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Thera X > 12 Principles of Pain Medications Han > Flashcards

12 Principles of Pain Medications Han Flashcards

1
Q

Why branches of pain fall under Nociceptive Pain?

A

Somatic. Visceral

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2
Q

What is Somatic Pain?

A

Skin, bone, joint, muscle, tissue. Throbbing, localized pain. Responds to opioids

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3
Q

What is Visceral Pain?

A

Internal organs. Poorly localized, generalized pain. Responds to Opioids

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4
Q

What is Neuropathic Pain?

A

Stimulation of pain receptors are NOT required. Nerve damage or abnormal conduction of nervous system. Burning, tingling, or shooting pain. Resistant to opioids

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5
Q

What are the characteristics of Nociceptive Pain?

A

Stimulation of nociceptors (afferent neurons on skin, muscle, joints, visceral organs). Transmission: peripheral nerve depolarizes and releases neurotransmitters (Glutamate, Substance-P, etc.). Pain perception. Adaptive inflammation (decreases pain threshold and magnifies sensitivity of injured area to pain)

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6
Q

What is the Modulation of Nociceptive pain like?

A

Endogenous opiate system (Enkephalins, Dynorphins, and beta-endorphins). N-methyl-D-aspartate (NMDA) receptors (Activation decreases u-receptors responsiveness to opiates)

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7
Q

What are the characteristics of Acute Pain?

A

Identifiable cause. Immediate and intense pain. Short-lived (< 6 months). Somatic and visceral. Can lead to chronic pain

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8
Q

What are the Keys to Effective Pain Management (ABCDE)?

A

A: Assess the pain. B: Believe the patient. C: Commit to a therapeutic agreement. D: Choose appropriate drugs. E: Educate patients and Evaluate therapy

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9
Q

What are the recommendations for Pain Assessment?

A

Make pain assessment/management a priority in daily practice. Consider pain intensity the fifth vital sign (measure along with temp, pulse, respiration, and BP). Patients’ rights: Full pain work-up when pain is not easily characterized or treated

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10
Q

What is APAP (Tylenol) used for?

A

Mild to moderate pain

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11
Q

What had the FDA mandated for APAP labeling to prevent overdose?

A

Do not use “APAP” on prescription bottles. BBW for risk of severe liver damage. Warning for potential for allergic reactions. All prescription acetaminophen should not contain > 325mg APAP per tablet

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12
Q

What are the new Tylenol dosing instructions for Extra Strength Tylenol?

A

Reducing the maximum daily dose from 8 pills (4,000mg) per day to 6 pills (3,000mg) per day. Changing the dosing interval from Q4-6h to Q6h

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13
Q

What are some APAP combination products?

A

Vicodin. Norco. Lorcet. Lortab. Percocet. Ultracet. Nyquil Cold and Flu Relief

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14
Q

What is Ofirmev?

A

Injectable APAP. Same dose/efficacy as other routes. Not approved for children < 2 yo. Infused over 15 minutes. Doesn’t really have a place in therapy

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15
Q

What are Salicylates (Aspirin) used for?

A

Pain, fever, inflammation, cardiovascular protection. Irreversible platelet inhibition (do not administer to patients w/ epidural). D/C 7 days prior to surgery

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16
Q

What are NSAIDs used for?

A

Mild to moderate pain

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17
Q

What are some characteristics of NSAIDs?

A

Must be taken with food. NSAIDs exhibit “ceiling” effect

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18
Q

What are the ADRs with NSAIDs?

A

GI ulceration/bleeding. Renal impairment

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19
Q

What is a caution to use with NSAIDs?

A

Fluid retention, CHF, nephrotic syndrome

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20
Q

What is Ketorolac (Toradol)?

A

IV/IM NSAID. Short-term use for acute and severe pain (max 5 days of treatment). Contraindicated in renal impairment

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21
Q

How is Ketorolac (Toradol) dosed?

