Acute Pain & Opioid-Free Analgesia (Cornelius) Exam II

Question 1

Which of the following best describes the function of acute pain?

A) A long-lasting pain meant to promote healing.
B) A direct stimulation of pain fibers that precedes potential tissue damage as a warning.
C) A direct response triggered by psychological factors only.
D) A type of chronic pain without a specific stimulus.

Answer 1

B) A direct stimulation of pain fibers that precedes potential tissue damage as a warning.

There is a close relationship between the intensity of the stimulus, the discharges in the primary afferents, and the subjective expression of pain.

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Question 2

Acute pain has been shown to affect which of the following systems? (Select 3)

A) Cardiac
B) Pulmonary
C) Immune
D) Integumentary

Answer 2

A) Cardiac - heart rate goes up.
B) Pulmonary -they may breathe faster.

C) Immune

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Question 3

Acute pain may lead to alterations in which of the following systems? (Select 3)

A) Endocrine
B) GI/GU
C) Coagulation pathways
D) Skeletal muscle function

Answer 3

A) Endocrine - things kind of get out of whack from a glycemic standpoint. Blood sugar may go up or go down.

B) GI/GU
C) Coagulation pathways

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Question 4

Which of the following is an example of somatic superficial pain?

A) Expanding bowel gas
B) Accidental knife cut to the finger
C) Pain radiating to the left shoulder due to cardiac ischemia
D) Acute appendicitis

Answer 4

B) Accidental knife cut to the finger

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Question 5

Somatic acute pain that originates from skin, subcutaneous tissues, or mucous membranes is known as __________ pain.

A) Deep
B) Superficial
C) Parietal
D) Referred

Answer 5

B) Superficial

Question 6

Which of the following is an example of parietal pain?

A) Pain due to appendicitis
B) Pain due to muscle strain
C) Pain from a skin abrasion
D) Pain in tendons

Answer 6

A) Pain due to appendicitis

Localized around an organ; Sharp and stabby ⚡️⚡️⚡️⚡️⚡️

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Question 7

Which of the following are types of somatic pain? (Select 2)

A) Pain from a skin abrasion
B) Pain from a tendon injury
C) Pain from myocardial ischemia
D) Pain from peritoneal irritation

Answer 7

A) Superficial pain from a skin abrasion
B) Deep pain from a tendon injury - can also be from muscles, joints and bone

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Question 8

Visceral pain can include which of the following characteristics? (Select 3)

A) Referred pain to cutaneous areas
B) Localized parietal pain
C) Deep pain from muscles and joints
D) Pain due to expanding bowel gas

Answer 8

A) Referred pain to cutaneous areas
B) Localized parietal pain,
D) Pain due to expanding bowel gas

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Question 9

Which of the following best defines referred pain ?

A) Pain localized to the area directly affected by tissue damage.
B) Pain that originates from the skin, muscles, or joints and is easily localized.
C) Pain that is felt in a location distant from the actual source of the pain
D) Pain that results only from organ damage and is sharp and well-defined.

Answer 9

C) Pain that is felt in a location distant from the actual source of the pain due to the convergence of visceral and somatic afferent input in the central nervous system (CNS).

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Question 10

One of the key goals in pain management, especially for an intubated patient is:

A) Reducing the need for oxygen therapy
B) Controlling anxiety and agitation
C) Enhancing motor function
D) Improving gastrointestinal motility

Answer 10

B) Controlling anxiety and agitation

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Question 11

Which of the following are goals of pain control? (Select 2)
A) Attenuation of adverse physiologic responses
B) Prevention of chronic pain syndromes
C) Increased blood glucose regulation
D) Allowing anxiety and agitation

Answer 11

A) Attenuation of adverse physiologic responses
B) Prevention of chronic pain syndromes,

Overall Patient Comfort 🩵

Overall Patient Comfort 🩵

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Question 12

Which of the following is a key component of achieving optimal pain control goals according to the slide?

A) Reactive analgesia
B) Preemptive and preventative analgesia
C) Postoperative analgesia only
D) Single-modality approach

Answer 12

B) Preemptive and preventative analgesia

C - if we’re able to control the pain before it happens, you don’t have quite the same risk of the agitation, the sympathetic responses, the development of chronic pain syndromes.

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Question 13

Which of the following strategies is becoming more common in modern pain management?

A) Increasing opioid usage
B) Reducing all analgesic usage
C) Opioid-free anesthesia
D) Solely using NSAIDs for pain management

Answer 13

C) Opioid-free anesthesia

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Question 14

The multimodal approach to pain control involves:

A) Using a single analgesic to target all receptors
B) Utilizing various analgesics to target multiple pain pathways
C) Decrease number of receptors
D) Administering pain medications only after surgery

Answer 14

B) Utilizing various analgesics to target multiple pain pathways

Corny - multimodal approach to do that and hitting as many receptors as possible, but with that in mind, you really have to target your analgesic plan to the patient.

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Question 15

Which of the following correctly describes the progression of pain phases?

A) Neuropathic pain → Acute pain → Chronic nociceptive pain

B) Acute pain → Chronic nociceptive pain → Neuropathic pain

C) Chronic nociceptive pain → Acute pain → Neuropathic pain

D) Acute pain → Neuropathic pain → Chronic nociceptive pain

Answer 15

B) *Transient *Acute pain → Chronic nociceptive pain → Neuropathic pain

C - Now you can have patients that start off with essentially neuropathic pain. Think about somebody with diabetic neuropathy.
They may never really have an acute pain phase because they don’t have adequate sensation.
So with those patients, neuropathic pain may be their start.

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Question 16

True or False

Pain is not exclusive - at anytime, several of the underlying mechanisms may coexist in the same individual

Answer 16

True

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Question 17

Which of the following disease states are commonly associated with pain?

A) Degenerative joint disease
B) Diabetes mellitus
C) Polymyalgia rheumatica
D) Wounds
E) End of Life
F) All of the above
G) None of the Above
H) A, B, & C
I) C, D, and E

Answer 17

F) All of the above

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Question 18

Which of the following can cause pain related to immobility? (Select 4)

A) Surgery
B) Dementia
C) Fractures
D) Finger cut
E) PVD

Answer 18

A) Surgery
B) Dementia
C) Fractures
E) PVD - Peripheral vascular disease

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Question 19

Which of the following strategies can help alleviate pain caused by immobility? (Select 2)

A) Mobilizing the patient early post-surgery
B) Using opioid-free anesthesia
C) Encouraging physical therapy and movement
D) Increasing bed rest to prevent pain

Answer 19

A) Mobilizing the patient early post-surgery,
C) Encouraging physical therapy and movement

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Question 20

Which of the following is NOT considered a red flag in pain management?

A) Pain that wakes the patient up
B) Severe or progressive neurologic deficit
C) Pain relieved by rest
D) Constitutional symptoms

Answer 20

C) Pain relieved by rest

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Question 21

Which of the following signs in a patient with pain would indicate a potential Red Flag?
Select 3

A) Severe pain with immunosuppression
B) Pain accompanied by a cold, pale limb
C) Pain that gradually decreases over time
D) Severe abdominal pain with hypotension and fever

Answer 21

A) Severe pain with immunosuppression
B) Pain accompanied by a cold, pale limb
D) Severe abdominal pain with hypotension and fever

Cornelius - Pain to the point where it’s causing immunosuppression, oftentimes with malignancy will see that patients develop severe pain as their presentation and then they go in and they’ve got something like osteosarcoma.

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Question 22

Which of the following describes a constitutional symptom that would be considered a red flag in pain management?

A) Back pain that resolves with rest
B) Chronic back pain that improves with NSAIDs
C) Acute back pain followed by loss of balance and new onset of incontinence
D) Pain localized to the joints after activity

Answer 22

C) Acute back pain followed by loss of balance and new onset of incontinence

Corn - Constitutional symptoms - So maybe they have back pain and it’s a chronic condition, maybe it’s acute back pain. You fall and you’re doing OK, but the next day you wake up in your incontinence.
That’s a huge red flag.

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Question 23

Matching!

Match the system with the consequences of poorly managed acute pain

Answer 23

Cardiovascular → Tachycardia, hypertension, and increase in cardiac workload

Pulmonary → Respiratory muscle spasm (splinting), decrease in vital capacity, atelectasis, hypoxia, and increased risk of pulmonary infection

Gastrointestinal → Postoperative ileus

Renal → Increased risk of oliguria and urinary retention

Coagulation → Increased risk of thromboemboli

Immunologic → Impaired immune function

Muscular → Muscle weakness and fatigue; limited mobility can increase the risk of thromboembolism

Psychological → Anxiety, fear, and frustration resulting in poor patient satisfaction

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Question 24

In a patient with a history of coronary artery disease (CAD) and uncontrolled pain, which of the following could result from tachycardia and increased cardiac workload?

A) Arrhythmias
B) Demand ischemia
C) Pulmonary edema
D) Stroke

Answer 24

B) Demand ischemia

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Question 25

What complication may develop in a patient with rib fractures and inadequate pain control due to decreased respiratory effort?

A) Pneumonia
B) Pleural effusion
C) Cardiac tamponade
D) Hemothorax

Answer 25

A) Pneumonia

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Question 26

In a post-abdominal surgery patient receiving large doses of opioids for pain management, what complication might arise due to slowed gastrointestinal function?

A) Bowel perforation
B) Intestinal obstruction
C) Postoperative ileus
D) Gastric ulcer

Answer 26

C) Postoperative ileus

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Question 27

Who proposed the Specificity Theory of Pain?

A) Sigmund Freud
B) Charles Darwin
C) Rene Descartes
D) Immanuel Kant

Answer 27

C) Rene Descartes

This guy

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Question 28

According to the Specificity Theory, the intensity of pain is directly related to:

A) The emotional response to pain
B) The amount and degree of tissue injury
C) The duration of the painful stimulus
D) The individual’s pain threshold

Answer 28

B) The amount and degree of tissue injury

C - if you hit your finger with a hammer versus a small needle, the pain you experience will be different in its intensity and is probably indicative of potential tissue damage

it doesn’t include other senses, you have to involve other senses like see feeling and those may impact things

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Question 29

One criticism of the Specificity Theory is that it overreacts to pain in cases where there is little tissue damage but the injury appears __________.
A) Insignificant
B) Severe
C) Superficial
D) Psychological

Answer 29

B) Severe

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Question 30

According to the Intensity Theory of Pain, which philosopher first conceptualized pain as an emotional experience rather than a sensory one?
A) Aristotle
B) Descartes
C) Plato
D) Socrates

Answer 30

C) Plato

The dude

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Question 31

The Intensity Theory of Pain views pain primarily as a(n) __________ experience, rather than a sensory one.
A) Physical
B) Emotional
C) Mechanical
D) Psychological

Answer 31

B) Emotional

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Question 32

Who proposed the Gate Control Theory of Pain in 1965?
A) Rene Descartes and Sigmund Freud
B) Ronald Melzack and Patrick Wall
C) Charles Darwin and Immanuel Kant
D) Plato and Aristotle

Answer 32

B) Ronald Melzack and Patrick Wall

this theory is the best one we have right now. it was the first cohesive explanation for the emerging complexities of pain phenomena, particularly chronic pain.

