Acute Pain

Question 1

What medications used for mild pain have the greatest dose dependent risk for hepatic toxicity?

Answer 1

Aspirin

APAP

Question 2

What medication used for mild pain can cause renal toxicity?

Answer 2

Aspirin

NSAIDs

Question 3

[True/False] To treat moderate pain you can use Tylenol w/ Codeine, Oxycodone or hydromorphone with APAP, and meperidine.

Answer 3

False

Meperidine is no longer recommended for moderate pain.

Question 4

What are some second line therapies to treat moderate pain?

Answer 4

Tramadol

Pentazocine, Butorphanol, etc. (rarely used)

Question 5

Characteristics of Tramadol

Answer 5

Onset is rapid
Half-life is 6-8 hours and for the active metabolite it is 7-9 hours.
Weak opiate and NE/SE reuptake inhibitor

Question 6

What are some examples of potent mu receptor agonists that are used to treat severe pain?

Answer 6

Morphine (prototypical)
Oxymorphone
Hydromorphone
Fentanyl
Methadone

Question 7

When treating an opioid naive patient for severe pain what is the recommended starting dose?

Answer 7

5-10mg Q4H

Question 8

When switching to a dose that is equivalent to another opioid what is recommended to do to account for variability in the conversion table?

Answer 8

Start at 75% of the equi-analgesic dose and provide something for breakthrough pain.

Question 9

When titrating opioids what are the guidelines to minimize adverse effects?

Answer 9

Start with a low dose and titrate slowly.

Question 10

When monitoring for respiratory depression in patients on opioids what do you need to have in uncomplicated patients?

Answer 10

Vital signs
Pain score
Ramsey Score (Q4H)

Question 11

What dose of naloxone do you give to a patient taking an opioid with a RR between 4-10?

Answer 11

40mcg.
This is 1/10 the dose of a rescue dose. You only give the full rescue dose of naloxone if the patient has stopped breathing.

Question 12

How do you treat a patient that is in apnea (respiratory failure) due to an opioid?

Answer 12

Give the full rescue dose of naloxone (400mcg) every 2-3 minutes until the patient wakes up.

You need to stop the opioid.

Question 13

For neurosurgery or craniotomy, why don’t you want to use opioids for pain?

Answer 13

You are trying to monitor the patient’s signs and symptoms to check for post-op complications. If you give opioids they can make it harder to read these values since they affect the CNS.

You can use NSAIDs instead since the pain is usually mild-moderate.