Chapter 58 Geriatric Pain

Question 1

Practitioners should be guided by two overarching principles when evaluating
the older adult with pain.

Answer 1

First, the rules of multiplicity rather than Occam’s razor should drive the assessment of the causes and contributors to pain. That is, pain should be
conceptualized as a syndrome potentially “caused by a multiplicity of pathologies in multiple organ systems. The second principle follows in that the symptom with which a patient presents may represent the
weakest link, but not necessarily the treatment target

Question 2

Low back pain in older adults commonly contributed to by

Answer 2

hip osteoarthritis, fibromyalgia syndrome, and myofascial pain

Question 3

Myofascial pain may be contributed to by

Answer 3

axial spondylosis, degenerative scoliosis, leg length discrepancy, and anxiety

Question 4

pain may present subtly as

Answer 4

loss of function, or change in mood or cognition

Question 5

Treatment may require targeting

Answer 5

biomechanics, insomnia, depression, and/or other

long-standing chronic disease often coexisting with persistent pain to optimize function and quality of life

Question 6

Older patients with persistent pain conditions should be screened routinely for

Answer 6

concurrent mental health conditions (e.g., depression, anxiety, and dementia). Failure to treat comorbid psychiatric illness will likely result in ineffective analgesia

Question 7

Other diseases common in older adults that may cause or exacerbate pain include

Answer 7

osteoporosis and osteoarthritis, diabetes, cancer, cardiovascular disease, and dementia.

Question 8

Alzheimer’s disease (AD) may pose a significant

challenge to the treating practitioner for a number of reasons:

Answer 8

(1) Patients with AD may have difficulty communicating their pain. (2) Anxiety/fear of pain may amplify the experience and expression of pain in patients with AD,
thus the most appropriate treatment may be uncertain.
(3) Patients with AD may perseverate on, but not suffer from, their pain, thus use of pain self-report as the gold standard
for guiding treatment becomes complicated.
(4) As dementia progresses, patients with AD may lose treatment
expectancy that may compromise analgesic efficacy.

Question 9

Risk factors for the development of disability include

Answer 9

high burden of medical comorbidities, depression, sensory impairments related to vision and hearing, and musculoskeletal disorders such as arthritis. Smoking, level of alcohol use, inactivity, and lack of social support also contribute significantly

Question 10

morphologic and functional changes in the peripheral and central nervous system that may impact pain processing

Answer 10

decline in the number of myelinated and unmyelinated fibers, an increase in the number of damaged nerve fibers, slowed nerve conduction velocity, loss of serotonergic and noradrenergic neurons in the dorsal horn, and a reduction in serotonergic receptor density in the anterior cingulate and prefrontal cortex, among others

Question 11

Neuropsychological performance (NP)

Answer 11

declines with age and brain volume loss, senile plaques, and neurofibrillary tangles occur in the absence of AD. Persistent pain itself is associated with deterioration of NP and evidence indicates that pain reduction is associated with improved NP

Question 12

Because provider–patient communication is an essential component in the treatment of pain

Answer 12

impairments in vision and hearing may alter treatment efficacy and require modified assessments. Vision and hearing change both structurally and functionally with age

Question 13

Common eye diseases

Answer 13

cataract, glaucoma, macular degeneration, and

diabetic retinopathy) associated with aging may result in moderate to severe vision loss

Question 14

Presbycusis

Answer 14

loss of hearing with age. Assistive technologies such as hearing aids and a frequency modulation (FM) device for those patients with speech
recognition difficulty, may be helpful when practitioners evaluate these patients, as they afford the opportunity to engage in more meaningful conversation and improved care

Question 15

Postural control abnormalities leading to

Answer 15

increased risk of falls. pain adds to this risk. assessment of balance should be a routine part of assessing the older adult with pain.