These old guys

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Question 33

According to the Gate Control Theory, pain transmission is modulated by impulses transmitted to the spinal cord and regulated by ________ .

A) Chemical neurotransmitters
B) Gate mechanisms
C) Electrical impulses
D) Hormonal signals

Answer 33

B) Gate mechanisms

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Question 34

According to the Gate Control Theory, where are the “gates” that regulate pain transmission located?

A) Cerebral cortex
B) Brainstem
C) Substantia gelatinosa of the spinal cord
D) Peripheral nerves

Answer 34

C) Substantia gelatinosa of the spinal cord

The cells in this area functions as a gate regulating transmission of impulses to the central nervous system.

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Question 35

According to the Gate Control Theory, pain perception can be influenced by psychological factors such as __________, which may amplify or diminish the pain experience.

A) Hormones
B) Nutrient intake
C) Immune response
D) Past experiences

Answer 35

D) Past experiences

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Question 36

What types of tissue damage activate nociceptors in the body?
Select 3

A) Thermal
B) Mechanical
C) Electrical
D) Chemical

Answer 36

A) Thermal
B) Mechanical
D) Chemical

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Question 37

Which of the following fibers are responsible for transmitting pain signals from nociceptors?
Select 2

A) Myelinated Alpha-β
B) Myelinated Alpha-δ
C) Unmyelinated Delta fibers
D) Unmyelinated Gamma fibers
E) Unmyelinated C fibers

Answer 37

B) Myelinated Alpha-δ
E) Unmyelinated C fibers

**free afferent nerve endings **

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Question 38

Which of the following are inflammatory mediators released with histamine during tissue injury?
Select 3

A) Bradykinin
B) Prostaglandins
C) Acetylcholine
D) Serotonin

Answer 38

A) Bradykinin (peptides)
B) Prostaglandins (lipids)
D) Serotonin (neurotransmitters)

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Question 39

First-order neurons transmit pain signals from which location to the spinal cord?

A) The thalamus
B) The periphery
C) The brainstem
D) The somatosensory cortex

Answer 39

B) The periphery

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Question 40

Second-order neurons transmit pain signals from the spinal cord to the:

A) Somatosensory cortex
B) Brainstem
C) Thalamus
D) Cerebellum

Answer 40

C) Thalamus

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Question 41

Third-order neurons transmit pain signals from the thalamus to the __________, where the final processing of pain occurs.

A) Brainstem
B) Cerebellum
C) Somatosensory cortex
D) Spinal cord

Answer 41

C) Somatosensory cortex

Question 42

First-order neurons receive pain signals in the periphery tissue receptors of the skin and the proprioceptors which are located in:
Select 3

A) Muscles
B) Joints
C) Thalamus
D) Tendons
E) Fascia

Answer 42

A) Muscles
B) Joints
D) Tendons

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Question 43

Where do the first-order neurons synapse with the second-order neurons in the pain pathway?
A. Thalamus
B. Somatosensory cortex
C. Dorsal horn of the spinal cord
D. Brainstem

Answer 43

C. Dorsal horn of the spinal cord

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Question 44

After synapsing with the first-order neurons, where do the second-order neurons cross to in the pain pathway?
A. Ipsilateral side of the spinal cord
B. Contralateral side of the spinal cord
C. Anterior side of the spinal cord
D. Ventral side of the spinal cord

Answer 44

B. Contralateral side of the spinal cord

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Question 45

The second-order neurons ascend to the thalamus via which of the following tracts?

A. Spinothalamic tracts
B. Corticospinal tracts
C. Dorsal column tracts
D. Reticulospinal tracts

Answer 45

B. Spinothalamic tracts

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Question 46

Through which structure do third-order neurons project to the postcentral gyrus of the cerebral cortex?

A. Corpus callosum
B. Internal capsule
C. Spinal tract
D. Limbic system

Answer 46

B. Internal capsule

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Question 47

The ________ fibers are small, unmyelinated and conduct pain signals at a slow velocity, while the _______ fibers are large, myelinated and transmit pain signals rapidly.

A) C fibers; A-delta fibers
B) A-beta fibers; A-delta fibers
C) C fibers; A-beta fibers
D) A-beta fibers; Delta Fibers

Answer 47

A) C fibers; A-delta fibers

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Question 48

Matching

Match the Four elements of Pain Processing to their definitions

Answer 48

Transduction: 1
Transmission: 3
Modulation: 4
Perception: 2

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Question 49

What is the definition of Allodynia?

A. Exaggerated response to a painful stimulus
B. Pain caused by a stimulus that normally provokes pain
C. Numbness or no pain from an affected area
D. Dull, aching pain
E. Pain caused by a stimulus that does not normally provoke pain

Answer 49

E. Pain caused by a stimulus that does not normally provoke pain

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Question 50

Which of the following describes Hyperalgesia?

A. Pain caused by a light touch
B. Exaggerated response to a painful stimulus
C. No pain response from the affected area
D. Numbness in the affected area

Answer 50

B. Exaggerated response to a painful stimulus

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Question 51

What is the primary mechanism of hyperalgesia?

A. Decreased sensitivity to painful stimuli
B. Augmented sensitivity to painful stimuli
C. Allodynia misinterpretation of non-painful stimuli as painful
D. Both B and C
E. Both A and C
F. All of the above
G. None of the above

Answer 51

D. Both B and C

Tissue trauma releases local inflammatory mediators that can produce augmented sensitivity to stimuli.

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Question 52

Which neurotransmitter is involved in secondary hyperalgesia by increasing excitablility of neurons and activating NMDA receptors?

A. Dopamine
B. Glutamate
C. Serotonin
D. Acetylcholine

Answer 52

B. Glutamate

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Question 53

What medication is commonly associated with causing hyperalgesia?

A. Fentanyl
B. Oxycodone
C. Morphine
D. Ketamine
E. Remifentanil

Answer 53

E. Remifentanil

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Question 54

Which medication is recommended to be used alongside remifentanil to prevent hyperalgesia?

A. Acetaminophen
B. Midazolam
C. Ketamine
D. Propofol

Answer 54

C. Ketamine

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Question 55

What is central hypersensitivity most associated with?

A) Increased tissue damage
B) Exaggerated pain responses
C) Reduced pain sensitivity
D) Increased nerve regeneration

Answer 55

B) Exaggerated pain responses

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Question 56

In the context of pain sensitization, which condition follows hyperalgesia on the stimulus intensity-pain intensity curve?

A) Normal pain response
B) Hyperesthesia
C) Neuropathy
D) Allodynia

Answer 56

D) Allodynia

C - if you’ve got a patient with a normal pain response, look at how they shift to hyperlgesia and then to allodyni and a chronic pain state.

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Question 57

Central hypersensitivity can cause pain in response to what type of stimuli?

A) Normal and minimal sensory stimuli
B) Only severe nociceptive stimuli
C) Deep tissue injury only
D) Minimal only sensory stimuli

Answer 57

A) Normal and minimal sensory stimuli

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Question 58

What is a hallmark ‘negative’ symptom of neuropathy resulting from complete denervation of a body part?

A) Burning sensation
B) Shooting pain
C) Numbness
D) Tingling sensation

Answer 58

C) Numbness

C -* it may also result in pain depending on how severe the denervation is for those patients. *

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Question 59

In addition to ‘negative’ symptoms, nerve trauma and disease are also associated with what type of symptoms?

A) Positive symptoms
B) Increased mobility
C) Loss of sensation only
D) Decreased pain perception

Answer 59

A) Positive symptoms

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Question 60

What effect does aging have on gastric acid secretion in the elderly?

a) Increases gastric acid secretion, decreased gastric pH
b) Decreases gastric acid secretion, elevating gastric pH
c) Has minimal effect on gastric acid secretion
d) Increases gastric acid, increases gastric pH

Answer 60

b) Decreases gastric acid secretion, elevating gastric pH

Increased use of medications alter pH

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Question 61

Absorption

What is the overall effect of aging on drug absorption?

a) Significant reduction in absorption
b) Increased absorption due to slower metabolism
c) Minimal effect on drug absorption
d) Complete inhibition of absorption

Answer 61

c) Minimal effect on drug absorption

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Question 62

Absorption

______ refers to the process where drugs are metabolized in the liver before reaching systemic circulation, which can be reduced in the elderly.

a) First-pass metabolism
b) Bioavailability
c) Active transport
d) Passive diffusion

Answer 62

a) First-pass metabolism

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Question 63

Distribution

Which of the following statements are true regarding protein binding in elderly patients?
Select 2

a) Low albumin levels can lead to more free drug in circulation.
b) Highly protein-bound drugs are less affected by first-pass metabolism.
c) Malnourished patients may require albumin administration to improve drug effectiveness.
d) Changes in albumin levels do not affect wound healing.

