (5):
Gabapentin
Celecoxib
Clonidine
Ketamine
Methadone
CELly GABby the CLOwn MET KETAl |
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Term
| Which non-opioid must be used with caution in patients with hepatic disease and anticoagulation with warfarin? |
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Definition
APAP
Dosage maximum (3g vs. 4g daily)
Account for combination products and APAP alone
Technically 4g is still the max but going towards 3g, keep look out. In hospital use 4g, bc only there short amt of time. Specifically for IV, it is rec to give 4g as max. since not giving long time. |
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Term
Which is indicated for mild to moderate pain? what about for mild, moderate and severe pain?
a)APAP
b)NSAIDs
which is better for pts with pain associated with movement or inflammation (since are antiinflammatory)?
Which should you avoid use in renal impairment, coagulopathies, GI (hx, CCS, >60yo), heart failure, HTN, EtOH? |
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Definition
Indicated for mild to moderate pain: APAP
Mild, moderate and severe pain: NSAIDs
NSAIDs for pain associated with movement or inflammation (since are antiinflammatory)
NSAIDs: Avoid use in renal impairment, coagulopathies, GI (hx, CCS, >60yo), heart failure, HTN, EtOH
Caution in HF bc can worsen HF
Caution in HTN bc has issues with some medications.
Caution: alcohol abuse bc high risk of gasttropathy. |
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Term
which is the only NSAID approved for use as IV/IM? often used for POST-OP?
does it have to be renally adjusted? |
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Definition
Ketorolac approved for IV/IM, severe and moderate (only one appv this way, often used POST-OP bc has IM/IV formulations). But this is potent NSAIDs (ulcers) so can ONLY USE 5 DAYS and HAS to be RENALLY adjusted.
Meloxicam may be better be less GI SE |
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Term
Which antidepressant is useful in neuropathic and when fatigue or somnolence are concern?
true or false: with antidepressant you should start with low doses, titrate slowly. Analgesia usually seen within 1 week.
which types of antidepressants have most evidence? |
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Definition
Bupropion: in neuropathic and when fatigue or somnolence are concern.
true, start low, titrate slowly. see effects in 1 week.
TCAs and SNRIs have the most evidence to support (vs. SSRIs)... SE profile for TCA’s limit use. so try to choose amitrip, nortrip, duloxetine, venlafaxine! But SE in amitrip like sedation (is limiting bc opioid already have resp depression effect). Also QT prolongation. Arrhythmias. Toxicities |
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Term
| Which adjuvant therapy is Useful in neuropathic, bone, bowel obstruction pain? |
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Definition
Glucocorticoids.
Mostly in palliative care: alleviates symptoms of NV, pain, fatigue, inc QOL
Dexamethasone is preferred (long t½ so less dosing, and has less mineralcorticoid effects) |
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Term
| Which adjuvant medication is Useful for pain assoc with muscle spasm and musculoskeletal pain? Sedation limits use? |
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Definition
Skeletal muscle relaxants
but would try neuropathic pain tx first. Often muscular spasm and neuro pain are veyr similar! Muscle relaxants have significant addiciton issue (soma, baclofen, skelaxin, cyclobenzaprine). She rly tries to avoid soma since addiction and minimal efficacy! |
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Term
| Which benzodiazepine is used for neuropathic pain? |
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Definition
Clonazepam usually neuropathic pain
Comorbidity with anxiety, acute depression (inpatient) and agitation, |
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Term
which two adjuvant antiepileptics exhibit increased analgesic effect?
what is a SE of them to watch out for?
do these have to be tapered? |
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Definition
Gabapentin and pregabalin
First line for neuropathic pain
But are very sedating. But less SE as other antiepileptic. Have to taper these, use table!
Few drug interactions (vs. other AEDs)
Must taper prior to discontinuation
Limited data for the other AEDs (ie phenytoin, valproate, carbamazepine, topiramate) |
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Term
Which adjuvant tx is both opioid and SNRI??
a)cannabinoids
b)tapentadol
c)alpha 2 aonist (clonidine)
d)ketamine (NMDA antagonist)
e)tramadol |
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Definition
Tapentadol
(brand: Nucynta)
avoid in severe renal impairment and severe hepatic impairment |
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Term
Which adjuvant tx is associated with being: More efficacious for neuropathic pain, tapering opioid withdrawal risk, or concomitant HTN, used topically, intraspinally, and orally, dexmeditomidine less evidence
a)cannabinoids
b)tapentadol
c)alpha 2 aonist (clonidine)
d)ketamine (NMDA antagonist)
e)tramadol |
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Definition
| clonidine (alpha2 agonist) |
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Term
Which adjuvant tx is associated as doing this:
-Sensitizes opioid receptor, opioid dose-sparing
-Use low doses for analgesia (vs. general anesthesia higher dose)
-Caution in high BP
a)cannabinoids
b)tapentadol
c)alpha 2 aonist (clonidine)
d)ketamine (NMDA antagonist)
e)tramadol |
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Definition
| ketamine (NMDA antagonist) |
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Term
Which adjuvant tx is an Opioid and 5HT?
