Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

pharm 2 > analgesics > Flashcards

analgesics Flashcards

1
Q

Definitions of Pain

A

— Definitions vary – no one universally accepted definition for pain terms
— Subjective experience
— “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

dental pain nociception diagrammed

A

Ad and C fibers involved to CN V ganglion then to caudal spinal tract then to thalamus and somatosensory

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Dental Pain
* — Affect what tissues?
* — Due to?
* — Dental pain is transmitted from the mouth through the:
* — Nociceptive pain?
* — Acute vs. chronic pain?

A
  • — Affect the hard and soft tissues of the oral cavity
  • — Due to underlying conditions or dental procedures or both
  • — Dental pain is transmitted from the mouth through the:
    ◦ Trigeminal nerve
    ◦ Trigeminal ganglia
    ◦ Thalamus
    ◦ Somatosensory cortex and limbic system
  • — Nociceptive pain – stimulation of nociceptors (pain nerves) from external stimuli
  • — Acute vs. chronic pain (>3 months)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Chemical Mediators in Pain:
excitatory (cause pain perception?)
inhibitory?
peripheral mediators?

A

targets of drug therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

somatic examples of nociceptive pain

most dental pain is?

A

Somatic (from teeth, skin, bone, joints, muscle, connective tissue) – Examples:
◦ Inflammatory (Rheumatoid arthritis)
◦ Mechanical/compression (spine/bone)
◦ Muscle dysfunction (Myofascial pain)
◦ Combinations common
◦ Most dental pain – inflammatory and/or mechanical
– Result of traumatic injury or bacterial infection originating from pulpal and periapical tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

visceral examples of nociceptive pain

A

Visceral (from internal organs)
◦ Example: appendicitis
◦ Often diffuse and poorly localized

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Neuropathic Pain
—

A

Pain that originates from direct dysfunction or damage to the peripheral or central nervous system.
◦ trauma or disease of neurons
◦ loss of nerve fiber function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

neuropathic pain peripheral/central fiber dysfunctions

A

Dysfunction of peripheral nerves
◦ focal area
◦ Widespread

Dysfunction of central nervous system
◦ reorganization of central somatosensory processing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

neuropathic pain and tissue damage? pain described as?

A

— Independent of any ongoing tissue injury
— Typically described as tingling, stinging, burning, and/or numb

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

is neuropathic pain MC in the orofacial region

A

Less common type of dental pain compared to somatic pain
◦ Sometimes referred to as neuropathic orofacial pain (NOP)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Chronic or Persistent Pain

A

— Not well understood
— May be associated with a chronic pathologic process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

mechanisms of chronic pain

A

◦ Peripheral – persistent stimulation of nociceptors
◦ Peripheral-central – abnormal function of peripheral and central somatosensory system
– Partial or complete loss of descending inhibitory pathways
– Spontaneous firing of regenerated nerve fibers
◦ Central – disease or injury to CNS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

is chronic pain common among various conditions?

what may pts be taking for this?

A

Many conditions result in chronic pain
◦ Patients may be taking chronic non-opioid and/or opioid pain medications daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Pain Classification

A

— Multiple ways to classify pain:
◦ Nociceptive vs. Neuropathic
◦ Acute vs. Chronic
◦ Mixed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

can we have objective findings for pain?

A

— NO OBJECTIVE ASSESSMENT TO MEASURE PAIN (INTENSITY)
◦ No Laboratory values
◦ No Diagnostic tests
◦ No Radiographic evidence
— May use labs, physical exam, diagnostic tests, radiographic evidence to identify or
diagnose a condition that causes pain
— Identify risk factors/contributing factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

potential pain assessment scales

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Common Non-Pharmacotherapy options for pain management

dental pain

A

◦ Definitive Dental Treatments: Extractions/Other dental procedures/treatments
◦ Thermal modalities (ice/heat)
– Ice/cold is often an important for treatment of dental pain
◦ Mouth Guards
◦ Occupational and Physical Therapy
◦ Acupuncture/Accupressure
◦ Others for medical conditions (cognitive-behavioral, splints therapy, massage, chiropractic etc.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Pharmacotherapy options for dental pain management

A

◦ In dentistry **used as an adjunct to dental treatments **(management of post-procedural pain or when there is not immediate access to definitive dental treatments)
– Analgesics: Non-opioids (Acetaminophen/NSAIDs)
– Adjuvant / Co-analgesics (pain modulators): Anticonvulsants, Antidepressants
– Opioids/opioid-like (e.g. morphine, hydrocodone, oxycodone/tramadol)
— Mechanisms of action relate to pathophysiology (chemical modulators)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Pharmacologic Treatment
* — Targeted at ?
* — Realistic pain goal?
* — Still pursuing?

A
  • Targeted at symptom relief
  • Realistic pain goal: reduce pain and improve function
    ◦ Target: 30%-50% reduction - clinical improvement
    ◦ May not be able to eliminate until underlying cause treated/healed
  • — Still pursuing better treatments to address underlying mechanisms of pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

NONOPIOID ANALGESIC CLASSIFICATIONS

A

Salicylates
Acetaminophen (APAP)
NSAIDS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Salicylates

A

ASA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

NSAIDS

A

IBU, naproxen, celecoxib

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Acetaminophen
(APAP) moa

A
  • Exact MOA unclear
  • May inhibit Cyclooxygenase (COX) pathway (possibly COX III) and nitric oxide pathway, mediating neurotransmitters in Central Nervous System (CNS) – inhibiting prostaglandins in the CNS
  • May activate the cannabinoid system
  • Weak COX-I and COX-II inhibitor in peripheral tissues – not primary mechanism of action
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Acetaminophen effect on blood and inflammation

A
  • Possesses NO significant anti-inflammatory activity
  • NO anti-platelet activity – No increased bleeding risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Clinical Uses of acteaminophen
*pain?
* fever?
* In combination with?
* APAP’s analgesic effects comapred to nsaids

A
  • Mild to moderate pain of varied origin (including dental pain)
  • Antipyretic activity
  • In combination with opioids (synergy)
  • APAP’s analgesic effects considered less than or similar to NSAIDs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Acetaminophen Adverse effects

A
  • **HEPATOTOXICITY **(rare but can be severe) - at high doses liver metabolizes to toxic metabolic metabolite (N-acetyl-p-benzoquinoneimine)
  • Associated with nephrotoxicity with long-term consumption
  • Rare skin reactions
  • Some complaints of **GI adverse effects **but less than other analgesic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

acetaminophen dosing
Over-the-counter (OTC) recommendations for adults?
* Target per dose?
* Up to gm/day under direction of healthcare provider?
* mg/day recommended for older adult patients?
* children?