Answer 63

a) Low albumin levels can lead to more free drug in circulation
c) Malnourished patients may require albumin administration to improve drug effectiveness

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Question 64

Distribution

Whic factor does not affect drug binding and distribution in elderly patients?

a) Molecular size
b) Protein binding
c) pH levels
d) Lipid solubility
e) Enzyme activity

Answer 64

e) Enzyme activity

Proportion relates the amount of drug in the body to the concentration measured in biological fluid

• Protein binding
• pH
• Molecular size
• Water
• Lipid solubility

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Question 65

Distribution

As patients age, their ____ mass decreases, which affects drug distribution.

a) Fat
b) Muscle
c) Bone
d) Liver

Answer 65

b) Muscle

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Question 66

Distribution

Which factors influence the distribution of drugs in elderly patients?
Select 3

a) Total body water decreases
b) Muscle mass increases
c) Proportion of body fat increases
d) Albumin levels decrease
e) Total body water increases

Answer 66

a) Total body water decreases, affecting water-soluble drugs,

c) Proportion of body fat increases, affecting lipid-soluble drugs

d) Albumin levels decrease, affecting protein-bound drugs

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Question 67

Metabolism

The ______ is the primary organ responsible for converting substances that are potentially harmful into forms that can easily be eliminated by the body.
a) Kidney
b) Heart
c) Liver
d) Lungs

Answer 67

c) Liver

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Question 68

Metabolism

As patients age, hepatic blood flow ______, which affects the metabolism of drugs.
a) Increases
b) Decreases
c) Stays the same
d) Does not affect drug metabolism

Answer 68

b) Decreases

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Question 69

Metabolism

Aging is associated with a ____ in liver mass and intrinsic metabolic activity, impacting drug metabolism.
a) Increase
b) Decrease
c) No change
d) Fluctuation

Answer 69

b) Decrease

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Question 70

Excretion/Elimination

The ______ is the primary organ responsible for the excretion and elimination of substances from the body.
a) Liver
b) Heart
c) Kidney
d) Lungs

Answer 70

c) Kidney

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Question 71

Excretion/Elimination

A significant change in kidney function with aging is a reduction in ______, which impacts the body’s ability to eliminate substances. Select 2 that apply.
a) Blood pressure
b) Blood flow
c) Glomerular filtration rate
d) Heart rate

Answer 71

b) blood flow
c) Glomerular filtration rate (considered one of the most important changes with aging)

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Question 72

Excretion/Elimination

Aging results in a decrease in kidney blood flow, mass and ______, which are essential for filtration and excretion.

a) Number of blood platelets
b) Muscle fibers
c) Number of red blood cells
d) Number of functioning nephrons

Answer 72

d) Number of functioning nephrons

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Question 73

The first step on the WHO Pain Relief Ladder recommends the use of _____ for pain persisting or increasing.

A. Opioids
B. Non-opioids
C. Corticosteroids
D. Neuromodulators

Answer 73

B. Non-opioids

C - first is non opioid medications.
So we use lots of NSAIDs at this point, and you can also think about kind of adjuvant therapy for these people, things like physical therapy braces, Heat, cold, movement.

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Question 74

When pain persists after non-opioid treatment, the second step of the WHO Pain Relief Ladder involves the addition of _____.

A. Mild to moderate opioids
B. Surgery
C. Non-pharmacological therapy only
D. Strong opioids

Answer 74

A. Mild to moderate opioids

C - we may then consider opioid therapy, but we usually go ahead and consider whatever non opioid therapy we’re using as well as the adjuvant therapy.

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Question 75

At the final step of the WHO Pain Relief Ladder, opioids for _____ pain are recommended alongside non-opioid therapies.

A. Mild
B. Moderate to severe
C. Minimal
D. Chronic only

Answer 75

B. Moderate to severe

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Question 76

Which of the following statements apply to non-opioid analgesics?
Select 2

A. They have anti-inflammatory effects.
B. They act centrally.
C. They are not controlled drugs.
D. They cause sedation and respiratory depression.

Answer 76

A. They have anti-inflammatory effects.
C. They are not controlled drugs.

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Question 77

What are some characteristics of opioid analgesics?
select 2

A. No ceiling effects
B. Anti-inflammatory effects
C. No adverse effects
D. Schedule II or III controlled drugs

Answer 77

A. No ceiling effects

D. Schedule II or III controlled drugs

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Question 78

Opioid (narcotic) analgesics:

A. Act peripherally
B. Are not habit-forming
C. Act centrally
D. Have ceiling effects

Answer 78

C. Act centrally

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Question 79

Non-opioid (non-narcotic) analgesics:

A. Have no anti-inflammatory effects
B. Are controlled substances
C. Act centrally
D. Act peripherally

Answer 79

D. Act peripherally

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Question 80

Which of the following are adverse effects of opioid analgesics?
Select 3

A. Sedation
B. Respiratory depression
C. Gastric irritation
D. Constipation
E. Bleeding

Answer 80

A. Sedation
B. Respiratory depression
D. Constipation

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Question 81

Which of the following adverse effects are associated with non-opioid analgesics?
Select 3

A. Renal toxicity
B. Sedation
C. Gastric irritation
D. Bleeding
E. Respiratory depression

Answer 81

A. Renal toxicity
C. Gastric irritation
D. Bleeding

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Question 82

True or False

For non-opioids, increasing the dose increases the analgesia but also increases side effects

Answer 82

FALSE

Ceiling effects:
For non-opiods, increasing the dose doesn’t increase the analgesia but it does increases side effects

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Question 83

Matching!

Match the receptor with its effects

Answer 83

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Question 84

True or False

The Mu (μ) receptor is the most common one we see with it’s effects, especially that kinda high feeling

Answer 84

TRUE

Cornelius - Mu is probably one of the most common ones that we see, and that’s really what results in the analgesia, but it also results in a lot of our complications. That’s where the respiratory depression comes from, the decrease in GI motility. That kinda high feeling.

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Question 85

Which of the following is NOT a function of opioids?

a) Reducing the perception of pain
b) Acting directly on the CNS
c) Treating the underlying cause of pain
d) Binding to opioid receptors

Answer 85

c) Treating the underlying cause of pain

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Question 86

What is the alternate name for codeine?

a) 3-Hydroxycodeine
b) 3-Methoxymorphine
c) 3-Methylcodeine
d) 3-Ethoxymorphine

Answer 86

b) 3-Methoxymorphine

derived from opium poppy the substitution for a methyl group for a hydroxyl group on the #3 carbon of morphine molecule

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Question 87

Which of the following is a benefit of codeine compared to morphine?

a) Codeine is more potent when given orally
b) Codeine is less addictive when absorbed orally
c) Codeine is more reliably absorbed orally
d) Codeine has fewer side effects when given IV

Answer 87

c) Codeine is more reliably absorbed orally

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Question 88

Codeine is commonly co-administered with which of the following medications?

a) Aspirin
b) Ibuprofen
c) Acetaminophen
d) Naproxen

Answer 88

c) Acetaminophen

dosing really varies between the Tylenol #3 and the Tylenol #4.

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Question 89

Codeine is metabolized by the P450 enzyme ________ which demethylates 10% of it into morphine in the liver?

a) CYP2C9
b) CYP3A4
c) CYP2D6
d) CYP1A2

Answer 89

c) CYP2D6

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Question 90

What happens to the remainder of the codeine dose that is not metabolized to morphine?

a) It is excreted unchanged
b) It is demethylated to inactive norcodeine by CYP3A4
c) It is metabolized into another active opioid
d) It is metabolized into an active analgesic

Answer 90

b) It is demethylated to inactive norcodeine by CYP3A4

Slide 40

Question 91

Which of the following are true regarding codeine metabolism?
Select 2

a) 10% of the population is resistant to codeine’s analgesic effect
b) Children under 12 have mature CYP2D6 enzyme activity
c) Codeine metabolism involves more than 50 polymorphisms leading to variability in analgesia
d) All administered codeine is converted into morphine

Answer 91

a) 10% of the population is resistant to codeine’s analgesic effect
c) Codeine metabolism involves more than 50 polymorphisms leading to variability in analgesia

Slide 40

Question 92

Which population is at risk of experiencing side effects from codeine without receiving adequate analgesia?

a) Adults over 65
b) Children under 12
c) Patients with liver disease
d) Pregnant women

Answer 92

b) Children under 12

slide 40

Question 93

What is the typical adult dosing range for codeine?

a) 5-30 mg every 2 hours
b) 10-40 mg every 6 hours
c) 15-60 mg every 4 hours
d) 20-80 mg every 8 hours

Answer 93

c) 15-60 mg every 4 hours

Cornelius - If its Tylenol #3, it’s 30mg. For Tylenol #4, it’s 60mg

60mg is equivalent to 650mg of Aspirin

Slide 41

Question 94

What is the maximum daily dose of codeine for adults?

a) 300 mg/day
b) 200 mg/day
c) 360 mg/day
d) 400 mg/day

Answer 94

c) 360 mg/day

Slide 41

Question 95

What is the pediatric dosing range for codeine?

a) 1-2 mg/kg/dose
b) 0.5-1 mg/kg/dose
c) 2-4 mg/kg/dose
d) 0.2-0.4 mg/kg/dose

Answer 95

b) 0.5-1 mg/kg/dose

60mg max per day

Slide 41

Question 96

What is the half-life of codeine?

a) 1-1.5 hours
b) 3-3.5 hours
c) 4-5 hours
d) 2-2.5 hours

Answer 96

b) 3-3.5 hours

Slide 41

Question 97

Which of the following are common drug interactions with codeine?

a) Antihistamines, alcohol, anticholinergics
b) Opioids, alcohol, anticholinergics
c) Antihistamines, caffeine, alcohol
d) Antibiotics, NSAIDs, alcohol

Answer 97

b) Opioids, alcohol, anticholinergics

Slide 42

Question 98

Which of the following is NOT a common side effect of codeine?

a) Hypotension
b) Urinary retention
c) Bradycardia
d) Hyperactivity

Answer 98

d) Hyperactivity

Other side effects - N/V, respiratory depression, dizziness and miosis

C - Something people don’t think about from opioids, a lot of the time is the increased incidence of urinary GI symptoms. So you’ll have patients that have constipation and urinary retention, just directly related to taking PO opioids.