Question 16

Common changes in the musculoskeletal system include

Answer 16

sarcopenia (i.e., progressive loss of lean body mass associated with muscle cell atrophy and infiltration of fat), degenerative arthritis, and decreased bone density. Pain practitioners need to be acutely aware of the fact that radiographic evidence of degeneration without pain is exceedingly common

Question 17

Management of changes in the musculoskeletal system

Answer 17

Over half of older adults with radiographic evidence of hip osteoarthritis (OA) are without hip pain. Thus, the history and physical examination should provide strong evidence of disease before imaging is ordered to avoid unnecessary procedures such as injections and surgery that carry the potential for morbidity.

Question 18

majority of older adults with chronic low back with or without leg pain have a combination of pathologies responsible for their symptoms. Ex

Answer 18

hip OA, fibromyalgia, iliotibial band pain

Question 19

Vertebral compression

fractures

Answer 19

occur in the absence of acute pain, but

as kyphosis develops, they may contribute to pain in the upper and lower back

Question 20

vitamin D deficiency

Answer 20

common in older adults and may contribute to muscular pain and falls. Assessment of serum 25-OH vitamin D may be considered as part of pain
assessment in older adults and correction of insufficiency a routine part of treatment.

Question 21

Pharmacokinetics

Absorption

Answer 21

Remains unchanged
Increase Gastric pH

Decrease Secretory capacity and GI blood flow

Question 22

Pharmacokinetics

Distribution

Answer 22

Decrease Plasma albumin, Protein affinity, Total body water

Increase alpha 1-acid glycoprotein, Expression and activity of
P-glycoprotein in live

Question 23

Pharmacokinetics

Metabolism

Answer 23

Decrease Liver volume, Hepatic blood flow, First-pass metabolism, Phase I metabolism, Phase II metabolism in frail

Increase Interindividual variability with age

Question 24

Pharmacokinetics

Elimination

Answer 24

Measurable and predictable decline
in renal function with age
Decrease Glomerular filtration rate and Renal plasma flow

Question 25

Body Composition

Answer 25

Increase Body fat | Decrease Lean and total body mass

Question 26

Central Nervous System

Answer 26

Decrease Blood supply to brain and Baroreceptor activity

Question 27

Cardiovascular Function

Answer 27

Decrease Resting heart rate, stroke volume, and cardiac output

Question 28

Renin-Angiotensin- | Aldosterone System

Answer 28

Decrease Plasma renin and Urine aldosterone

Question 29

Medications that have a high hepatic extraction ratio may undergo

Answer 29

decreased clearance and experience a longer half life in older adults because of diminished liver size and blood flow

Question 30

Meperidine and Morphine use in older patient

Answer 30

Meperidine (contraindicated in older adults because of its renally cleared active metabolite that can cause seizures) and morphine are high extraction ratio analgesics whose first-pass effect and clearance is reduced with age.

Question 31

long half-life nonsteroidal antiinflammatory drugs are hepatically metabolized and their clearance may be reduced in older adults:

Answer 31

celecoxib, diflunisal, | naproxen, oxaprozin, prioxican, salsalate, and sulindac

Question 32

Analgesics that are affected by aging-associated decline in | renal function include

Answer 32

codeine, duloxetine, gabapentin, meperidine, pregabalin, propoxyphene, salicylate, tramadol, and the opioids morphine, oxycodone, hydromorphone, fentanyl, and methadone

Question 33

Cockcroft-Gault equation, shown below, to estimate creatinine clearance (CrCl) that helps to guide dose adjustment of renally cleared medications

Answer 33

CrCl = ( (140 ¬- age) * (Wt in kg) * (0.85 if female)) / | 72 *Cr

Question 34

Pharmacodynamics refers to

Answer 34

tissue sensitivity and how a drug interacts with its end organ. The body’s response to medications may be therapeutic or adverse

Question 35

Opioid sensitivity increases with associated decline

Answer 35

in mu opioid receptor density and increase in opioid affinity. Thus older adults may respond to opioid doses that are significantly smaller than those in younger individuals.