A

Over-the-counter (OTC) recommendations ≤ 3,000mg (3 gm)/day for adults
* Target 325-650 mg/dose (max 1000 mg/dose)
* Up to 4 gm/day under direction of healthcare provider
* 2,000-3,000mg (2-3 gm)/day recommended for older adult patients
* See dosing/package information for children’s weight-based dosing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Avoid APAP use in patients with?

A

Avoid APAP use in patients with active/severe hepatic disease and alcohol
abuse/dependence → ↑ risk of hepatotoxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

APAP effect in GI PG’s/plattlets?

A

Has no effect on GI prostaglandins, CV/platelet effects (vs. NSAIDss)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

APAP OD tx

A

N-acetylcysteine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

APAP Drug Interactions:
* compared to other pain medications?
* Caution in combination with other drugs that cause?
◦ examples?
* blood med?
* More than ? alcoholic drinks a day increases liver toxicity risk

A
  • Few, compared to other pain medications
  • Caution in combination with other drugs that cause liver toxicity
    ◦ Leflunomide (Rheumatoid arthritis medication)
    ◦ Methotrexate (Rheumatoid arthritis medication)
    ◦ Carbamazepine (Anti-convulsant)
    ◦ (Others)
  • Warfarin (but considered safer than NSAIDs)
  • More than >3 alcoholic drinks a day increases liver toxicity risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

APAP Patient Education:
* Found in?
* Do not take?
* Watch for acetaminophen in?
* Never take more than the recommended dose of acetaminophen or take it for longer than?
* Caution with?
* Pediatrics?

A
  • Found in more than 600 different medicines (RX and OTC)
  • Do not take more than one medicine at a time that contains acetaminophen.
  • Watch for acetaminophen in OTC cough/cold, allergy, sleep, pain medications
  • Never take more than the recommended dose of acetaminophen or take it for longer than directed on the label, unless directed by a healthcare professional to do so.
  • Caution with alcohol (limit to 1-2 drinks/day)
  • Pediatrics – follow weight-based guidelines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

APAP Prescribing Checklist:
q tolerated?
q Often used in combination with what for dental pain?
q Precautions/Contraindications:

A

APAP Prescribing Checklist:
q Overall, well tolerated
q Often used in combination with NSAIDs for dental pain
q Precautions/Contraindications
* Allergy to APAP (rare)
* Active liver disease/dysfunction (e.g. active hepatitis)
* Inactive hepatitis or treated hepatitis may not not be a contraindications (check with the patient’s physician for questions about the safety of APAP use)
* > 3 alcoholic drinks/day
* Do not exceed > 4 gm/day in adults (see pediatric weight-based dosing guidelines)
* Only use one APAP containing product at a time
* Caution use with other drugs that cause liver toxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

NSAID FAMILY

A
  • Non-steroidal Anti-inflammatory Drugs (NSAIDs)
  • Traditional/Non-Selective/Non-Aspirin NSAIDs
  • Cox-selective NSAIDs
  • Related:
    Aspirin (acetylsalicylic acid - ASA)
    Non-Acetylated Salicylate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

How NSAIDs work in Dental Pain

A
  • — Tissue injury activates cyclooxygenase II (COX 2)
  • — COX II converts arachidonic acid to prostaglandin E2 (PGE2)
    ◦ resulting in pain and inflammation
    ◦ alters vascular tone and permeability, causing edema
  • PGE2 sensitizes and lowers threshold to stimulate nociceptors which initiates
    transmission of pain to CNS**
    — NSAIDs block COX II
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Blockage of COX Enzymes diagrammed

A

COX I block causes ADEs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

NONSELECTIVE NSAIDS MOA (NSAIDS & ASA

A

Nonselective inhibition of COX-1 and COX-2 → inhibition of biosynthesis of prostaglandins→ ↓ number of pain impulses received by the CNS, decreases fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

NONSELECTIVE NSAIDS MOA (NSAIDS & ASA) act where for pain?

A

periphery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

NONSELECTIVE NSAIDS (NSAIDS & ASA) effects?

A
  • Anti-inflammatory
  • Analgesic
  • Antipyretic
  • Antiplatelet (low dose ASA)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

NONSELECTIVE NSAIDS:
* Anti-inflammatory effects + inhibits pain stimuli
* Anti-inflammatory effects associated with?
* Mediated by?
* ASA- Irreversibly inhibits ?
* Main role ASA?
* ASA use in pain management limited due to?

A
    • Anti-inflammatory effects + inhibits pain stimuli
  • Anti-inflammatory effects associated with higher doses
  • Mediated by both COX inhibition + inhibition of interleukin-1
  • ASA- Irreversibly inhibits platelet COX (lasts 8-10 days). (NSAIDs – reversible platelet effects)
  • Main role – low dose in CV event prevention
  • ASA use in pain management limited due to adverse effec
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

COX2 INHIBITORS
(SELECTIVE NSAIDS)
MOA:

A

Selectively inhibits COX-2 isoenzyme at the site of inflammation → inhibit prostaglandin synthesis → ↓ number of pain impulses received by the CNS, decreases fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

COX2 INHIBITORS effects

A
  • Anti-inflammatory
  • Analgesic
  • Antipyretic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

COX2 INHIBITORS act where for pain

A

periphery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

COX2 INHIBITORS effects on plattlets

A

non-significant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

COX-2 Inhibitors
◦ name (approved one)
— Drug class associated with?
◦ increased risk with what doses?
— cost?
◦ reserve for patients with?