Initiate at lower doses in eldery
Renally and hepatically adjusted
Seizure risk (especially higher when use other meds like opioids, SSRIs, TCAs)
Good if mod pain, abuse potential present so use this to help dec risk
a)cannabinoids
b)tapentadol
c)alpha 2 aonist (clonidine)
d)ketamine (NMDA antagonist)
e)tramadol |
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Definition
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Term
What are two topical adjuvants for pain?
which has to be applied for 12h every 24hrs?
which can be used for post-herpetic neuralgia?
which has Limited efficacy in moderate to severe pain? which is for weak to moderate analgesic effects? |
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Definition
Lidocaine 5% (Lidoderm Patch)
Topically applied for 12 h every 24 hrs (Can use multiple patches, worry about it becoming systemic, its an anti-arrhythmic which is scary)
Limited efficacy in moderate to severe pain
May use multiple patches cautiously (≥3)
Cost limits use
Post herpetic neuralgia!
Capsaicin
Weak to moderate analgesic effects
Burning at site of application limits use
Application is 3 -4 times a day
Good for pt that doesn’t want to take tabs, etc |
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Term
| Perispinal Analgesia/Anesthesia is indicated when ....? and has two main types known as ___ and ____. |
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Definition
Indicated when:
-Conventional drug therapy proves ineffective or produces intolerable side effects.
-want to use perioperatively (labor, other things too)
Intrathecal and Epidural |
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Term
What three ways that complications may occur with Perispinal Analgesia/Anesthesia?
What are major contraindications to catheter placement??
a)coagulopathy
b)infection at catheter insertion site
c)sepsis |
|
Definition
a)from the procedure (e.g. post-spinal headache)
b)from medications (e.g. opioid-related respiratory depression, sedation, urinary retention, pruritis)
c)from hardware (e.g. catheter kinking/disconnection/dislodgement, infection).
Major contraindications to catheter placement include: coagulopathy, infection at catheter insertion site, and sepsis. |
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Term
| Describe Intrathecal Pump System. what drug are used with it? |
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Definition
| with baclofen, clonidine, almost permanent application through spine. Going into space around spinal cord (intrathecal) |
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Term
| true or false: Botox is an up and coming agent as MULTI-MODAL (for many different types of pain) |
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Definition
Increasing evidence for use in pain
Refractory low back pain
Neuropathic pain
Osteoarticular pain
More to come…
Botox may be used for pain! Has some evidence for things listed above. These four had more benefit seen. Don’t memorize these. Botox is up coming agent as MULTI-MODAL! |
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Term
Which of the following are Patient-Specific Factors to Consider?
a)Age, Cognitive Function, Medication History, Potential for Abuse/Misuse, Allergies or Pseudoallergy, Comorbidities, Renal and Hepatic function, Nutritional Status |
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Definition
| Age, Cognitive Function, Medication History, Potential for Abuse/Misuse, Allergies or Pseudoallergy, Comorbidities, Renal and Hepatic function, Nutritional Status |
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Term
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Definition
Ask about pain regularly (QOL, etc)
Believe the patient and family (err on the side of treating pain, be cautious about thinking everyone is drug seeker)
Choose pain control options that are appropriate (IM, intrathecal? PO? Etc)
Deliver interventions in timely manner (esp whenc omes to nurses)
Empower patients and their families (tell them its ok tot alk about paina nd to have it treated. Entitled to pain relief) |
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Term
true or false: When changing opiate drug classes, decrease the converted drug dosage by 25-50% (when using equipotent conversion chart. From morph to oxycodone, may have cross tolerance. Some pts have own specific response)
Use patient specific factors to help determine |
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Definition
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Term
true or false:
If the patient requires >3 breakthrough doses per day
Add ATC if not on already
Add the breakthrough into the ATC
Increase the daily dose by 25% for mild pain, 25-50% for moderate pain and 50-100% for severe pain
If using >3 breakthrus a day, is it rly enough? It may be uncontrolled pain and not managed adequately. But sometimes they will use it bc the nurse tells them to even f they don’t need it. |
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Definition
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