A

30mg IV/IM Q6h, or 10mg PO QID (max of 120mg/day IM/IV (>65 yo or < 50kg: IM/IV 60mg/day), 40mg/day PO

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22
Q

What patient properties need to be looked at before dosing Ketorolac (Toradol)?

A

Age, weight, and renal function

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23
Q

How does Ketorolac (Toradol) compare to opiates?

A

30mg IM comparable to 12mg morphine or 100mg meperidine

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24
Q

What is Caldolor?

A

IV Ibuprofen indicated for: Mild to moderate pain, adjunct to opioid for moderate and severe pain, Fever in adults. No limitation on duration of therapy

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25
Q

What is the BBW with Caldolor?

A

CV risk-thrombotic events, MI, stroke. CI in CABG surgery. GI risk-bleeding, ulceration, and perforation of the stomach

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26
Q

What is the Flector Patch?

A

1st transdermal NSAID used for acute pain d/t minor sprains, strains, and contusions

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27
Q

How is the Flector Patch dosed?

A

Apply 1 patch (180mg) to painful area Q12h. Should not be worn during showering or bathing

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28
Q

What are Opiates?

A

Naturally occurring alkaloids (i.e. Morphine or Codeine)

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29
Q

What are the characteristics of Opioid Receptors?

A

Stimulated by endogenous peptides produced in response to noxious stimulation. Mu (u) receptor: Analgesia (pure agonists = most potent analgesia, i.e. morphine, hydromorphone, fentanyl)

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30
Q

What are the ADRs with Mu (u) receptor agonism?

A

Respiratory depression, euphoria, sedation, decrease GI motility, vomiting, pruritis, urinary retention

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31
Q

What are Opioid Analgesics used for?

A

Moderate to severe pain. No “ceiling” effect except Tramadol

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32
Q

What is the onset time for Opioid analgesics?

A

PO: 30-60 minutes. IM/SC: 15-30 minutes. IV: ~5 minutes

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33
Q

What are the Naturally occuring opioid analgesics?

A

Morphine. Codeine

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34
Q

What are the Semisynthetic occuring opioid analgesics

A

Hydromorphone. Oxymorphone

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35
Q

What are the Synthetic occuring opioid analgesics

A

Meperidine. Methadone

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36
Q

What are the “Morphine-Like Opioids”?

A

Morphine. Hydromorphone. Codeine. Hydrocodone. Oxycodone

37
Q

What are the “Meperidine-Like Opioids”?

A

Meperidine. Fentanyl

38
Q

What are the “Methadone-Like Opioids”?

A

Methadone

39
Q

What are the “Central Analgesic” Opioids?

A

Tramadol (Ultram). Tapentadol (Nucynta)

40
Q

What is Morphine used for?

A

Prototype pure u-agonist. First-line agent for moderate to severe pain. PO, IM, IV, PR

41
Q

What is the metabolism of Morphine like?

A

Morphine-6-Glucuronide (M6G): contributes to analgesia. Morphine-3-Glucuronide (M3G): contributes to side effects. Excreted renally. Lower doses in renal dysfunction and in elderly

42
Q

Why can Morphine be useful in Ischemic Cardiac Patients?

A

Decreases myocardial oxygen demand

43
Q

What are the characteristics of Hydromorphone (Dilaudid)?

A

More potent than morphine (7:1). Better oral absorption than morphine. Less pruritis and constipation than morphine. Tolerance and physical dependence is greater than morphine. No active metabolite-maybe preferred in renally insufficient patient

44
Q

What are the characteristics of Codeine?

A

Low affinity for opioid receptors. Mild to moderate pain. Analgesic effect from metabolite (Prodrug): metabolized to morphine (potency: 50% of morphine). Used with NSAIDs, aspirin, or APAP (NEVER used as monotherapy). Has antitussive properties

45
Q

What is the concern with Codeine and its metabolism?

A

10% converted to morphine via CYP2D6. Ultra-metabolizers will have a greater effect. CYP2D6 inhibitors will block conversion to morphine

46
Q

What is Hydrocodone (Vicodin)?