A

— Only one COX2 inhibitor in the US
◦ celecoxib/Celebrex
— Drug class associated with ↑ incidence of CV thrombotic events (rofecoxib, valdecoxib – removed from US market)
◦ Celecoxib – associated with higher CV risk >400 mg/day
—More expensive than most nonselective NSAIDs (even with generic)
◦ reserve for patients with increased GI risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Celecoxib/Celebrex (Selective NSAID) adult dose

A

100- 200 mg BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

ibuprofen/Motrin* usual adult dose:
* ? mg 3 to 4 times daily;
* Usual dose:
* Usual total daily dose:
* Maximum dose (debated)

A
  • 200 to 800 mg 3 to 4 times daily;
  • Usual dose: 400 mg;
  • Usual total daily dose: 1,200 to 2,400 mg/day;
  • Maximum dose (debated) 2,400 - 3200 mg/day
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Naproxen Sodium or Naproxen /Naprosyn,
Aleve* (Nonselective NSAID) usual adult dose

A
  • 440 mg every 12 hours; maximum daily dose: 1,100 mg
  • 500 mg every 12 hours or 250 mg every 6 to 8 hours; maximum daily dose: 1,250 mg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Clinical uses of Nonselective NSAIDs and COX-2 inhibitors
— Dental pain often includes an? preffered? preop? used in combo with for dental pain?
◦ moderate pain?
◦ Preoperative use 24 hours before the appointment decreases?
◦ Often used in combination with what for dental pain?
* — Mild-moderate pain and inflammation of?
* — Used in combination with what for treatment of of more severe pain?
◦ NSAID/COX-2 inhibitor + opioid = ?
— Used for treatment of joints?
— fever?
— ASA (low dose) primarily use for?

A
  • — Dental pain often includes an inflammatory component
    ◦ Often considered first line in dental pain for moderate
    ◦ Preoperative use 24 hours before the appointment decreases postoperative edema and hastens healing time
    ◦ Often used in combination with acetaminophen for dental pain
  • — Mild-moderate pain and inflammation of varied origin
  • — Used in combination with opioid analgesics for treatment of of more severe pain
    ◦ NSAID/COX-2 inhibitor + opioid = synergistic analgesic effect
  • — Used for treatment of rheumatoid arthritis and other acute/chronic inflammatory joint conditions
  • — Treatment of fever
  • — ASA (low dose) primarily use for cardiovascular event prevention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Non-Aspirin NSAID Blackbox Warnings
—

A

— GI Risk - “NSAIDs cause an increased risk of serious gastrointestinal
adverse events including** bleeding, ulceration, and perforation of the
stomach or intestines,** which can be fatal.These events can occur at any
time during use and without warning symptoms. Elderly patients are at
greater risk for serious gastrointestinal events.”
* — CV Risk - “NSAIDs may cause an increased risk of serious**
* cardiovascular thrombotic events, myocardial infarction and stroke, which**
can be fatal.This risk may increase with duration of use. Patients with
cardiovascular disease or risk factors for cardiovascular disease may be
at greater risk.”
— Coronary Artery Bypass Graft (CABG) Surgery - NSAID use
is contraindicated in the setting of CABG surgery - (short-term) before
and after CABG surgery (aspirin is commonly indicated after CABG
surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Key NSAID Adverse Effects:

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

NSAIDS at renal

A
  • Kidney injury/acute renal failure (prostaglandin mediated kidney flow)
  • Decreases renal blood flow. Increased risk in dehydration and other renal toxic medications
  • Less with celecoxib and low dose ASA. Avoid NSAIDs with GFR < 30 mL/min
  • Can occur after 1 dose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

NSAIDS at GI

A
  • Dyspepsia/Nausea – NSAIDs, ASA and celecoxib – can occur after 1 dose. Take with food.
    GI ulcers/bleeding - usually long-term complication with NSAIDs and low dose ASA (less with celecoxib). Do not use if patient has active ulcer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

NSAIDS and plattlets

A

Increased bruising and bleeding – NSAIDs and ASA (less with
celecoxib

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

NSAIDS and CV

A

NSAIDs, celecoxib (possibly less with naproxen, more with higher doses of celecoxib >400 mg/day)
**Low dose ASA has CV protective **effects due to irreversibility binding platelets
**All other NSAIDs carry BLACK BOX WARNING **for increased risk of CV events. Avoid in patients with recent coronary artery bypass graft or recent MI without consulting physician

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

NSAIDS with HTN/HF

A

Fluid retention/edema = worsen hypertension (HTN) and heart failure (HF)
NSAIDs and celecoxib (less with low dose ASA) – Avoid in uncontrolled HTN
May or may not be clinically significant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

When Prescribing OTC or RX NSAIDs
doses? length of tx? ADRs onset? pregnancy?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Key Drug Interactions of NSAIDS and ASA

A
  • ASA/NSAIDs + warfarin
  • ASA/NSAIDs + Blood Pressure Medications
  • NSAIDs + High Dose Methotrexate
  • NSAIDs + Lithium
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

ASA/NSAIDs + warfarin

A

◦ Increased bleeding and INR (consider benefit vs. risk- short-term use may outweigh risks)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

ASA/NSAIDs + Blood Pressure Medications

A

– + ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)
– + Diuretics
◦ May diminished BP effects but may not be clinically significant (particularly if the patient’s BP is well controlled)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

NSAIDs + High Dose Methotrexate

A

◦ Decreased Methotrexate renal clearance/increased toxicity
◦ This interaction is CLINICALLY SIGNFICIANT if methotrexate used in high dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

NSAIDs + Lithium

A

◦ Increase serum concentrations of lithium (decrease clearance)
◦ Monitory lithium concentrations and symptoms of toxicity /consider decreasing dose of lithium if NSAID initiated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Patient Education for NSAIDs
* doses
* mixes
* risks
* take with?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Topical NSAID Treatment
—

A

— Diclofenac (Voltaren® gel, generics)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Diclofenac (Voltaren® gel, generics)
— Use:
* Possible option if patient has?
– <% of the amount absorbed after oral administration, but still carries?

A

— Use: FDA approved for treatment of osteoarthritis (OA)
* Possible option if patient has contraindications to PO NSAIDs
– <5% of the amount absorbed after oral administration, but still carries Black Box warning for systemic ADRs (see below

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

diclofenac doses
◦ Lower extremity dose :
◦ Upper extremity dose:
◦ Total body maximum:

A

◦ Lower extremity dose : 4 gm up to QID, Max dose/joint: 16 g/day
◦ Upper extremity dose: 2 gm up to QID, Max dose/joint 8 g/day
◦ Total body maximum 32 g/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

how could we use diclofenac in dentistry

A

TMD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

diclofenac black box/contraindications

A

Black Box Warning: GI bleed/ulceration and CV thrombotic events
* Avoid in advanced renal disease - no dosing adjustments provided by manufacturer
* Contraindicated in perioperative pain in the setting of coronary artery bypass graft surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

diclofenac adrs

A

Adverse Effects: pruritus, burning, rash
* Still a risk for systemic adverse effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

can we use PO NSAIDS with diclofenac?