Question 36

The purpose of pain assessment is twofold:

Answer 36

(1) to identify contributors to pain that are usually multiple, and (2) to identify outcome measures to follow during the course of treatment, that is, each patient’s individual “pain signature

Question 37

Pain assessment in older adults

Answer 37

Pain assessment should be an ongoing process to measure change in pain over time as this will affect any necessary modifications in the treatment course. Assessment of pain alone is not sufficient; providers should inquire about changes in appetite, sleep, and/or mood, loss of mobility, and diminished activity level.

Question 38

indicative of an acute | pain event

Answer 38

Abnormalities in traditional vital signs such as abrupt changes in respiratory rate or heart rate

Question 39

For cognitively intact older adults, there are many pain rating tools from which to choose

Answer 39

Numeric rating scales (NRS) and verbal descriptor scales (VDS)

Question 40

Medication that enhance fall risk

Answer 40

opioids, tricyclic antidepressants, gabapentin, and pregabalin

Question 41

How to manage patient who are taking Medication that enhance fall risk

Answer 41

it is prudent to optimize mobility (e.g., by referring the patient to a physiatrist or physical therapist for instruction in using the appropriate assistive device and gait/balance training) prior to prescribing medications that may further increase this risk

Question 42

Assessment of cognitive function is critical. Mini-Cognitive Assessment Instrument (Mini-Cog)

Answer 42

Step 1 Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “television.” Step 2 Ask the patient to draw a simple clock set to 10 min after 11 o’clock (11:10). A correct response is a drawing of a circle with all of the numbers placed in approximately the correct positions, with the hands point to the 11 and 2. Step 3 Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.

Question 43

On Mini-Cognitive Assessment Instrument | (Mini-Cog) If there is evidence of dementia

Answer 43

in addition to treating the patient’s pain, the provider should refer the patient for neuropsychological testing or to a specialist who can address this important problem such as a geriatrician or neurologist.

Question 44

Cognitively impaired older adults are at increased risk of pain undertreatment because of

Answer 44

the belief among many health-care workers that their pain ratings are unreliable. In fact, patients with mild to moderate cognitive impairment can reliably report pain using verbal descriptor scales. In patients with more advanced dementia who have difficulty using self-report instruments, caregivers rely on behavioral cues to determine the presence and severity of pain

Question 45

one of the most sensitive and reliable behavioral indicators of pain in patients with dementia or poor verbal communication

Answer 45

Facial grimacing

Question 46

other indicators of pain in patients with dementia or poor verbal communication

Answer 46

guarding, bracing, rubbing and sighing

Question 47

Common Pain Behaviors in Cognitively Impaired | Elderly Persons

Answer 47

Facial expressions - Frown; sad, frightened face, Grimace, wrinkled forehead, tightened eyes Verbalizations/ vocalizations - Sighing, moaning, groaning, grunting Calling out, asking for help Noisy breathing; verbally abusive Body movements Rigid, tense body posture; guarding, fidgeting Pacing, rocking; restricted movement Gait or mobility changes

Question 48

Common Pain Behaviors in Cognitively Impaired | Elderly Persons

Answer 48

Changes in interpersonal interactions Changes in activity patterns or routines Mental status changes Changes in interpersonal interactions Aggressive, combative, resisting care Decreased social interactions, withdrawn Socially inappropriate, disruptive Changes in activity patterns or routines Refuses food, appetite change Sleep, rest pattern changes Sudden cessation of common routines Mental status changes Crying, tears Increased confusion Irritability or distress

Question 49

For all patients presenting with pain ruling out serious | conditions (i.e., red flag symptoms) that require immediate attention is paramount

Answer 49

fever, sudden unexplained weight loss, acute onset of severe pain, neural compression, loss of bowel or bladder function, jaw claudication, new headaches, bone pain in a patient with a history of malignancy or that awakens the patient from sleep, and sudden pain in an extremity that is associated with pallor, pulselessness, and paresthesias

Question 50

After determining the older adult’s pain signature, multifaceted treatment should be designed

Answer 50

an antidepressant, cognitive behavioral | therapy, and physical therapy may be the most appropriate components of the treatment regimen.