A

Derivative of codeine. For moderate to severe pain. Available only in combination products. Mostly with APAP. Dose limiting factor is the APAP dose

47
Q

What is Oxycodone?

A

Equal in potency to morphine. Moderate to severe pain. Most effective when used with NSAIDs, ASA, or APAP

48
Q

What is Oxymorphone?

A

Metabolite of Oxycodone. No pharmacologic advantage over morphine. Not used much

49
Q

What is a common allergic reaction to Morphine?

A

Itching

50
Q

What is Meperidine (Demerol)?

A

Weak opioid agonist. Less potent and shorter duration than morphine. Used for rigors (Postanesthetic shivering, Infusion related rigors, One-time premed for endoscopy)

51
Q

What are the drug interactions of concern with Meperidine (Demerol)?

A

Serotonin Syndrome with MAO-I (severe respiratory depression or excitation, delirium, hyperpyrexia, and convulsion)

52
Q

Why is Meperidine (Demerol) not on formulary at many institutions?

A

Toxic metabolite Normeperidine: CNS exciatbility, Not reversible by Naloxone, Renally excreted, Should not be used longer than 48 hours

53
Q

What is Fentanyl?

A

Strong opioid agonist (80x more potent than morphine). IV formulation only used in perioperative setting or in ICUs

54
Q

What is Fentanyl Patch (Duragesic)?

A

For persistent moderate-to-severe pain. Generally applied Q72h. 12 to 24 hrs for full onset and up to 6 days for steady state. May be Q48h if patient has break through pain at end of dosing interval

55
Q

What should Fentanyl Transdermal Patch NOT be used for?

A

Opioid-naive patients. Post-operative pain or Acute pain. Mild pain. Breakthrough pain (d/t delay of onset)

56
Q

What should the Fentanyl patch be reserved for?

A

Chronic Pain Management

57
Q

What is Oral Fentanyl used for?

A

Breakthrough pain in cancer patients. Actiq (Oral lozenge on a stick), Fentora (Buccal Fentanyl)

58
Q

What is Methadone?

A

Unrelated to other opioid structures. Exists as 2 enantiomers. Used for Chronic pain. Duration of action «< elimination half-life

59
Q

What are the different enantiomers of Methadone?

A

R: u-agonist (more potent). S: NMDA antagonist (allows better activity)

60
Q

How can Methadone be used for treating opioid abuse?

A

Lack profound euphoria. Withdrawal s/sx milder than morphine. Treatment of heroin users

61
Q

What is Tramadol?

A

Synthetic codeine analogue. Moderate to Moderately Severe pain. Weak affinity for opioid receptor. Part of analgesic effect d/t inhibition of NE and Serotonin uptake

62
Q

What are some concerns with Tramadol use?

A

Avoid with MAO-I (d/t inhibition of NE and serotonin uptake). Can cause seizure and lower seizure threshold for those at risk for seizure

63
Q

How is Tramadol cleared?

A

Hepatic metabolism to active metabolite and renally excreted. Maximum of 200mg per day if hepatic or renal dysfunction

64
Q

What is Tapentadol (Nucynta)?

A

Centrally acting opioid. Dual MOA: u-agonist, NE reuptake inhibitor. Used for Moderate to Severe ACUTE pain

65
Q

What is Tapentadol (Nucynta) contraindicated?

A

Paralytic ileus, use of MAO-I w/in 14 days, impaired pulmonary function. Avoid in severe renal and hepatic insufficiency. Caution in seizure patients

66
Q

Which Morphine opioids are controlled/extended release and should NOT be used PRN?

A

Controlled (MS Contin, Kadian). Extended (Avinza (Q24h))

67
Q

Whats the rational behind partial agonist-antagonist opioids?

A

Stimulate analgesic portion of opiate receptors but block toxicity of receptors. Exhibit mixed agonist-antagonist activity. Provide analgesia with few side effects

68
Q

What are the steps when calculating opioid conversion?