A

Avoid oral NSAIDS in combination - no additional efficacy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

NSAID Prescribing Checklist:

A

q Often considered first line for dental pain (and in combination with APAP)
qOTC doses – more analgesic effects
qRX doses – analgesic + anti-inflammatory

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Precautions/Contraindications to Rx NSAIDS
q Allergy?
qGI?
qConcurrent use of ?
qBP?
q CV?
q renal?
q Drug interactions with ?
q Avoid when in pregnacy?

A

q Allergy to NSAIDs/ASA
qPatients with active GI ulcer or multiple GI risk factors:
qAge > 65, history of GI ulcers/bleed
qConcurrent use of chronic antiplatelets, anticoagulants, corticosteroids, high dose NSAIDs
qUncontrolled BP
q Severe/advanced HF or exacerbations
q Patients with CV disease or multiple CV risk factors
q Patients with renal insufficiency/chronic kidney disease
q Drug interactions with NSAIDs (warfarin, high dose methotrexate)
q Avoid in third trimester pregnancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Adjuvants / Co-analgesics

A

— Diverse group of drugs with individual characteristics that are useful in the management of pain but aren’t typically considered analgesics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

examples of Adjuvants / Co-analgesics

how they works?

A

◦ Anticonvulsants – may decrease neuronal excitability (blocking sodium channels, modulating calcium channels?)
◦ Antidepressants – block reuptake of serotonin or norepinephrine, enhancing pain inhibition
◦ Local anesthetics (example - topical) – block sodium channels
◦ Corticosteroids – strong anti-inflammatory affects
◦ Others

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Most anticonvulsants and antidepressants commonly used in?

A

Most anticonvulsants and antidepressants commonly used in chronic, neuropathic pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Full affects of anticonvulsants and antidepressants for pain management usually take?

A

Full affects of anticonvulsants and antidepressants for pain management usually take 4-6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Common Adjuvants / Co-analgesics classes

MC ones used>?

A

pregabalin and gabapentin MC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

TCAs used as common adjuvants

A

amitriptyline
nortriptyline
desimpramine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

SNRIs used for common adjuvants

A

desvenlafaxine
duloxetine
levomilnacipran
milnacipran
venlafaxine / venlafaxine XR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Anticonvulsants used as co-analgesics

A

carbamazepine
gabapentin
lamotrogine
pregabalin
topiramate
valproic acid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

LA used as co-analgesics

A

lidocaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

roids used as coanalgesics

A

prednisone
dexamethasone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

TCAs common adrs

A

Anticholinergic side effects (constipation, dry mouth, blurry
vision, trouble urinating), orthostasis, nightmares, weight
gain, confusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

TCA monitoring

A
  • Weight
  • Serotonin syndrome
  • BP/HR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

SNRI adrs

A

Nausea, vomiting, upset stomach, increased blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

SNRI monitoring

A
  • BP
  • Mental status
  • Serotonin syndrome
87
Q

Gabapentin adrs

A

Dizziness, drowsiness, leg swelling, weight gain, ataxia

88
Q

Pregabalin (Schedule V) adrs

A

Dizziness, drowsiness, leg swelling, weight gain, ataxia

89
Q

gabapentin and pregabalin monitoring

A
  • Periodic renal function
  • Weight
  • Edema
90
Q

lidocaine adrs

A

Itching, rash, changes in skin color

91
Q

lidocaine monitoring

A

Skin changes

92
Q

Perioperative Use of Gabapentinoids

A

— Limited evidence in dental procedures but may decrease pain and amount of opioid medications
— No anti-inflammatory property benefits vs. using NSAIDs pre procedure/post procedure
— Single dose or 2-3 dose peri operatively

93
Q

gabapentin and pregabalin perioperative dosing

A
94
Q

gabapentionoid abuse?

A

— Growing concerns about gabapentionoid abuse, particularly in combination with opioids/other CNS depressants
◦ Limit use to short-term/small quantities

95
Q

Trigeminal Neuralgia

A

— Often felt in the jaw, teeth or gums
◦ May result in misdiagnosis and unnecessary dental procedures

96
Q

what can be used in trigeminal neuraligia

A

carbazepine and oxcarbazipine

97
Q

carbazepine use in trigem neuralgia:
level?
◦ doses?
◦ titrate?
◦ ADRs:
◦ Drug interactions:

A

Carbamazepine (most evidence – Level A=preffered agent)
◦ 200-1200 mg/d in 2-3 doses/day
◦ titrate by 100 mg every other day until sufficient pain relief is attained or until intolerable side effects prevent further upward titration.
◦ ADRs: sedation, dizziness, nausea, vomiting, diplopia, memory problems, ataxia, elevation of hepatic enzymes, and hyponatremia, leucopenia, aplastic anemia, allergic rash, systemic lupus erythematosus, hepatotoxicity, and Stevens-Johnson syndrome (SJS)
◦ Drug interactions: CYP450 (macrolide antibiotics, tramadol, tapentadol, calcium channel blockers

98
Q

Oxcarbazepine use as trigem neuralgia tx
level?
◦ doses?
◦ titrating?
◦ side effects?

A

◦ 300-1800 mg/d in 2 doses/day
◦ increased as tolerated in 300 mg increments every third day until pain relief occurs
◦ improved side effect profile and fewer drug interactions than with carbamazepine

level B

99
Q

Opioid defined

A

Any substance whether endogenous or synthetic, that produces morphine-like effects that are blocked by antagonists such as naloxone

100
Q

Opiate defined

A

Compounds that are found in opium poppy such as morphine and codeine

101
Q

Narcotic analgesic

A
  • Old term for opioids
  • Narcotic refers to their ability to induce sleep
  • “negative connotations” – used as a term for drugs of abuse
102
Q

long or short acting opioids in dentistry

A
  • Very limited role for long-acting opioids in dentistry
  • FOCUS: SHORT-ACTING OPIOIDS
103
Q

Potency of Common Opioids/Opioid-Like Agents

A
104
Q

gold standard opioid

A
  • Morphine – “standard” opioid to which others are compared
  • Opioids discussed in terms of morphine milligram (mg) equivalents = MMEs
105
Q

Partial agonist opioid

A

Buprenorphin

106
Q

Pure agonist opioids

A

Hydrocodone
Morphine
Oxycodone
Methadone
Hydromorphone
Oxymorphone
Fentany

107
Q

Agonist / Antagonist opioids

A

Pentazocin

108
Q

Antagonists of opioids

A

Naloxone
Naltrexone

109
Q

Opioids
MOA

A
  • Bind to opioid receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain
  • Produces generalized CNS depression
  • Affects opioid receptors in other areas of the body (GI)
110
Q