Slide 42

Question 99

Select all contraindications for the use of codeine:
Select 4

a) Hypersensitivity
b) Acute/severe asthma
c) Respiratory depression
d) Paralytic ileus
e) Renal impairment
f) Hypertension

Answer 99

a) Hypersensitivity
b) Acute/severe asthma
c) Respiratory depression
d) Paralytic ileus

Slide 42

Question 100

Tramadol is a synthetic opioid that acts on which of the following receptors?

a) Mu, Kappa, and Delta
b) Alpha 2 and Beta 1
c) NMDA and serotonin
d) GABA and nicotinic receptors

Answer 100

a) Mu, Kappa, and Delta

Synthetic 4 -phenylpiperdine analogue of morphine

the - enantiomer stimulates alpha-2 receptors

Slide 43

Question 101

Which enantiomer of Tramadol is responsible for inhibiting norepinephrine reuptake and stimulating alpha-2 receptors?

a) The + enantiomer
b) The – enantiomer
c) Both enantiomers
d) Neither enantiomer

Answer 101

b) The – enantiomer

The Great Cornholio - A caution is that it opposes serotonin reuptake and norepinephine uptake, while it stimulates the A2 receptors, so if you’re trying to treat somebody’s blood pressure.
You may have issues. Likewise, if you’re administering dexmedatomidine, you may say that it’s potentiated

Slide 43

Question 102

The + enantiomer of tramadol acts as a __________ with moderate affinity at __________ receptors, contributing to its analgesic effects.

a. opioid agonist, mu
b. serotonin antagonist, kappa
c. norepinephrine reuptake inhibitor, delta
d. acetylcholine antagonist, sigma

Answer 102

a. opioid agonist, mu

Slide 43

Question 103

In addition to binding at mu receptors, the + enantiomer of tramadol opposes the reuptake of __________ and has weak affinity at __________ receptors.

a. dopamine, delta and sigma
b. norepinephrine, alpha-2
c. serotonin, kappa and delta
d. acetylcholine, mu and sigma

Answer 103

c. serotonin, kappa and delta

Slide 43

Question 104

Tramadol is metabolized by the hepatic P-450 enzymes __________ and __________ to O-desmethyltramadol, which is 2-4 times more potent than the original compound.

a. CYP 2D6, CYP 3A4
b. CYP 1A2, CYP 2C9
c. CYP 3A5, CYP 2B6
d. CYP 2C19, CYP 2E1

Answer 104

a. CYP 2D6, CYP 3A4

Slide 44

Question 105

Tramadol is __________ the potency of morphine.

a. 1/3 to 1/10
b. 1/2 to 1/5
c. 1/5 to 1/15
d. 1/5 to 1/10

Answer 105

d. 1/5 to 1/10

Slide 45

Question 106

The onset of action of oral tramadol is __________.

a. 30 minutes
b. 1-2 hours
c. 2-4 hours
d. 4-6 hours

Answer 106

b. 1-2 hours (oral)

Slide 45

Question 107

The volume of distribution of tramadol is __________.

a. 1.5-2.5 L/kg
b. 2.6-2.9 L/kg
c. 3.0-3.5 L/kg
d. 4.0-4.5 L/kg

Answer 107

b. 2.6-2.9 L/kg

Slide 45

Question 108

The half-life (T₁/₂) of tramadol is __________ hours, while its metabolite has a half-life of __________ hours.

a. 5.3, 6.0
b. 4.5, 6.5
c. 6.3, 7.4
d. 7.4, 9.0

Answer 108

c. 6.3, 7.4

Slide 45

Question 109

What is the percentage of protein binding of tramadol?

a. 10%
b. 20%
c. 30%
d. 40%

Answer 109

b. 20%

Slide 45

Question 110

Which of the following patients would tramadol be contraindicated for?

a. Patients with seizure disorders
b. Patients with hypertension
c. Patients with asthma
d. Patients with diabetes

Answer 110

a. Patients with seizure disorders

slide 46

Question 111

Which of the following are NOT associated with tramadol use?

a. High incidence of nausea and vomiting
b. Minimal incidence of constipation
c. Associated with dependence and addiction
d. Minimal respiratory depressant effects

Answer 111

c. Associated with dependence and addiction

or tolerance

Slide 46

Question 112

Who originally isolated morphine in 1804?

A) Albert Hofmann
B) Friedrich Serturner
C) Louis Pasteur
D) Alexander Fleming

Answer 112

B) Friedrich Serturner

Slide 47

Question 113

Morphine was named after which Greek God?

A) Zeus
B) Apollo
C) Morpheus
D) Hermes

Answer 113

C) Morpheus

Slide 47

Question 114

The oral dose requirement of morphine is about _____ times the intramuscular (IM) or intravenous (IV) dose.

A) Two
B) Three
C) Four
D) Five

Answer 114

B) Three

Slide 47

Question 115

Morphine affects primarily which receptors?

A) Kappa and Delta
B) Alpha-1 and Alpha-2
C) Mu-1 and Mu-2
D) Beta-1 and Beta-2

Answer 115

C) Mu-1 and Mu-2

Slide 47

Question 116

In which year was morphine first marketed for distribution?

A) 1787
B) 1804
C) 1827
D) 1853

Answer 116

C) 1827

Slide 47

Question 117

What is the principal pathway of morphine metabolism?

A) Sulfation in the liver
B) Conjugation with oxidation
C) Oxidation via CYP450 enzymes
D) Reduction in the kidneys
E) Conjugation with glucuronic acid

Answer 117

E) Conjugation with glucuronic acid

in hepatic AND extrahepatic sites especially the kidneys

slide 48

Question 118

Which active metabolite of morphine contributes to analgesia?

A) Morphine-3-glucuronide
B) Morphine-6-glucuronide
C) Morphine sulfate
D) Normorphine

Answer 118

B) Morphine-6-glucuronide

Slide 48

Question 119

Which of the following morphine metabolites is associated with neurotoxicity and hyperalgesia?

A) Morphine-6-glucuronide
B) Morphine-3-glucuronide
C) Morphine sulfate
D) Normorphine

Answer 119

B) Morphine-3-glucuronide

Slide 48

Question 120

Which of the following factors contribute to the minimal absorption of morphine into the CNS? (Select 3)
A) Poor lipid solubility
B) High degree of protein binding
C) Extensive first-pass effect
D) Low ionization at physiologic pH
E) High degree of metabolism via CYP450 enzymes
F) High degree of ionization at physiologic pH

Answer 120

A) Poor lipid solubility
B) High degree of protein binding
F) High degree of ionization at physiologic pH

Slide 48

Question 121

What is the typical onset of effect for morphine after intramuscular administration?

A) 5-10 minutes
B) 15-30 minutes
C) 30-45 minutes
D) 45-60 minutes

Answer 121

B) 15-30 minutes

Slide 49

Question 122

Which of the following are characteristics of morphine’s pharmacokinetics? (Select 2)

A) 35% protein binding
B) Well absorbed after intramuscular administration
C) Peak effect occurs within 15 minutes of administration
D) Elimination half-life ranges from 1.5 to 3.7 hours
E) Volume of distribution is 100 liters

Answer 122

A) 35% protein binding,
B) Well absorbed after intramuscular administration,

Slide 49

Question 123

Morphine exhibits greater analgesic potency and slower speed of offset in _____.

A) Men compared to women
B) Women compared to men
C) Patients under 40 years of age
D) Patients with renal impairment

Answer 123

B) Women compared to men

Slide 49

Question 124

The volume of distribution of morphine is approximately _____.

A) 50 liters
B) 100 liters
C) 224 liters
D) 300 liters

Answer 124

C) 224 liters

Slide 49

Question 125

What is the elimination half-life range of morphine?

A) 0.5 to 1 hour
B) 1.7 to 3.3 hours
C) 5 to 6 hours
D) 10 to 12 hours

Answer 125

B) 1.7 to 3.3 hours

Slide 49

Question 126

In patients with renal impairment, morphine-6-glucuronide can accumulate and lead to which of the following serious side effects?

A) Respiratory depression
B) Hypertension
C) Seizures
D) Tachycardia

Answer 126

B) Respiratory depression

Slide 50

Question 127

Which of the following is associated with morphine use? (Select 4)

A) Histamine release
B) Tolerance and dependence
C) Tachycardia
D) Euphoria
E) Excitability
F) Sedation

Answer 127

A) Histamine release
B) Tolerance and dependence
D) Euphoria
F) Sedation

Slide 50

Question 128

Which of the following is NOT a common side effect of morphine?

A) Euphoria
B) Sedation
C) Constipation
D) Diarrhea

Answer 128

D) Diarrhea

Slide 50

Question 129

Which of the following drugs is a synthetic derivative of thebaine?
A) Morphine
B) Codeine
C) Oxycodone
D) Fentanyl

Answer 129

C) Oxycodone

recently replaced Morphine as the most opioid used worldwide

Slide 51

Question 130

Oxycodone is often combined with medications such as __ , __ , and __ , and is widely used in the treatment of __ pain.

A) Acetaminophen, Aspirin, Ibuprofen; Neuropathic
B) Acetaminophen, Naproxen, Ibuprofen; Inflammatory
C) Aspirin, Ibuprofen, Codeine; Post-surgical
D) Acetaminophen, Aspirin, Morphine; Musculoskeletal

Answer 130

A) Acetaminophen, Aspirin, Ibuprofen;
Neuropathic pain
acute and chronic pain

Slide 51

Question 131

What is the controlled-release form of oxycodone known as and what is its immediate-release counterpart?
A) Oxycontin; OxyIR
B) Percocet; Oxycontin
C) OxyIR; Vicodin
D) Oxycontin; Percocet

Answer 131

A)
Oxycontin (controlled-release)
OxyIR (immediate-release)

Slide 51

Question 132

Oxycodone is primarily considered a prodrug and it is metabolized into ___which is active and ___ which is inactive.

A) Oxymorphone; Noroxycodone
B) Noroxycodone; Oxymorphone
C) Morphine; Codeine
D) Hydromorphone; Norcodeine

Answer 132

A)
Oxymorphone (active)
Noroxycodone (inactive)

Slide 52

Question 133

Oxycodone primarily acts on which receptors?

A) μ and κ receptors
B) δ and κ receptors
C) σ and δ receptors
D) μ and δ receptors

Answer 133

A) μ and κ receptors
of the CNS

Slide 52

Question 134

Where is oxycodone primarily metabolized, and how is it excreted from the body?

A) Metabolized in the liver by the CYP450 2D6 pathway; excreted in urine
B) Metabolized in the kidneys; excreted in bile
C) Metabolized in the liver by the CYP450 3A4 pathway; excreted in urine
D) Metabolized in the lungs; excreted in urine

Answer 134

A) Metabolized in the liver by the CYP450 2D6 pathway; excreted in urine

extensive first pass effect

Slide 52

Question 135

What is the typical dose of oxycodone, and how does it compare to morphine?

A) 10-15 mg, equal to 10 mg of morphine
B) 5-10 mg, equal to 15 mg of morphine
C) 15-20 mg, equal to 5 mg of morphine
D) 20-25 mg, equal to 10 mg of morphine

Answer 135

A) 10-15 mg,
equal to 10 mg of morphine

Slide 53

Question 136

What is the onset of action of oxycodone?

A) Less than 1 hour
B) 1-2 hours
C) 2-3 hours
D) 3-4 hours

Answer 136

A) Less than 1 hour

Slide 53

Question 137

What is the typical duration of effect for immediate-release (IR) and controlled-release (CR) formulations of oxycodone?