A

Calculate 24 hr dose requirement of the current opioid. Convert to the 24 hr total dose of the new drug or route. Divide 24 hr dose to individual doses. Reduce dose of new drug by 30-50%. Calculate a breakthrough dose (10-20% of the total daily dose or 25-50% of the single standing dose). Titrate to patients response

69
Q

Which opioid requires an EMPTY stomach?

A

Oxymorphone (Opana)

70
Q

What are the monitoring parameters while on opioids?

A

Respiratory depression! Hypotension. Pruritus. Urinary retention, constipation. Rash (true allergy). Biliary spasm (morphine). Meperidine (Irritability, tremor, muscle twitching, seizure)

71
Q

How does Respiratory Depression happen?

A

Due to reduction in responsiveness to CO2. Reversed with Naloxone. Monitor vigilantly. Tolerance develops

72
Q

What are some characteristics of Itching caused by Opioids?

A

Histamine release. May decrease dose of analgesia is satisfactory. Treat with antihistamines. Tolerance develops over time

73
Q

What are some characteristics of Opioid induced constipation?

A

Decreased intestinal secretions. Decreased GI motility. All patients on ATC opioids should receive stool softener and mild stimulant laxative (do NOT use fiber laxatives). Tolerance does NOT occur over time

74
Q

What is Hydroxyzine (Vistaril)?

A

Used for pruritis, emesis. Used with Demerol for synergistic analgesic effects. IM administration only

75
Q

What are some Antiemetics to use for nausea?

A

Ondansetron. Dolasetron. Prochloperazine

76
Q

What is Alvimopan (Entereg)?

A

Peripherally acting u-receptor antagonist. Does NOT cross BBB. Indicated for post-op ileus following partial large or small bowel resection. Only indicated for inpatient (d/t its MI risk). Hospital must be enrolled in EASE program

77
Q

What is Methylnaltrexone (Relistor)?

A

Peripherally acting u-receptor antagonist. Indicated for opioid-induced constipation in patients with advanced illness receiving palliative care. Given SQ, weight based Q48h PRN

78
Q

Which opioids cause the most sedation?

A

Morphine. Codeine. Oxymorphone. Oxycodone

79
Q

Which opioids cause the most N/V?

A

Oxymorphone. Oxycodone. Morphine. Meperidine

80
Q

Which opioids cause the most respiratory depression?

A

Morphine. Oxymorphone

81
Q

Which opioids cause the most constipation?

A

Morphine. Oxymorphone

82
Q

Which opioids cause the most physical dependence?

A

Oxymorphone. Morphine. Hydromorphone. Meperidine. Oxycodone

83
Q

Which analgesic is used when patients have a TRUE opioid allergy?

A

Central Analgesics (Tramadol, Tapentadol)

84
Q

What is Naloxone (Narcan)?

A

Used for rapid reversal of opioid-induced respiratory depression. Onset ~2 minutes. Naloxone continuous infusion for refractory respiratory depression or itching not responsive to diphenhydramine

85
Q

What is Naltrexone (Revia)?

A

Orally effective with long duration of action. Useful in abuse deterrent, detoxification, and maintenance treatment modalities. Also used for EtOH dependence

86
Q

What is Patient-Controlled Analgesia (PCA)?

A

Preferred to PRN administration of opioids. Patient has limited control of dosing. Avoids delays in pain relief and give patients greater sense of control. Morphine, Hydromorphone, Fentanyl, Meperidine

87
Q

What is Epidural Catheter Infusion?

A

Decreases incidence of pulmonary complications compared to systemic opioids. Lower doses of opioids than PCA. Less systemic side effects than PCA

88
Q

What should not be given when doing an Epidural Catheter Infusion?

A

Lovenox, SQ Heparin should be held for ~12 hours before insertion or removal of epidural catheter (risk of spinal hematoma and paralysis). No ASA or ASA containing products while epidural in place d/t risk of spinal hematoma and paralysis

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