Pharmacologic Actions of opioids
— Effects on the CNS

— Effects on the GI Tract

A

— Effects on the CNS
◦ Analgesia
◦ Euphoria
◦ Respiratory depression
◦ Depression of cough reflex
◦ Nausea and vomiting
◦ Pupillary constriction

— Effects on the GI Tract
◦ Constipation

111
Q

opioids and histamine

A

— Histamine Release
◦ Urticaria and itching at inject site or after IV
◦ Bronchoconstriction
◦ Hypotension

112
Q

Overview of Effects of Opioid Receptors Sub-types

A

all produce analgesia

113
Q

Opioid Black Box Warnings
— Addiction, misuse and abuse can lead to?
— Alcohol use?
— Crushing, dissolving or chewing of long-acting products can cause?
— Risk of medication errors with the oral solution ?
— Opioid analgesic Risk Evaluation and Mitigation Strategy (REMS)?
— respiratory?
— neonatal?
— Accidental ingestion of even one dose?
— Risks from concomitant use with benzodiazepines or other CNS depressants, including alcohol,
may result in? Reserve concomitant prescribing of morphine and benzodiazepines or other CNS depressants for use in patients for whom?

A

— Addiction, misuse and abuse can lead to overdose and death
— Alcohol use with extended-release formulations (Kadian, Oxymorphone ER, Zohydro) result in
increased plasma levels and potentially fatal overdoses
— Crushing, dissolving or chewing of long-acting products can cause the delivery of a potentially fatal
dose
— Risk of medication errors with the oral solution - dosing errors due to confusion between mg and
mL, and other opioid solutions of different concentrations, can result in accidental overdose and
death
— Opioid analgesic Risk Evaluation and Mitigation Strategy (REMS) for all opioids which includes an
education program for health care providers, Medication Guides provided to patients and emphasis
on education and safe use
— Life threatening respiratory depression
— Life threatening neonatal opioid withdrawal syndrome with prolonged use during pregnancy
— Accidental ingestion of even one dose, especially by children, can result in a fatal overdose
— Risks from concomitant use with benzodiazepines or other CNS depressants, including alcohol,
may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant
prescribing of morphine and benzodiazepines or other CNS depressants for use in patients for
whom alternative treatment options are inadequate. Limit dosages and durations to the minimum
required. Follow patients for signs and symptoms of respiratory depression and sedation

114
Q

Opioid Adverse Events (ADE)

A
115
Q

possible tx of opioid induced sedation

due to stim of?

A
  • Mild sedation with oral common, more severe sedation a risk with injectables (tolerance develops over time)
  • Consider holding or decreasing dose if impairs function
  • If severe – naloxone (antagonist)

mu receptor stimulated

116
Q

aacute overdose opioid tx

due to stim of?

A

naloxone

stimulation of Mu receptor – decreases sensitivity to CO2 in brain stem

117
Q

opioid nausea and vomitting tx

due to stim of?

A
  • If oral form (take with food to prevent)
  • Anti-nausea medication (examples: promethazine, prochlorperazine,
    ondansetron)

(stimulation of chemoreceptor trigger zone)

118
Q

opioid induced constipation tx

A

Constipation ( stimulation of Mu receptor)
* only ADE for which tolerance does not develop
**Laxative **(examples: polyethylene glycol/Miralax, senna)
o Fiber, water and stool softeners often ineffective in opioid induced constipation

119
Q

opioid induced itching tx

A

more common with injectable forms, use of antihistamines (diphenydramine)

120
Q

Centrally Acting Opioid-Like Agents

A

Tramadol
Tapentadol

121
Q

Tramadol moa

A

– μ-opioid activity (30%)
– inhibition of NE and 5HT reuptake (70%)

122
Q

tramadol abuse

A

Considered less abuse potential (C-IV)

123
Q

tramadol interactions

A

CYP2D6 and CYP3A4 interactions

124
Q

tramadol side effects

A

◦ dizziness, nausea, constipation, headache, sedation
—** Increased seizure risk**
— Increased risk of** serotonin syndrome** with other serotonergic drugs

125
Q

when to use tramadol

A

— Most effective for mild-moderate (not severe) pain
— Do not use in pediatric patients (variable metabolism)
◦ < 12 years of age or < 18 years following tonsillectomy/adenoidectomy surgery

126
Q

tapentadol moa

A

– μ-opioid activity
– inhibition of NE

127
Q

tapentadol abuse potential

A

CL II controlled

128
Q

tapentadol interactions

A

less than tramadol
Do NOT consume alcohol with Nucynta ER

129
Q

tapentadol side effects

A

◦ nausea, dizziness, vomiting, constipation and somnolence
— Increased seizure risk

130
Q

tapentadol indicated for?

A

Indicated for moderate to severe pain
— Expensive!

— Safety and efficacy in pediatric patients less < 18 years have not been established

131
Q

Short-acting Oral Opioids (Commonly used in Dentistry)

A
132
Q

dosing oxycodone

A
133
Q

oxycodones with NSAIDS or APAP

A

able to dose with separate NSAID and/or
acetaminophen

134
Q

Oxycodone/APAP dosing

A
135
Q

Oxycodone/APAP dose can be limited by?

A

Dose may be limited by acetaminophen
content

136
Q

Hydrocodone/APAP dosing

A
137
Q

Hydrocodone/APAP dosing can be limited by?

A

APAP content

138
Q

Tramadol dosing

A
139
Q

Tramadol not given to?

A

Opioid-like ADEs. Decreases seizure threshold.
Not recommended in pts <12 yrs old

140
Q

Tramadol/APAP dosing

A
141
Q

Tramadol/APAP
Dose may be limited by?
Decreases ?
Tramadol not recommended in ?

A

Dose may be limited by acetaminophen content.
Decreases seizure threshold.
Tramadol not recommended in pts <12 yrs old

142
Q

APAP/Codeine dosing

A
143
Q

APAP/Codeine:
high rate of?
limited effects of?
Codeine contraindicated in?

A

high rate of GI ADEs (especially constipation)/
limited analgesic effects.
Codeine contraindicated in pts < 12 yrs ol

144
Q

Opioid Conversion Charts

A

morphine mg equivalents

145
Q

Opioid Partial Agonists/Antagonists

do not use with?

A

nalbuphine and pentazocine
◦ Don’t use with other opioids because it can precipitate withdrawal

146
Q

pure opioid antagonists

A

naloxone/naltrexone

147
Q

naloxone:
– Blocks?
– Produces?
– Increases?
– Treatment of ?
– Precipitates?