A) IR: 3-4 hours, CR: 12 hours
B) IR: 2-3 hours, CR: 10 hours
C) IR: 4-5 hours, CR: 14 hours
D) IR: 1-2 hours, CR: 8 hours

Answer 137

A) IR: 3-4 hours, CR: 12 hours

Slide 53

Question 138

Oxycodone has ___ effects when combined with other central nervous system depressants.

A) Additive
B) Synergistic
C) Antagonistic
D) Neutral

Answer 138

A) Additive

Slide 54

Question 139

Hope the question format isn’t too complicated

Select all the side effects of oxycodone based on their respective body systems:

A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity

B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate

C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea

D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence

Answer 139

A) Central Nervous System:
* Sedation
* Euphoria

B) Respiratory System:
* Respiratory depression

C) Gastrointestinal System:
* Constipation
* Nausea and vomiting

D) Miscellaneous:
* Histamine release
* Tolerance and dependence

Corn: As I mentioned, there is less risk, but you do still have a risk of tolerance and dependence in these patients

Slide 54

Question 140

Methadone is a synthetic broad-spectrum opioid primarily used for:
A) Acute pain management
B) Maintenance therapy for opioid addiction
C) Neuropathic pain relief
D) Anesthetic induction

Answer 140

B) Maintenance therapy for opioid addiction
- 60-90% oral bioavailability
- High potency
- Long duration of action

Corn: So methadone is a mixed agonist antagonist and as a result of that we see that it’s used for weaning patients off of more opioids

Slide 55

Question 141

What should be known about methadone’s half-life? (Select 2 that apply)

A) It is very long and unpredictable, up to 36 hours
B) It is short and predictable, less than 12 hours
C) Can accumulate with repeated doses
D) It does not accumulate with repeated doses
E) It has a half-life similar to other opioids such as morphine

Answer 141

A) It is very long and unpredictable, up to 36 hours
C) Can accumulate with repeated doses

Slide 55

Question 142

Methadone has affinities for which of the following receptors and actions? (Select 4 that apply)

A) Weak noncompetitive NMDA receptor antagonist
B) Serotonin reuptake inhibitor
C) Monoamine reuptake inhibitor
D) Alpha-adrenergic receptor agonist
E) μ receptor affinity

Answer 142

A) Weak noncompetitive NMDA receptor antagonist
B) Serotonin reuptake inhibitor
C) Monoamine reuptake inhibitor
E) μ receptor affinity

Slide 55

Question 143

What would occur if methadone is used concurrently with carbamazepine?

A) Methadone levels will increase due to slower metabolism
B) Methadone will be metabolized faster
C) Methadone levels will remain unchanged
D) Methadone’s half-life will be extended

Answer 143

B) Methadone will be metabolized faster
Carbamazepine is a CYP450 inducer

*Methadone is Metabolized in the liver by CYP450 system (primarily by CYP3A4, out also cYP1A2 and cYP2D6. Into Inachve metabolites)

Slide 56

Question 144

Which of the following agents can inhibit the metabolism of methadone? (Select 2 that apply)

A) Antiretrovirals
B) Carbamazepine
C) Grapefruit juice
D) Rifampin

Answer 144

A) Antiretrovirals
C) Grapefruit juice

CYP450 Inhibitors

Slide 56

Question 145

How is methadone excreted from the body?

A) Primarily in urine with no unchanged drug
B) Primarily in bile, with significant amounts of unchanged drug
C) Excreted in both urine and bile, with small amounts of unchanged drug
D) Primarily through feces

Answer 145

C) Excreted in both urine and bile, with small amounts of unchanged drug

Hepatic and renal impairment do not influence clearance of Methadone significantly

SAFE FOR OLDER PATIENTS

Slide 56

Question 146

What is the typical dose of methadone for pain management?

A) 2.5-10 mg PO/IM/SC every 4-12 hours
B) 5-20 mg PO/IM/SC every 8-24 hours
C) 10-30 mg PO/IM/SC every 2-6 hours
D) 1-5 mg PO/IM/SC every 12-24 hours

Answer 146

A) 2.5-10 mg PO/IM/SC
every 4-12 hours

Steady state concentrations may take up to 10 days to achieve due to extensive restribution of the drug. Can accumulate and result in high plasma concentrations

Slide 57

Question 147

Why are standardized simple dosing guidelines unachievable for methadone?

A) It has a low bioavailability
B) It has a highly variable half-life ranging from 8 to 80 hours
C) It is primarily metabolized by the kidneys
D) It is rapidly eliminated from the body

Answer 147

B) It has a highly variable half-life ranging from 8 to 80 hours

Slide 57

Question 148

What is the most dangerous medication interaction associated with methadone?

A) Carbamazepine
B) Antiretrovirals
C) Monoamine oxidase inhibitors (MAOIs)
D) Grapefruit juice

Answer 148

C) Monoamine oxidase inhibitors (MAOIs)

can cause severe, unpredictable reactions with these drugs
effects similar to other opioids: hypotensiton, respiratory depression, confusion, sedation

Slide 58

Question 149

Which of the following drugs are known to increase the concentration or effects of methadone? (Select 3 that apply)

A) Ciprofloxacin
B) Diazepam
C) Carbamazepine
D) Acute alcohol consumption
E) Rifampin

Answer 149

A) Ciprofloxacin
B) Diazepam
D) Acute alcohol consumption

Slide 58

Question 150

Which of the following drugs are known to decrease the concentration or effects of methadone? (Select 5 that apply)

A) Amprenavir
B) Phenobarbital
C) Phenytoin
D) Rifampin
E) Monoamine oxidase inhibitors (MAOIs)
F) Ciprofloxacin

Answer 150

A) Amprenavir
B) Phenobarbital
C) Phenytoin
D) Rifampin
E) Monoamine oxidase inhibitors (MAOIs)

Slide 58

Question 151

Which of the following are cardiac complications that can rarely occur with methadone usage? (Select 3 that apply)

A) Pause-dependent dysrhythmia (associated with bradycardia)
B) QT prolongation
C) Torsades de pointes
D) Atrial fibrillation

Answer 151

A) Pause-dependent dysrhythmia (associated with bradycardia)
B) QT prolongation
C) Torsades de pointes

Slide 58

Question 152

Fentanyl is structurally similar to which of the following drugs?

A) Morphine
B) Meperidine
C) Codeine
D) Hydromorphone

Answer 152

B) Meperidine

Slide 59

Question 153

Fentanyl has ___ potency, ___ onset of action, and ___ duration of action.

A) Low; slow; long
B) High; rapid; short
C) Moderate; slow; long
D) High; slow; short

Answer 153

B) High; rapid; short

Fentanyl has high potency, rapid onset of action, and short duration of action.

Onset: 30 - 60 sec; Duration of action: 1 - 1.5 hr

Slide 59

Question 154

True or False

Fentanyl was initially developed for intravenous anesthetic use but later gained additional roles in cancer and chronic pain management through transdermal and transmucosal preparations.

Answer 154

True

Slide 59

Question 155

What is the principal metabolite of fentanyl?

A) Norfentanyl
B) Normeperidine
C) Morphine-6-glucuronide
D) Codeine

Answer 155

A) Norfentanyl

Detectable in urine up to 72 hours after single dose.

Slide 60

Question 156

Why is the elimination of fentanyl slightly prolonged despite its very short duration of action?

A) It is metabolized by the kidneys
B) It binds strongly to plasma proteins
C) The lungs serve as a large inactive reservoir
D) It undergoes extensive hepatic metabolism

Answer 156

C) The lungs serve as a large inactive reservoir
up to 75% of initial dose undergoes first pass pulmonary uptake)

Slide 60

Question 157

Why is fentanyl more potent and has a more rapid onset of action compared to morphine?

A) Greater water solubility
B) Lower protein binding
C) Greater lipid solubility
D) Higher molecular weight

Answer 157

C) Greater lipid solubility

Slide 61

Question 158

The short duration of action of fentanyl is mainly due to:

A) Liver metabolism
B) Slow movement into fat and muscle
C) rapid distribution into inactive tissues like fat and muscle
D) Long time in the liver

Answer 158

C) rapid distribution into inactive tissues like fat and muscle

Slide 61

Question 159

Which of the following is true about fentanyl’s pharmacokinetics? (Select 3 that apply)

A) It has a protein binding of 84%
B) Its volume of distribution is 335 liters
C) Its elimination half-time is between 3.1 and 6.6 hours
D) Its initial dose is not subject to first-pass metabolism

Answer 159

A) It has a protein binding of 84%

B) Its volume of distribution is 335 liters

C) Its elimination half-time is between 3.1 and 6.6 hours

Slide 61

Question 160

Fentanyl dosing is highly dependent on which of the following factors?

A) Patient’s weight
B) Route of administration
C) Patient’s age
D) Kidney function

Answer 160

B) Route of administration

Corn: So your dose really depends on how you’re administering. So say for instance. somebody’s having their lap, Chole, I may give them 50 to 100 mcg of it now,. On the other hand, if I’m putting it in a spinal injection, I may only use 10 mcg. So quite a bit of variability as far as how you dose it.

Slide 61

Question 161

What percentage of an initial fentanyl dose undergoes first-pass pulmonary uptake, limiting the initial amount that reaches systemic circulation?

A) 50%
B) 75%
C) 25%
D) 90%

Answer 161

B) 75%

lungs also serve as a large inactive storage

Slide 61

Question 162

What type of drug interaction occurs when fentanyl is used with other central nervous system depressants?

A) Antagonistic effects
B) Additive effects
C) Synergistic effects
D) No significant interaction

Answer 162

B) Additive effects

Slide 62

Question 163

Select all the side effects of Fentanyl based on their respective body systems:

A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity

B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate

C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea

D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence

Answer 163

A) Central Nervous System:
* Sedation
* Euphoria

B) Respiratory System:
* Respiratory depression

C) Gastrointestinal System:
* Constipation
* Nausea and vomiting

D) Miscellaneous:
* Histamine release
* Tolerance and dependence

Yes, it’s a repeated question :)

Slide 62

Question 164

Hydromorphone (Dilaudid) is a semisynthetic drug and can be formed by which of the following processes? (Select 2 that apply)

A) N-demethylation of hydrocodone
B) Hydrogenation of the ketone group in morphine
C) Oxidation of the ketone group in morphine
D) N-demethylation of morphine
E) Reduction of the ketone group in morphine

Answer 164

A) N-demethylation of hydrocodone
B) Hydrogenation of the ketone group in morphine

Similar to morphine in that it is hydrophilic and has a comparable duration of analgesia ten times more lipophilic than morphine

Slide 63

Question 165

How much more potent is hydromorphone than morphine when administered orally?