Question 51

For the older adult with dementia and excessive fear of pain because of social isolation

Answer 51

placement in an assisted living facility may most effectively improve quality of life. If the practitioner determines that pain itself requires treatment, a stepped care approach should be utilized

Question 52

EXERCISE

Answer 52

participation in regular exercise improves psychological well-being, reduces pain, and increases functional capacity in older adults with persistent pain. A combination of endurance, resistance, balance, and flexibility exercises may yield important health benefits

Question 53

exercise prescribed for treating osteoarthritic pain

Answer 53

individualized programs should be created to meet the patient’s unique needs. It has been demonstrated in older adults with knee OA that both low-intensity and high-intensity stationary bicycling for 25 min three times a week promote decreased pain and improved function

Question 54

Goal of Physical therapy

Answer 54

Reducing pain, optimizing fitness, and promoting functional dependence should be the goals of treatment. It is critical that the patients view themselves as taking an active role in treatment rather than as a passive recipient.

Question 55

key to successful pain rehabilitation in Physical therapy

Answer 55

being committed to maintaining a home exercise program, learning how to pace activities and self-manage pain flares

Question 56

Assistive devices for older adults with pain serve the following purposes:

Answer 56

(1) pain relief, (2) enhancement of mobility | and stability, and (3) modification of painful activities.

Question 57

Assistive devices

Answer 57

canes and walkers exert their analgesic effect by reducing load (e.g., canes for lower extremity arthritis, walkers for low back pain). Canes are generally used for those patients with mild to moderate mobility impairment; walkers tend to be prescribed for those patients with “generalized weakness, extreme inability for lower-limb weight bearing, debilitating conditions or poor balance control

Question 58

Upper extremity assistive devices can help | to modify painful activities

Answer 58

Reachers, jar openers, button aids, and zipper pulls are often prescribed for patients with osteoarthritis

Question 59

Topical therapies for pain are an attractive option for older adults given

Answer 59

their mild side effect profile, less systemic | absorption compared to oral medications, and ease of application

Question 60

Topical therapies for pain

Answer 60

capsaicin cream and a topical lidocaine patch 5% for joint and low back pain, postherpetic neuralgia, and other neuropathic symptoms; diclofenac gel for osteoarthritis; and a topical diclofenac epolamine patch for acute pain associated with minor strains and sprains

Question 61

side effects of Topical therapies

Answer 61

local irritation or rash and a burning sensation, the latter occurring most commonly with capsaicin cream

Question 62

intra-articular corticosteroid and/or hyaluronic acid injections may be beneficial

Answer 62

patients with pauciarticular joint pain associated with inflammatory and noninflammatory arthritides

Question 63

Patient with neuropathic pain (e.g., postherpetic neuralgia) treated with

Answer 63

nerve blocks may aid in reducing pain but their benefits are typically shortlived, lasting only a few days or weeks

Question 64

Trigger-point injections with local anesthetic have proven effective in alleviating

Answer 64

myofascial pain

Question 65

Epidural steroid injections (ESI) have been used to treat pain conditions associated with

Answer 65

lumbar spinal stenosis involving the central and/or lateral canal. Patients with herniated discs, spondylolisthesis, scoliosis, and degenerative disc disease may see benefits following ESI

Question 66

Two of the most commonly used medications in the older adult with mild to moderate pain are

Answer 66

acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs)

Question 67

first-line treatment in patients with osteoarthritis and other types of musculoskeletal pain

Answer 67

Acetaminophen

Question 68

a risk of unintentional acetaminophen overdose

Answer 68

>4000 mg/day

Question 69

treatment of patients with inflammatory pain (e.g., gout, pseudogout

Answer 69

NSAIDs may be indicated for short-term use although intra-articular corticosteroid injections may be used when one or two joints are involved.