A

– Blocks all opioid receptors
– Produces rapid reversal of opioid effects
– Increases patient’s pain
– Treatment of respiratory depression cause by opioid overdose
– Precipitates opioid withdrawal symptoms but saves live

148
Q

naloxone dosing

A

– Dose: IV, IM, SubQ: Initial: 0.4 to 2 mg; may need to repeat doses every 2 to 3 minutes
– Nasal spray also available (see subsequent slides

149
Q

Naltrexone
– Similar to? dif how?
– Treatment option for ?

A

– Similar actions to naloxone but longer duration of action
– Treatment option for alcoholics and opioid dependence

150
Q

naltrexone dosing

A

Dose: Initial: oral 25 mg; if no withdrawal signs occur, administer 50 mg/day thereafter
– Alternative regimens may include higher doses on the weekends or 150 mg 3 times a day
– IM: 380 mg once every 4 week

151
Q

Uses of Opioids in Dentistry
—

A

— Pain from:
◦ Abscesses/Infection/Inflammation
◦ Trauma
◦ Surgery/Procedures:
— Post Procedural Management
— Other potential dental conditions causing pain including temporomandibular disorders (TMDs) and masticatory muscle disorder
— **Should be considered “last line” for all indications
**

152
Q

Managing Acute Dental Pain – Putting It All Together
* best regimen?
growing concerns of?
– No research on effectiveness of?
— Many patients’ first experience with an opioid coincides with?
◦ Among prescribers of opioids for adolescents, who is most common?
– misuse often occurs from?
– use of prescribed opioid pain medication before high school graduation is associated with a?
– misuse of opioids in adolescence - strong predictor of?

A

— Limited evidence of best regimen - best practice is based on anecdotal reports, case studies, systematic reviews, a few randomized controlled clinical trial, and the opinions of experts.
— Current practice often includes multimodal analgesic combinations
◦ Most effective combinations and doses not well studied
— Growing concerns over opioid abuse
– The US consumes 99% of the world’s hydrocodone/acetaminophen combinations
– No research on effectiveness of hydrocodone in dental pain
— Many patients’ first experience with an opioid coincides with a dental procedure, such as the extraction of wisdom teeth
◦ Among prescribers of opioids for adolescents, dentists are proportionately the most prevalent prescribers (~31%)
◦ In children/ adolescents < 18 yrs old
– misuse often occurs from misuse of own previous prescriptions
– use of prescribed opioid pain medication before high school graduation is associated with a 33% increase in risk of later opioid misuse
– misuse of opioids in adolescence - strong predictor of later onset of heroin use

153
Q

Comparing NSAID, Opioids, Combination pain relief graph

A

IBU alone comprable to oxy/IBU

154
Q

buprofen + APAP vs. Opioid + APAP

A

ibuprofen + APAP may be more effective than Opioid + APAP

155
Q

Post-Op Pain After Surgical and Simple Tooth Extractions in Children (12 and under) flow chart

A

never opioids

156
Q

oothache Pain with No Immediate Access to Definitive Dental Treatment in Children (12 and under) flow chart

A

exact same as with extractions, same options and progression

never opioids

157
Q

Tooth Removed — Simple and Surgical
Children: 0–less than 12 years old medication chart

A
158
Q

ibuprofen children dosing guidelines

A
159
Q

naproxen children dosing guidelines

A
160
Q

APAP children dosing guidelines

A
161
Q

Post-Op Pain After Surgical and Simple Tooth Extractions in Adolescents, Adults and Older Adults analgesic flow chart

A
162
Q

Toothache Pain with No Immediate Access to Definitive Dental Treatment in Adolescents, Adults and Older Adults analgesic flow chart

A
163
Q

tooth ext rx regimens:
first line?
extended management?
if nsaids contra?
if nsaids contra for surgical?

A
164
Q

Comparison of Hydrocodone and Oxycodone
— Both are?
— Both are Schedule?
— which is more potent (takes less mg for similar effects)?
— differences in efficacy or tolerability at equianalgesic doses?
— Noted interpatient ?
◦ Discussing previous patient experiences?
— ADEs?
◦ Some studies show hydrocodone is more likely to cause?
◦ Some studies show oxycodone is more likely to cause?
— Both have what formulations?
◦ long-acting formations use?
— Both are available as combination products with?
◦ using separate tablets rather than combination tablet may be less confusing to patients and minimize risk of exceeding maximum acetaminophen dosing if planning to continue acetaminophen use with NSAID

A

— Both semi-synthetic opioids
— Both are Schedule II controlled substances
— Oxycodone is more potent (takes less mg for similar effects)
— No significant evidence on a populations level of major differences in efficacy or tolerability at equianalgesic doses
— Noted interpatient variability with efficacy and tolerability
◦ Discussing previous patient experiences with using hydrocodone or oxycodone may contribute to decision-making
— Mostly similar adverse events
◦ Some studies show hydrocodone is more likely to cause GI ADRs, especially constipation
◦ Some studies show oxycodone is more likely to cause sedation, grogginess, fatigue, etc.
— Both have short-acting and long-acting formations
◦ long-acting formations should NOT typically be used for dental pain
— Both are available as combination products with acetaminophen
◦ using separate tablets rather than combination tablet may be less confusing to patients and minimize risk of exceeding maximum acetaminophen dosing if planning to continue acetaminophen use with NSAID

165
Q

Opioids and specific formulations that should NOT be used in acute pain

why are these not used?

A

any long acting opioid is never used

166
Q

pre-procedure nsaids?

A

START pre-procedure NSAID 24 hrs prior - unless contraindication
◦ Decreases postoperative edema and hastens healing time
◦ Example ibuprofen 400-600 mg qid X4

167
Q

NSAIDS/APAP in first 24-74 hrs

A

Consider scheduled doses of NSAID +/- acetaminophen the first 24-72
hours (depending on procedure) then prn

168
Q

ADA and corticosteroids use?

A

The ADA panel suggests against adding oral, submucosal, or intramuscular corticosteroids to standard analgesic therapy for management of post-op dental pain
◦ Recommendations did not address IV administration or post-op complications such as trismus, facial swelling or infection)
◦ Perioperative IV steroids (e.g., dexamethasone) may decrease swelling and discomfort after third molar extractions

169
Q

If opioid prescribed, the ADA panel recommends to use?