A) 2 to 3 times
B) 5 to 7 times
C) 3 to 5 times
D) 8 to 10 times

Answer 165

C) 3 - 5 times

Regarded as an effective alternative to morphine for the treatment of moderate to severe pain, available in oral, parenteral, and rectal use

Slide 63

Question 166

Hydromorphone is approximately how many times more potent than morphine when administered parenterally?

A) 3 times
B) 5 times
C) 8.5 times
D) 10 times

Answer 166

C) 8.5 times

Slide 63

Question 167

What is the primary metabolite of hydromorphone?

A) Hydromorphone-6-glucuronide
B) Hydromorphone-3-glucuronide
C) Morphine-6-glucuronide
D) Normeperidine

Answer 167

B) Hydromorphone-3-glucuronide

like its parent compound is excreted renally

Slide 64

Question 168

What should be known about hydromorphone-3-glucuronide? (Select 2 that apply)

A) It has strong analgesic effects
B) It lacks analgesic effects
C) It may potentiate neurotoxic effects
D) It is responsible for the majority of hydromorphone’s pain-relieving properties

Answer 168

B) It lacks analgesic effects
C) It may potentiate neurotoxic effects (allodynia, myoclonus, seizures).

Slide 64

Question 169

When are hydromorphone-3-glucuronide’s neurotoxic side effects an actual concern?

A) Patients with hepatic insufficiency
B) Patients with renal insufficiency
C) Patients with cardiovascular disease
D) Patients with pulmonary disease

Answer 169

B) Patients with renal insufficiency

Slide 64

Question 170

What is the typical dose of parenteral hydromorphone for pain management?

A) 1 - 5 mg
B) 0.2 - 2 mg
C) 5 - 10 mg
D) 2 - 4 mg

Answer 170

B) 0.2 - 2 mg

intravenously every 3 to 5 minutes which is titrated to achieve a balance between pain relief and respiratory depression

Corn: …repeat it over 10 or 15 minutes. Remember that your onset time is gonna be a little bit longer than something like Fentanyl, so don’t rush and get too much in there because you may then have kind of a compounded effect

Slide 65

Question 171

What is the typical oral dose of hydromorphone for pain management?

A) 1 - 4 mg
B) 2 - 8 mg
C) 5 - 15 mg
D) 10 - 20 mg

Answer 171

B) 2 - 8 mg

Slide 65

Question 172

What is the typical duration of action of hydromorphone?

A) 1 - 2 hours
B) 3 - 4 hours
C) 5 - 6 hours
D) 7 - 8 hours

Answer 172

B) 3 - 4 hours

half life is 2.3 hours

Slide 65

Question 173

What type of drug interaction occurs when Hydromorphone is used with other central nervous system depressants?

A) Antagonistic effects
B) Additive effects
C) Synergistic effects
D) No significant interaction

Answer 173

B) Additive effects

Same as all other opiods

Slide 66

Question 174

Select all the side effects of Hydromorphone based on their respective body systems:

A) Central Nervous System (2):
* Sedation
* Euphoria
* Hyperactivity

B) Respiratory System (1):
* Respiratory depression
* Bronchoconstriction
* Increased respiratory rate

C) Gastrointestinal System (2):
* Constipation
* Nausea and vomiting
* Diarrhea

D) Miscellaneous (2):
* Histamine release
* Hypertension
* Tolerance and dependence

Answer 174

A) Central Nervous System:
* Sedation
* Euphoria

B) Respiratory System:
* Respiratory depression

C) Gastrointestinal System:
* Constipation
* Nausea and vomiting

D) Miscellaneous:
* Histamine release
* Tolerance and dependence

yes, another repeated question :)

Slide 66

Question 175

Hydrocodone is a semi-synthetic opioid that is a derivative of which substance?

A) Morphine
B) Codeine
C) Oxycodone
D) Hydromorphone

Answer 175

B) Codeine

Slide 67

Question 176

How much more potent is hydrocodone compared to codeine?

A) 2 to 4 times
B) 4 to 6 times
C) 6 to 8 times
D) 8 to 10 times

Answer 176

C) 6 to 8 times

Slide 67

Question 177

What are the two most commonly abused opioids?

A) 1st: Morphine, 2nd: Codeine
B) 1st: Hydromorphone, 2nd: Hydrocodone
C) 1st: Oxycodone, 2nd: Hydrocodone
D) 1st: Fentanyl, 2nd: Oxycodone

Answer 177

C) 1st: Oxycodone,
2nd: Hydrocodone

Corn: So we were saying there was a pretty significant amount of abuse that was being done. If you go back and look 10 or 15 years ago, the pill mills in Florida and Appalachia were passing out tons of oxycodone and hydrocodone.

Slide 67

Question 178

Hydrocodone is most often combined with which of the following medications?

A) Ibuprofen
B) Aspirin
C) Acetaminophen
D) Naproxen

Answer 178

C) Acetaminophen

Norco, Vicodin, and Lortab

Slide 67

Question 179

What are the two primary metabolites of hydrocodone metabolism?

A) Hydromorphone
B) Codeine
C) Morphine
D) Norhydrocodone
E) Oxycodone

Answer 179

A) Hydromorphone (via CYP2D6)
D) Norhydrocodone (inactive) via CYP3A4

Slide 68

Question 180

What is the morphine equivalent of 30 mg of hydrocodone?

A) 10 mg of morphine
B) 15 mg of morphine
C) 20 mg of morphine
D) 30 mg of morphine

Answer 180

A) 10 mg of morphine

10 mg morphine = 30 mg hydrocodone
(1:3)

Slide 69

Question 181

While oxycodone is often used for ___ pain management, hydrocodone is typically used for __ administration durations.

A) short-term; long-term
B) long-term; short-term
C) moderate; acute
D) chronic; extended

Answer 181

B) long-term; short-term

Corn: So while we were using oxycodone for long-term pain medications, we may use hydrocodone for short-term administrations.

Hydrocodone:
Peak: 1.3 + 0.3 hours
Elimination T½: 3.8 + 0.3 hours

Slide 69

Question 182

What is the typical dosing range for hydrocodone when combined with acetaminophen, and what is the maximum daily dose of acetaminophen?

A) 2.5-10 mg hydrocodone with 300-750 mg acetaminophen; 4 g acetaminophen/24h
B) 5-15 mg hydrocodone with 500-1000 mg acetaminophen; 3 g acetaminophen/24h
C) 10-20 mg hydrocodone with 200-600 mg acetaminophen; 6 g acetaminophen/24h
D) 15-25 mg hydrocodone with 400-900 mg acetaminophen; 5 g acetaminophen/24h

Answer 182

A) 2.5-10 mg hydrocodone with 300-750 mg acetaminophen;
4 g acetaminophen/24h (max dose)

q4-6h

Available as tablet, capsule, syrup, solution, XR suspension, XR tablet

Slide 69

Question 183

Hydrocodone is commonly combined with which of the following drugs? (Select 3 that apply)

A) Acetaminophen
B) Aspirin (ASA)
C) Guaifenesin
D) Ibuprofen

Answer 183

A) Acetaminophen
B) Aspirin (ASA)
C) Guaifenesin
various antihistamines

Slide 69

Question 184

Which of the following interactions are associated with hydrocodone? (Select all that apply)

A) Increased sedation with other opioids
B) Increased sedation with benzodiazepines
C) Hypotension with barbiturates
D) Intravenous magnesium or calcium channel blockers may increase opioid effects

Answer 184

All of the above

Slide 70

Question 185

Which of the following is NOT a known side effect of hydrocodone?

A) Meiosis
B) Histamine release
C) Pruritis
D) Increased hypercapnic drive
E) Decreased respiratory rate/airway reflexes
F) Bradycardia
G) Hypotension
H) Nausea/vomiting and Constipation

Answer 185

D) Increased hypercapnic drive

decreased hypercapnic drive

Slide 70

Question 186

Which of the following should be used with caution in patients taking hydrocodone?

A) Alcoholism
B) Drug abuse
C) Drugs containing acetaminophen (Tylenol)
D) All of the above

Answer 186

D) All of the above

Slide 70

Question 187

Buprenorphine is classified as a:

A) Full opioid agonist
B) Partial agonist-antagonist opioid
C) Pure antagonist
D) Non-opioid analgesic

Answer 187

B) Partial agonist-antagonist opioid
derived from the opium alkaloid thenaine
Available in a variety of preparations to include: Cizdol, Subutex, Suboxone, Zubsolv, Bunavail

Slide 71

Question 188

Buprenorphine has affinity for which of the following receptors? (Select 3 that apply)

A) Mu receptor as a partial agonist
B) Kappa receptor as a strong antagonist
C) Delta receptor as a weak agonist
D) Sigma receptor as a strong agonist

Answer 188

A) Mu receptor as a partial agonist
B) Kappa receptor as a strong antagonist
C) Delta receptor as a weak agonist

Slide 71

Question 189

What are the benefits provided by buprenorphine? (Select 3 that apply)

A) Less respiratory depression
B) Less immune suppression
C) Increased constipation
D) No accumulation in renal patients
E) More sedation

Answer 189

A) Less respiratory depression

B) Less immune suppression

reduced constipation

D) No accumulation in renal patients

Slide 71

Question 190

What is the primary metabolite of buprenorphine?

A) Norbuprenorphine
B) Hydromorphone
C) Morphine-6-glucuronide
D) Codeine

Answer 190

A) Norbuprenorphine

a full agonist at the Mu, Delta, and ORL-1 opioid receptors and a partial agonist at the Kappa receptor

Slide 72

Question 191

What should be known about norbuprenorphine? (Select 2 that apply)

A) It has 1/50th the analgesic activity of buprenorphine
B) It has equal analgesic activity to buprenorphine
C) It significantly increases respiratory depression
D) It reduces respiratory depression compared to buprenorphine

Answer 191

A) It has 1/50th the analgesic activity of buprenorphine
C) It significantly increases respiratory depression

Slide 72

Question 192

What is the IV/IM dose equivalence of buprenorphine to morphine?

A) 0.3 mg IM buprenorphine = 5 mg IV morphine
B) 0.3 mg IM buprenorphine = 10 mg IV morphine
C) 0.3 mg IM buprenorphine = 15 mg IV morphine
D) 0.3 mg IM buprenorphine = 20 mg IV morphine

Answer 192

B) 0.3 mg IM buprenorphine = 10 mg IV morphine

Slide 73

Question 193

Oral administration of buprenorphine results in high first-pass metabolism, which can be overcome by ___ or ___ administration.

A) Intravenous; intramuscular
B) Sublingual; transdermal
C) Oral; rectal
D) Intranasal; inhalation

Answer 193

B) Sublingual; transdermal

Sublingual administration has a relatively rapid onset of 30 minutes with a long duration of analgesia of 6-9 hours

Transdermal patches deliver 5-70 ug hr for 4-7 days

Slide 73

Question 194

What is the half-life of buprenorphine?

A) 5 - 10 hours
B) 10 - 20 hours
C) 20 - 73 hours
D) 80 - 100 hours

Answer 194

C) 20 - 73 hours

Slide 73

Question 195

Buprenorphine is primarily eliminated through which organ, resulting in little risk of accumulation in patients with renal impairment?

A) Kidneys
B) Liver
C) Lungs
D) Intestines

Answer 195

B) Liver

Slide 73

Question 196

Which of the following are common side effects of buprenorphine? (Select 4 that apply)

A) Drowsiness
B) Nausea
C) Vomiting
D) Depression of ventilation
E) Hypertension

Answer 196

A) Drowsiness
B) Nausea
C) Vomiting
D) Depression of ventilation

Slide 74

Question 197

Buprenorphine’s antagonist properties can precipitate withdrawal symptoms in patients physically dependent on:

A) Methadone
B) Morphine
C) Fentanyl
D) Codeine

Answer 197

B) Morphine

Slide 74

Question 198

How do withdrawal symptoms in patients physically dependent on buprenorphine compare to those associated with morphine?

A) They develop quickly and are more intense
B) They develop slowly and are of lesser intensity
C) They are more severe but develop at the same pace
D) They are identical to withdrawal symptoms from morphine

Answer 198

B) They develop slowly and are of lesser intensity

Slide 74

Question 199

Which of the following are parenteral routes of delivery suitable for a person who cannot swallow? (Select all that apply)

A) Topical
B) Rectal
C) Intravenous (IV)
D) Subcutaneous
E) “Trans mucosal”
F) Transdermal

Answer 199

All of the above

Slide 75

Question 200

Which of the following are benefits associated with the long-term use of opioids? (Select 3 that apply)

A) Pain reduction
B) Constipation
C) Increase in functionality
D) Fewer episodes of severe pain “spikes”

Answer 200

A) Pain reduction
C) Increase in functionality
D) Fewer episodes of severe pain “spikes”

Slide 76

Question 201

Which of the following is NOT a risk associated with long-term opioid use?

A) Dependence
B) Addiction
C) Overdose
D) Withdrawal
E) Constipation
F) Delirium
G) Worsening of pain
H) Pain reduction

Answer 201

H) Pain reduction

Slide 76

Question 202

Which of the following strategies can be used for the prevention and treatment of opioid side effects? (Select 4 that apply)

A) Choosing the “two-fer”
B) Opioid rotation
C) Pharmacologic interventions
D) Non-pharmacologic interventions
E) Decreasing education efforts

Answer 202

A) Choosing the “two-fer”
think about medications that do more than one thing, so perhaps medications that have a nonopioid component as well. Or medications that hit multiple receptors as opposed to just hitting new receptors

B) Opioid rotation
Consider moving on to something else

C) Pharmacologic interventions

D) Non-pharmacologic interventions
just little things like getting up out of bed may be the best approach for the patient

educate the patients

Slide 77

Question 203

Which of the following is NOT a characteristic of non-opioid analgesics?

A) Analgesic, anti-inflammatory, and antipyretic properties
B) Act on peripheral tissues to inhibit formation of pain-causing substances
C) Bind directly to opioid receptors
D) Block production of cyclooxygenase (COX) enzymes

Answer 203

C) Bind directly to opioid receptors

Do not bind to receptors

Slide 78

Question 204

Which of the following statements are true about acetaminophen (Tylenol®)? (Select 3 that apply)

A) It is effective for reducing pain and fever
B) It has strong anti-inflammatory properties
C) Caution is advised in patients with liver or kidney impairment
D) It can be used safely with excessive alcohol consumption
E) It has little anti-inflammatory effect

Answer 204

A) It is effective for reducing pain and fever
C) Caution is advised in patients with liver or kidney impairment (and alcohol use)
E) It has little anti-inflammatory effect

Slide 79

Question 205

Which of the following statements are true about COX-2 inhibitors? (Select 3 that apply)

A) They decrease inflammation
B) They should be taken with food
C) They can cause abdominal side effects, such as constipation and cramps
D) They bind directly to opioid receptors

Answer 205

A) They decrease inflammation
B) They should be taken with food
C) They can cause abdominal side effects, such as constipation and cramps

Slide 79

Question 206

Which of the following are non-opioid analgesics mentioned in the slide? (Select all that apply)

A) Acetaminophen (Tylenol®)
B) NSAIDs
C) COX-2 Inhibitors
D) Other
E) Steroids

Answer 206

All of the above

Slide 79

Question 207

What is the typical dosing range for acetaminophen?

A) 100-200 mg every 8 hours
B) 250-500 mg every 12 hours
C) 500-1000 mg every 6 hours
D) 1000-1500 mg every 4 hours

Answer 207

C) 500-1000 mg every 6 hours

Slide 80

Question 208

NSAIDs

What is the recommended dose for celecoxib?

A) 50 mg daily
B) 100 mg daily
C) 200 mg daily
D) 400 mg daily

Answer 208

B) 100mg daily

Slide 80

Question 209

NSAIDs

What is the typical dosing regimen for diclofenac?

A) 25 mg once daily
B) 50 mg twice daily
C) 75 mg three times daily
D) 100 mg twice daily

Answer 209

B) 50 mg twice daily

Slide 80

Question 210

NSAIDs

What is the typical dosing regimen for ibuprofen?

A) 100 mg once daily
B) 200 mg three times daily
C) 400 mg four times daily
D) 600 mg every 8 hours

Answer 210

B) 200 mg three times daily

Slide 80

Question 211

NSAIDs

What is the typical dosing regimen for naproxen?

A) 100 mg once daily
B) 150 mg three times daily
C) 220 mg twice daily
D) 500 mg once daily

Answer 211

C) 220 mg twice daily

Slide 80

Question 212

Which of the following are true regarding the use of antidepressants for nerve pain? (Select 3 that apply)

A) They increase transmission in the spinal cord to reduce pain signals
B) They provide immediate pain relief
C) They do not work right away and may take time to be effective
D) Common side effects include dizziness, drowsiness, and dry mouth
E) They increase appetite and energy levels

Answer 212

A) They increase transmission in the spinal cord to reduce pain signals
*nerve pain

C) They do not work right away and may take time to be effective
Often times you’re going to need 5 to 10 days to get really good coverage

D) Common side effects include dizziness, drowsiness, and dry mouth
Other times the issue you run into is patients don’t appreciate the side effects with it
Memory Trick: side effects when you’re drunk = dizzy, drowsy, dry mouth

Slide 81

Question 213

Which of the following anticonvulsants are commonly used for nerve pain? (Select 4 that apply)

A) Gabapentin (Neurontin®)
B) Phenytoin (Dilantin®)
C) Carbamazepine (Tegretol®)
D) Topiramate (Topamax®)
E) Acetaminophen (Tylenol®)

Answer 213

A) Gabapentin (Neurontin®) most common
B) Phenytoin (Dilantin®)
C) Carbamazepine (Tegretol®)
D) Topiramate (Topamax®)

Corn: Anticonvulsants are one of the newer medications that we’ve really started using for acute surgical pain…all these are primarily targeted at neuropathic pain, but we may treat that neuropathic pain for becomes a problem.

Side effects:
Drowsiness, dizziness, headache, weight gain

Slide 81

Question 214

Which of the following are true regarding skeletal muscle relaxants and topical adjuvant medications? (Select 3 that apply)

A) Skeletal muscle relaxants are used for muscle pain, tension headaches, and lower back pain
B) Common side effects of skeletal muscle relaxants include drowsiness, dizziness, dry mouth, and constipation
C) Topical medications such as creams and patches provide long-term pain relief
D) Topical medications are used for a shorter period of time to relieve pain

Answer 214

A) Skeletal muscle relaxants are used for muscle pain, tension headaches, and lower back pain

Baclofen( Lioresal®),
Carisoprodol(Soma®), Cyclobenzaprine(Flexeril®) Methocarbamol(Robaxin®), Tizanidine(Zanaflex®)

B) Common side effects of skeletal muscle relaxants include drowsiness, dizziness, dry mouth, and constipation

D) Topical medications are used for a shorter period of time to relieve pain

Topical (over-the-counter):
Capsaicin Cream
Menthol‐ Methyl Salicylate Cream (Bengay®)
Lidoderm 5% Patch

Slide 82

Question 215

Which of the following is a topical intervention used for pain management?

A) Menthol
B) Nerve blocks
C) Salsa
D) Accupuncture
E) Petroleum Jelly

Answer 215

A) Topical menthol

Slide 83

Question 216

Which of the following are physical interventions used for pain management? (Select 5 that apply)

A) Massage/Range of motion
B) Hypnosis
C) Physical therapy
D) Heat/Cold therapy
E) Radiation
F) Nerve blocks

Answer 216

A) Massage/Range of motion
C) Physical therapy
D) Heat/Cold therapy
E) Radiation
F) Nerve blocks

Slide 83

Question 217

Which of the following are mind-body interventions used for pain management? (Select 6 that apply)

A) Relaxation techniques
B) Hypnosis
C) Acupuncture/Acupressure
D) Psychotherapy
E) Yoga/Tai Chi
F) Aromatherapy
G) Nerve blocks

Answer 217

A) Relaxation techniques
B) Hypnosis
C) Acupuncture/Acupressure
D) Psychotherapy
E) Yoga/Tai Chi
F) Aromatherapy

Slide 83

Question 218

Which of the following are barriers to the use of opioids for pain management? (Select 5 that apply)

A) Fear of addiction
B) Fear of side effects
C) Fear of death
D) Lack of effectiveness for acute pain
E) Care plan adherence due to functional limitations
F) Not being the best drug for chronic pain

Answer 218

A) Fear of addiction
Concept of pseudo‐addiction
The patient with current or past substance abuse

B) Fear of side effects

C) Fear of death

E) Care plan adherence due to functional limitations

F) Not being the best drug for chronic pain

Slide 85

Question 219

Which of the following are key principles in opioid dosing for effective pain management? (Select 3 that apply)