Question 70

Chronic use of NSAIDs may be fraught with a number of risks including

Answer 70

congestive heart failure, exacerbation of hypertension, renal insufficiency, and gastrointestinal bleeding.

Question 71

risk factors for GI bleeding

Answer 71

age 75 and older, peptic ulcer disease, GI bleed, and use of glucocorticosteroids.

Question 72

Risk factors associated with renal insufficiency include

Answer 72

age 75 and older, diabetes mellitus, hypertension, and use of angiotension-converting enzyme inhibitor or diuretics.

Question 73

Avoiding NSAIDs in patients with congestive heart failure due to

Answer 73

the possibility of exacerbation and in patients with renal dysfunction who have serum Cr concentration over 150 mmol or glomerular filtration rate of less than 50 ml/hr.

Question 74

Corticosteroids are commonly prescribed in older adults with

Answer 74

inflammatory disorders (e.g., giant cell arteritis, polymyalgia rheumatica, rheumatoid arthritis).

Question 75

Corticosteroids are indicated for pain associated with malignancy because they

Answer 75

reduce tumor-associated edema that can cause spinal cord compression, brain herniation, and compressive neuropathy

Question 76

Corticosteroids common side effects include

Answer 76

glucose intolerance, | hypertension, psychosis, and osteoporosis,

Question 77

Consider using opioids for the treatment of

Answer 77

moderate to severe pain (both nociceptive and neuropathic), earlier in the course of disease than previously recommended to avoid the multiple potential toxicities associated with NSAIDs

Question 78

A general rule is that long-acting opioids should

Answer 78

never be initiated in the older adult who is opioid-naïve. A short-acting preparation should always be initiated and once the total daily dose requirement is determined, the patient can then be switched to a long-acting preparation, supplemented with an as-needed short-acting drug for breakthrough pain

Question 79

adverse effects of opioids

Answer 79

constipation, falls and fractures, urinary retention (e.g., in the patient with prostatic enlargement) and delirium

Question 80

Buprenorphine has been shown to be both effective | and well-tolerated in patients with

Answer 80

cancer and nonmalignant | persistent pain such as neuropathic pain

Question 81

Fentanyl patches vs. transdermal buprenorphine

Answer 81

Fentanyl patches have been used increasingly to treat persistent pain in the older adult; while it appears that transdermal buprenorphine may have a better side effect profile, therapeutic index, and ease of titration, inadequate data exist to support recommending its use in older adults

Question 82

Contraindications of using | buprenorphine

Answer 82

Patients with opioid dependence, myasthenia gravis, respiratory depression, and delirium tremens

Question 83

methadone may be very useful

Answer 83

Given its low cost, long-acting properties, and efficacy when used in small doses in frail older adults

Question 84

Risk of metahdone

Answer 84

its very long and variable half-life. In addition to having all of the same potential adverse effects as the other opioids, patients on methadone may suffer from QTc prolongation. patients being started on methadone should receive an EKG at baseline, 30 days after initiating methadone, and then annually and sleep-disordered breathing.

Question 85

first-line treatment for Neuropathic Pain

Answer 85

antidepressants with both norepinephrine and serotonin reuptake inhibition properties (SNRIs), calcium channel a2-d ligands, and topical lidocaine

Question 86

second line treatment for Neuropathic Pain

Answer 86

opioids and tramadol

Question 87

Most commonly studied SNRI antidepressants for treating neuropathic pain

Answer 87

duloxetine and venlafaxine. Both have evidence of efficacy for painful diabetic neuropathy

Question 88

Venlafaxine

Answer 88

used in cases of painful polyneuropathies, although caution should be exercised in patients with cardiovascular disease

Question 89

Treatment of trigeminal neuralgia | is different from that of other neuropathic pain states

Answer 89

For this disorder, carbamazepine or oxcarbazepine are recommended as first line

Question 90

Treatment of postherpetic | neuralgia

Answer 90

gabapentin, pregabalin, and tricyclic antidepressants

Question 91

Tertiary amines should be avoided | in older adults because of

Answer 91

``` Tertiary amines (amitriptyline, imipramine, trimipramine, doxepin, clomipramine) should be avoided in older adults because of their anticholinergic side effects (sedation, delirium, urinary retention, constipation, glaucoma exacerbation, and dizziness). ```

Question 92

Secondary amines have been shown to have more tolerable side effect profiles

Answer 92

nortriptyline, desipramine, protriptyline, amoxapine

Question 93

a baseline EKG should be obtained prior to starting | a tricyclic antidepressant and monitored periodically with dose titration

Answer 93

Because of their potential for QT prolongation

Question 94

For Neuropathic pain opioids | have proved efficacious in patients with

Answer 94

postherpetic neuralgia | and painful peripheral neuropathy

Question 95

Tramadol

Answer 95

weak mu-opioid receptor agonist that also inhibits the reuptake of norepinephrine and serotonin, may fare better in older adults at reducing neuropathic pain.

Question 96

Benzodiazepines have been used to treat

Answer 96

Muscular spasms, neuropathic pain, and anxiety related to pain crises.

Question 97

Benzodiazepines should generally be avoided in older adults for the treatment of neuropathic pain because of

Answer 97

the risk of symptomatic rebound, dizziness, falls, and confusion

Question 98

Fibromyalgia

Answer 98

symptoms occurring for longer than 3 months varying | from morning stiffness, fatigue, and nonrestorative sleep to headaches, myofascial pain, and pelvic pain

Question 99

Treatments for fibromyalgia

Answer 99

low-dose tricyclic antidepressants, cyclobenzaprine, aerobic exercise, cognitive behavioral therapy, or a combination of these treatment methods

Question 100

Food and Drug Administration (FDA) approved for the treatments of fibromyalgia

Answer 100

Duloxetine, pregabalin, and | milnacipra

Question 101

Outcomes used to monitor treatment efficacy in patients with fibromyalgia include

Answer 101

pain intensity and physical and emotional functioning

Question 102

complementary and alternative medicine (CAM) approaches to persistent pain

Answer 102

Meditation, vitamin and mineral supplements, herbs, and chiropractic medicine are commonly used in older adults with back pain, arthritis, and mental illness.

Question 103

eight common behavioral modalities in treating | persistent pain in older adults

Answer 103

biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga. The benefits of complementary therapies such as these improve not only the self-reported pain but also pain related comorbidities such as depression, anxiety, and disability.

Question 104

In the practice of interdisciplinary pain medicine

Answer 104

it is important to consider geriatricians, geriatric psychiatrists, physiatrists, rheumatologists, neurologists, and endocrinologists as important potential collaborators in the care of frail older adults with complex conditions.

Question 105

Anticonvulsant | Carbamazepine (Tegretol)

Answer 105

100 mg daily SE: Monitor hepatic transaminases (aspartate transaminase, alanine transaminase), complete blood count, creatinine, blood urea nitrogen, electrolytes, serum carbamazepine levels. Multiple drug-drug interactions

Question 106

Anticonvulsant | Gabapentin (Neurontin)

Answer 106

100 mg at bedtime | Monitor sedation, ataxia, edema

Question 107

Anticonvulsant | Pregabalin (Lyrica)

Answer 107

50 mg at bedtime Monitor sedation, ataxia, edema

Question 108

Anticonvulsant | Lamotrigine (Lamictal)

Answer 108

25 mg at bedtime Monitor sedation, ataxia, cognition. | Associated with rare cases of Stevens-Johnson syndrome

Question 109

Antiarrhythmic | Mexiletine (Mexitil)

Answer 109

150 mg twice daily Monitor electrocardiogram at baseline and after dose stabilization. Avoid use in patients with conduction block, bradyarrhythmia

Question 110

Corticosteroids (prednisone, methylprednisolone, e.g., | Deltasone, Medrol dose pak Liquid Pred, Orasone)

Answer 110

5 mg prednisone daily and taper as soon as feasible. Use lowest possible dose to prevent steroid effects. Anticipate fluid retention and glycemic effects in short-term use and cardiovascular and bone demineralization with long-term use.

Question 111

Lidocaine (topical) | Lidoderm 5%

Answer 111

1–3 patches for 12 hr per day | Monitor for rash or skin irritation

Question 112

Muscle Relaxants | Baclofen (Lioresal)

Answer 112

5 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation. Avoid abrupt discontinuation because of central nervous system irritability. Older persons rarely tolerate doses greater than 30 to 40 mg per day

Question 113

Muscle Relaxants | Tizanidine (Zanafex)

Answer 113

2 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation, orthostasis. Potential for many drug–drug interactions.

Question 114

Muscle Relaxants | Clonazepam (Klonopin)

Answer 114

0.25–0.5 mg at bedtime Monitor sedation, memory, complete blood count

Question 115

Cannabinoid | Nabilone (Cesamet)

Answer 115

1 mg 1 or 2 times daily Monitor ataxia, cognitive effects, sedation. High incidence of dizziness or drowsiness. Cardiovascular effects with tetrahydrocannabinol or cannabidiol. Older persons may be prone to postural hypotension. Nabilone is approved for nausea and vomiting but may help with some pain syndromes.

Question 116

Cannabinoid | Dronabinol (Marinol)

Answer 116

2.5 mg 1 or 2 times daily Dizziness, somnolence, cognitive impairment, dysphoria

Question 117

Tramadol (Ultram/Ultram ER)

Answer 117

12.5–25 mg every 4–6 hr Mixed opioid and norepinephrine or serotonin reuptake inhibitor mechanisms of action. Monitor for opioid side effects, including drowsiness, constipation, and nausea. Risk of seizures if used in high doses or in predisposed patients. May precipitate serotonin syndrome if used with selective serotonin reuptake inhibitors.

Question 118

Tapentadol (Nucynta)

Answer 118

50 mg every 4–6 hr by mouth (equivalent to oxycodone 10 mg every 4–6 hr by mouth) Clinical trials of tapentadol suggest lower incidence of gastrointestinal adverse events than comparator opioids.

Question 119

Sustained release (Avinza, Kadian, MSContin, Oramorph SR)

Answer 119

15 mg every 8–24 hr Usually started after initial dose determined by effects of immediate-release opioid or as an alternative in a different long-acting opioid due to indications for opioid rotation. Toxic metabolites of morphine may limit usefulness in patients with renal insufficiency or when high-dose therapy is required. Continuous-release formulations may require more-frequent dosing if end-of-dose failure occurs regularly. Significant interactions with food and alcohol toxicity

Question 120

Hydromorphone (Dilaudid, Hydrostat) Methadone (Dolophine)

Answer 120

1–2 mg every 3–4 hr For breakthrough pain or for around-the-clock dosing. Highly variable half-life and nonlinear dose equivalencies when switching from other opioids. Not recommended as first-line agent.

Question 121

Tricyclic Antidepressant Desipramine (Norpramine), Nortryptyline (Aventyl, Pamelor), Amitriptyline (Elavil)

Answer 121

``` 10 mg at bedtime Significant risk of adverse effects in older patients. Anticholinergic effects (visual, urinary, gastrointestinal); cardiovascular effects (orthostasis, atrioventricular blockade). Older persons rarely tolerate doses greater than 75 to 100 mg per day. ```

Question 122

Duloxetine (Cymbalta

Answer 122

30 mg daily Monitor blood pressure, dizziness, cognitive effects, and memory. Has multiple drug-drug interactions.

Question 123

Venlafaxine (Effexor)

Answer 123

37.5 mg daily Venlafaxine associated with dose-related increases in blood pressure and heart rate.