A

If opioid prescribed, the ADA panel recommends to use at lowest effective
dose, fewest tablets, and the shortest duration, which rarely exceeds 3 days

170
Q

Counsel patients on expectations

A

◦ some pain, analgesics should make their pain manageable
◦ discuss with patient their past experiences, preferences and values regarding pain management (shared decision making)

171
Q
  • — Avoid routine use of?
  • — If opioids are used, counsel patients regarding?
  • — Review the state’s?
A
  • — Avoid routine use of “just-in-case” opioid prescriptions for breakthrough pain
  • — If opioids are used, counsel patients regarding appropriate storage and disposal
  • — Review the state’s prescription drug monitoring program to determine the co-prescribing of other controlled substances
172
Q

or all patients who are prescribed opioid pain relievers,
health care professionals should discuss the availability
of ?

A

or all patients who are prescribed opioid pain relievers,
health care professionals should discuss the availability
of naloxone, and consider prescribing it

173
Q

Patients who are at increased risk of opioid overdose:

A

– using benzodiazepines or other medicines that depress the central nervous system
– history of opioid use disorder (OUD)
– who have experienced a previous opioid overdose

174
Q

Consider prescribing naloxone if:

A

– Patient has household members, including children, or other close contacts at risk for accidental ingestion or opioid overdose.

175
Q

Key Drug Interactions with Opioids

A

Avoid Combination CNS depressants:
◦ Alcohol
◦ Benzodiazepines/ Anxiolytics (examples: alprazolam, diazepam, lorazepam)
◦ Sedative-hypnotics (examples: eszopiclone, zaleplon, zolpidem)
◦ Anticonvulsants (including gabapentinoids)
◦ Muscle relaxants

Caution in offering opioids to patients taking gabapentinoids and central nervous system active medications or additional opioids to patients already taking opioids for other medical reasons

Consider length of therapy and individual risk to patient (co- morbidities)

176
Q

Sources of Prescription Opioids for Nonmedical Use

A
177
Q

Prescription Drug Collection Boxes

A
178
Q

Proper Disposal of Opioids
— done?
— Remove ?
— FDA recommends mixing with?
— Some long-acting opioid/others recommended to be?

A

When preferred options are not available/create barriers
Remove or scratch out personal information from bottles
FDA recommends mixing with unpalatable substances and placing in a non-descript container in the trash:
◦ Coffee grounds
◦ Kitty litter
◦ Dirt
◦ Packets from pharmacy (biodegradable gel)
Some long-acting opioid/others recommended to be flushed due to dangers
◦ Morphine ER, Oxycontin, Fentanyl patches, etc.
◦ See “FDA flush list

179
Q

Consideration for Prescribing Opioids – Controlled Substances
— Most opioids:
◦ Follow?
— Tramadol:
— Tylenol w/ Codeine tablets:
— Opioid containing cough suppressants: C-
— Pregabalin:
— Caution: do not provide larger quantities than needed due to?
— If patient calls requesting additional pain medications after initial quantity,
have patient?
— what is required for controlled substances in Missouri and Kansas?
◦ Missouri - annual waiver and exceptions/Kansas biannual waiver and exceptions
— Practitioners issuing electronic prescriptions for controlled substances must use a software application that?

A

Consideration for Prescribing Opioids – Controlled
Substances
— Most opioids: C-11
◦ Follow Federal and State Laws
— Tramadol: C-IV
— Tylenol w/ Codeine tablets: C-111
— Opioid containing cough suppressants: C-V
— Pregabalin: CV
— Caution: do not provide larger quantities than needed due to abuse, misuse,
and/or sharing (most states have quantity limits for opioids for acute pain)
— If patient calls requesting additional pain medications after initial quantity,
have patient return for assessment and look for other causes of pain
— E-prescribing required for controlled substances in Missouri and Kansas
◦ Missouri - annual waiver and exceptions/Kansas biannual waiver and exceptions
— Practitioners issuing electronic prescriptions for controlled
substances must use a software application that meets all Drug
Enforcement Administration (DEA) requirements

180
Q

State Prescription Drug Monitoring Programs (PDMPs)
— Purpose:

A

— Purpose: reduce prescription drug misuse, abuse and diversion while ensuring patients have access to safe, effective treatment

181
Q

Missouri law PDMPs

and KS

A

Missouri law does not mandate checking PDMP before prescribing a controlled substance to a patient except for MO HealthNet participants. Kansas law also required checking for KS Medicaid participants

182
Q

In states not requiring checking the PDMP it is recommended to?

A

In states not requiring checking the PDMP it is recommended to monitor state’s PDMP to identify concerns BEFORE writing a prescription

183
Q

Using PDMPs
— Centers for Disease Control Opioid Guidelines - ?
— Activity report
— Dentists - sign up?

A

— Centers for Disease Control Opioid Guidelines - Do not dismiss patients from care
— Activity report
◦ Not punitive for prescriber
◦ Reports the prescriber’s controlled-prescription prescribing
◦ Impacts on patients’ overall morphine mg equivalents (MMEs)
— Dentists - sign up to access PDMP in MO or their state
◦ May appoint a staff member to be a delegate

184
Q

Writing an Opioid Prescription format

A

NO REFILLS FOR CL-2 Rx

185
Q

Opioid Overdoses: in practice or in the
community

A
186
Q

Naloxone Education Basics:
CALL?
Ø If must leave temporarily put in?
Ø Indication for naloxone rescue:

A

CALL 911- first step
Ø If must leave temporarily put in recovery position (on side)
Ø Indication for naloxone rescue: signs of overdose

187
Q

Administer naloxone as ?

A

Administer naloxone as directed/ how to administer, depending on formulation – most common
nasal spray

188
Q

recovery position for OD pts

A

Position patients on their side after naloxone administration (recovery position), if breathing
§ they may vomit

189
Q

if od pt not breathing?

A

perform rescue breathing or if no pulse, CPR as indicated (may vomit)

190
Q

how often is naloxone administered

A

Administer naloxone every 2-3 minutes:
Ø If a patient’s symptoms return or if the patient doesn’t respond or achieve the desired response (i.e., adequate spontaneous breathing), and emergency medical help has not yet arrived
Ø When giving additional doses of Narcan nasal spray, alternate nostrils
Ø Long-acting/potent opioids may require more than 2 doses and repeated doses (EMS should have additional supply – important to transport to Emergency Department ASAP)

191
Q

Most OD patients respond to?

A

Most patients respond to naloxone with a return to spontaneous
breathing

192
Q

If naloxone is given to a patient who is not opioid-dependent or is not
opioid-intoxicated?