A) Initial dosing
B) Up-titration
C) Maximum dose
D) Frequency of administration
E) Duration of treatment

Answer 219

A) Initial dosing
somebody that’s opioid naive that’s really just getting opioids for acute pain

B) Up-titration

C) Maximum dose
* For acute pain
* For persistent pain
* For cancer pain
* For other end of life pain

Slide 86

Question 220

When considering Patient Controlled Analgesia (PCA), which of the following are key considerations? (Select 2 that apply)

A) Barriers to effective PCA use
B) Built-in safety mechanisms
C) Decreased effectiveness with prolonged use
D) Increased risk of sedation

Answer 220

A) Barriers to effective PCA use

B) Built-in safety mechanisms
*Negated by proxy dosing
*Consider provider administered bolus

Slide 87

Question 221

In which of the following scenarios is Patient Controlled Analgesia (PCA) commonly used? (Select 2 that apply)

A) Hospital
B) End of life
C) Emergency room for minor injuries
D) Dental procedures
E) Outpatient rehabilitation

Answer 221

A) Hospital
*Post op
*Pain crisis

B) End of life
*Transition to home

Slide 87

Question 222

Match the route of administration with its correct dosage for Morphine:

Intravenous
Intramuscular
Oral

A) 30 - 60 mg
B) 2.5 - 15 mg
C) 10 - 15 mg

Answer 222

Intravenous B) 2.5 - 15 mg

Intramuscular C) 10 - 15 mg

Oral A) 30 - 60 mg

Slide 88

Question 223

Match the route of administration with its correct dosage for Hydromorphone:

Intravenous
Intramuscular
Oral

A) 1 - 4 mg
B) 0.2 - 1 mg
C) 1 - 4 mg

Answer 223

Intravenous B) 0.2 - 1 mg

Intramuscular A) 1 - 4 mg

Oral C) 1 - 4 mg

Slide 88

Question 224

Match the route of administration with its correct dosage for Fentanyl:

Intravenous
Transmucosal
Transdermal

A) 200 - 1600 µg
B) 12.5 - 100 µg
C) 20 - 50 µg

Answer 224

Intravenous C) 20 - 50 µg

Transmucosal A) 200 - 1600 µg

Transdermal B) 12.5 - 100 µg

Slide 88

Question 225

Match the route of administration with its correct dosage for Oxymorphone:

Oral
Intravenous
Subcutaneous
Intramuscular

A) 0.5 - 1 mg
B) 1 - 1.5 mg
C) 1 - 1.5 mg
D) 5 - 10 mg

Answer 225

Oral D) 5 - 10 mg

Intravenous A) 0.5 - 1 mg

Subcutaneous C) 1 - 1.5 mg

Intramuscular B) 1 - 1.5 mg

Slide 88

Question 226

Compare the equianalgesic dose of Morphine for parenteral and oral administration:

A) 10 mg Parenteral = 30 mg Oral
B) 7.5 mg Parenteral = 30 mg Oral
C) 10 mg Parenteral = 20 mg Oral
D) 30 mg Parenteral = 100 mg Oral

Answer 226

A) 10 mg Parenteral = 30 mg Oral

Slide 89

Question 227

Compare the equianalgesic dose of Hydromorphone for parenteral and oral administration:
A) 1.5 mg Parenteral = 30 mg Oral
B) 10 mg Parenteral = 30 mg Oral
C) 1.5 mg Parenteral = 7.5 mg Oral
D) 7.5 mg Parenteral = 15 mg Oral

Answer 227

C) 1.5 mg Parenteral = 7.5 mg Oral

Slide 89

Question 228

Compare the equianalgesic dose of Codeine for parenteral and oral administration:

A) 130 mg Parenteral = 100 mg Oral
B) 10 mg Parenteral = 30 mg Oral
C) 130 mg Parenteral = 200 mg Oral
D) 200 mg Parenteral = 130 mg Oral

Answer 228

C) 130 mg Parenteral = 200 mg Oral

Slide 89

Question 229

Compare the equianalgesic dose of Methadone for parenteral and oral administration:

A) 2.5 mg Parenteral = 5 mg Oral
B) 130 mg Parenteral = 200 mg Oral
C) 1.5-2.5 mg Parenteral = 3-5 mg Oral
D) 130 mg Parenteral = 150 mg Oral

Answer 229

C) 1.5-2.5 mg Parenteral = 3-5 mg Oral

Slide 89

Question 230

Case Study

Test Question: Mary is a 70-year-old female with a past medical history of spinal stenosis, presenting with left leg pain and weakness. Given her chronic pain and potential signs of neuropathic pain, what might be an appropriate opioid treatment option that minimizes the risk of respiratory depression, sedation, and other common opioid-related side effects? (2)

A) Oxycodone
B) Fentanyl
C) Methadone
D) Buprenorphine

Answer 230

C) Methadone
D) Buprenorphine

So a lot of times with these patients, especially if they’re a little bit older, we try and go to something that’s a little bit more of a mixed picture…we don’t have a lot of those complications and that way we can kind of get her to this steady state without the risk of sedation

Slide 92-93

Question 231

Case Study

David is an 86-year-old nursing home resident with end-stage dementia. He is bed-bound, contracted, dependent in all activities of daily living (ADLs), and presents with a new Stage 5 sacral decubitus ulcer. Surgery is planned to debride the ulcer. Considering his condition, which of the following anesthesia and long-term care options are most appropriate? (Select 4 that apply)

A) Administer a traditional opioid like morphine or fentanyl to manage pain and behavior during surgery.

B) Consider a general anesthetic to manage positioning challenges and behavioral control due to dementia.

C) Use a sacral erector spinae plane (ESP) block or spinal anesthesia to minimize the cognitive impact of anesthesia.

D) Administer minimal sedation and have the surgeon infiltrate local anesthetic into the wound to manage pain.

E) Focus on regional anesthesia like a quadratus lumborum block for pain management, even if positioning is difficult.

F) Begin discussing palliative care or hospice options given his end-stage dementia, functional decline, and ongoing weight loss.

G) Consider transitioning David to intensive physical therapy after surgery to restore mobility and function.

H) Continue aggressive nutritional support, including enteral feeding, to reverse his weight loss and prevent further decline.

Answer 231

B) Consider a general anesthetic to manage positioning challenges and behavioral control due to dementia.

C) Use a sacral erector spinae plane (ESP) block or spinal anesthesia to minimize the cognitive impact of anesthesia.

D) Administer minimal sedation and have the surgeon infiltrate local anesthetic into the wound to manage pain.

F) Begin discussing palliative care or hospice options given his end-stage dementia, functional decline, and ongoing weight loss.

Slide 94-95

Question 232

Jack, a 65-year-old man with squamous cell lung cancer, experiences right-sided pelvic pain rated at 8/10 in the region of known pelvic metastases. His pain limits mobility and awakens him from sleep. Positioning during his care is a concern due to the increased pain he experiences. He has been on 30 mg of morphine every four hours, but it no longer provides relief. What would be an appropriate pain management plan for Jack during surgery to control his pain, considering his history and current condition? (Select all that apply)

A) Continue administering 30 mg of morphine every four hours during surgery.

B) Switch to a longer-acting opioid, such as continuous-release oxycodone, to maintain more consistent pain relief.

C) Consider a ketamine infusion during surgery to help manage pain and potentially use ketamine nasal spray post-operatively for continued pain relief.

D) Administer a fentanyl patch for additional analgesia during surgery and post-operatively.

E) Use a patient-controlled analgesia (PCA) system with a non-opioid option to manage post-surgical pain.

Answer 232

All of the above

Slide 96-97

Question 233

Which of the following medications have both a bolus dose and continuous infusion options? (Select 4 that apply)

A) Alfenatnil
B) Morphine
C) Methadone
D) Hydromorphone
E) Fentanyl
F) Sufentanil
G) Oxymorphone

Answer 233

B) Morphine
*Bolus: 0.5-2.5 mg
*Continuous Infusion: 1-2 mg/h

D) Hydromorphone
*Bolus: 20-50 µg
*Continuous Infusion: 10-100 µg/h

E) Fentanyl
*Bolus: 0.05-0.25 mg
*Continuous Infusion: 0.2-0.4 mg/h

F) Sufentanil
*Bolus: 2-5 µg
*Continuous Infusion: 2-8 µg/h

Slide 98

Question 234

What is a common reference range for lockout intervals in Patient-Controlled Analgesia (PCA)?

A) 1-5 minutes
B) 10-20 minutes
C) 20-30 minutes
D) 30-40 minutes

Answer 234

B) 10-20 minutes

Corn: Some will be shorter than that, but most of these medications have a duration of action that’s a lot longer than that, and that’ll get you enough time for onset. But it also gives you enough time that they should be comfortable. So Lockout 10 to 20 minutes is pretty common.

Slide 98

Question 235

Which of the following opioids is commonly used for its longer duration of action in epidural top-offs?

A) Fentanyl
B) Naloxone
C) Duramorph
D) Sufentanil

Answer 235

C) Duramorph
(Neuraxial Morphine)

Corn: Top off an opioid before we pull it.Durhamorph is a pretty common agent that we use for that because it does provide a little bit longer duration of action than something like fentanyl

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Question 236

What are the most common opioids used intrathecally for neuraxial analgesia?

A) Fentanyl and Morphine
B) Oxycodone and Methadone
C) Buprenorphine and Nalbuphine
D) Hydromorphone and Codeine

Answer 236

A) Fentanyl and Morphine

Corn: pretty much any of our opioids can be used intrathecally. But I think the most common ones you see are fentanyl and Morphine

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Question 237

In epidural medications, which combination is commonly seen for continuous infusion?

A) Lidocaine with Hydromorphone
B) Bupivacaine or Ropivacaine with Fentanyl
C) Ketamine with Naloxone
D) Propofol with Sufentanil

Answer 237

B) Bupivacaine or Ropivacaine with Fentanyl

Corn: The other thing you’ll see is that a lot of times our continuous infusion epidural medications will already have opioids added to it.
I think probably one of the most common ones we see is either bupivacaine or ropivocaine with fentanyl in it.

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Question 238

How do spinal doses of opioids typically compare to epidural doses?

A) Spinal doses are higher than epidural doses.
B) Spinal doses are the same as epidural doses.
C) Spinal doses are lower than epidural doses.
D) Spinal doses are irrelevant to epidural doses.

Answer 238

C) Spinal doses are lower than epidural doses.

Corn: Keep in mind your spinal dose is going to be significantly lower than your epidural dose.

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