A

If naloxone is given to a patient who is not opioid-dependent or is not
opioid-intoxicated, it has no clinical effects

193
Q

Dealing with Opioid Allergies: what most pts describe?

A

What most patient describe as opioid allergies are really ADRs/intolerances
* Examples: nausea, constipation, sedation
* Even histamine related flushing from IV opioids or itching is considered an ADR

194
Q

If a patient reports an opioid ADR/intolerance options include

A
  • Find an alternative non-opioid, if appropriate
  • Change to another opioid either within or in a different class
  • Lower the dose of the current drug (if still provides pain relief)
195
Q

true opioid allergies occurence?

A

infrequent

196
Q

When a patient describes or there is documentation of a true opioid allergy:
* cross reactions possible within?
* cross reaction less likely with?
* opioid-like agents?
* Therefore, ?

A
  • cross reactions possible within same structural class
  • cross reaction less likely with opioid in a different classes
  • opioid-like agents are also contraindicated
  • Therefore, reconsider if opioid is needed, pick an opioid in a different drug class if possible or consult with patient’s medical provider or pharmacist for recommendations
197
Q

Patient Education with opioids?
—goals?
— safe?

A

Realistic Goals
Opioids are usually safe to use when prescribed for short periods of time under care of medical professional when other treatments aren’t options (contraindications) or aren’t controlling the pain

198
Q

pt education: monitoring
Monitoring
◦ Pain improvement?
◦ Side Effects?
– Education on using?

A

◦ Pain improvement (if not improved or worsening have patient return for
follow up appointment)
◦ Side Effects
– Education on using laxative for constipation (stool softener and fiber may
not be effective)

199
Q

Cannabinoids

A
  • 100 cannabinoids in cannabis - two of the main active cannabinoids of cannabis
    are delta-9-tetraydrocannabinol (THC) and cannabidiol (CBD)
  • Hemp-derived - CBD (< 0.3% tetrahydrocannabinol [THC] dry weight) vs. Marijuana – derived products
200
Q

Quality and variability of canniboid products?

A

Quality and variability of products complicate and contribute to concern
◦ 2021 CDC Health Advisory: CBD product labeling may underestimate the concentration of THC by not reporting delta-8 THC concentrations, which may result in psychoactive and other adverse effects
◦ May not contain claimed ingredients or may be contaminated with other ingredients, including small amounts of THC or toxins
— Complicated by federal and state laws

201
Q

Cannabinoids in Dental Pain
—literature?
— Any role in therapeutic use is?
—evidence?
◦ further research?

A

— A PAUCITY OF LITERATURE AVAILABLE related to clinical benefits
— Any role in therapeutic use is in its infancy
— Insufficient evidence exists to support a tangible clinical benefit of cannabinoids in managing orofacial pain
◦ further research is recommended to investigate the benefits of cannabinoids’ use.

202
Q

CAUTION: Use of cannabis and THC can?

A

CAUTION: Use of cannabis and THC can enhance sedative, psychomotor, respiratory and other effects of CNS depressants such as opioids, benzodiazepines and alcohol

203
Q

cannaboids DDI

A

Potential for CYP450 (liver enzyme) drug interactions with other medications

204
Q

Marijuana smokers
— oral health?
— Higher rate/increased risk of:
– “cannabis stomatitis” –
— Immuno?

A

— Associated with poor quality of oral health
— Higher rate/increased risk:
◦ Tooth decay
◦ Missing teeth
◦ Plaque and greater severity of gingivitis than non-users
◦ Xerostomia – higher rate than tobacco smokers
◦ Leukoplakia
◦ Mouth and neck cancers
– “cannabis stomatitis” – risk to develop into malignant neoplasia
— Immunosuppressant properties - higher prevalence of oral candidiasis compared to non-users

205
Q

Recommended Pharmacologic Options for Dental Pain Management:
— NSAIDs
– Consider startin?
– Other options?

A

◦ Ibuprofen* (400 mg q 6 hrs) or Naproxen* (440 mg q 12 hrs)
– Consider starting pre-op for extractions/procedures
– Other NSAIDs possible options (similar efficacy/safety)

206
Q

Recommended Pharmacologic Options for Dental Pain Management: APAP
◦ In combination with?

A

Acetaminophen* (650-1000 mg q 6 hrs)
◦ In combination with NSAID or when NSAID contraindicated

207
Q

Recommended Pharmacologic Options for Dental Pain Management: opioids
* when to use?
* hydro/oxy doses?

A

Opioids (for inadequate post-op pain control with non-opioids in adolescents and adults)
◦ Hydrocodone 5-7.5 mg q 6 hrs
◦ Oxycodone 5 mg q 6 hrs

208
Q

Recommended Pharmacologic Options for Dental Pain Management: Supplemental local anesthetics

A

◦ Bupivacaine + Epinephrine by block or infiltration injection
◦ Articaine + Epinephrine by infiltration injection

209
Q

foundation of pain managment?
* avoid products with?
* scheduled then prn?

A

Use non-opioid analgesics (NSAID +/- Acetaminophen) as foundation of pain
management unless contraindicated
qAvoid multiple APAP//NSAID containing products
qConsider scheduled doses the first 24-72 hours then prn

210
Q

If prescribing opioid:
qCheck?
qUse ?
qAvoid in patients?
qMay be one of limited options in patients with contraindications to?

A

qCheck Prescription Drug Monitoring Program (PDMP)
qUse lowest dose/shortest duration Use in combinations with non-opioids (NSAID/APAP)
qAvoid in patients in recovery for substance abuse (work with substance abuse provider)
qMay be one of limited options in patients with contraindications to NSAIDs and APAP

211
Q

Opioid Precautions/Contraindications
qCodeine and tramadol are contraindicated inwhat ages/why?
qAvoid prescribing opioids in combination with?
q Caution with elderly why?
q Screen for?

A

qCodeine and tramadol are contraindicated in children younger than 12 and should be avoided/used with extreme caution in ages 12-17, due to variability in metabolism
qAvoid prescribing opioids in combination with benzodiazepines, sedative-hypnotics, or anxiolytics.
q Caution in elderly and patients with renal and hepatic insufficiency
q Screen for drug interactions (cumulative CNS depression)

212
Q

Educate patients about use, adverse effects
qOpioids:
qMaximum dose of APAP

A

Educate patients about use, adverse effects
qOpioids: abuse risks and appropriate disposal
qMaximum dose of APAP (4,000 mg)

213
Q

analgesics site of action?

A

pharm 2 (20 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions