Chapter 58: Pain Flashcards
____ pain occurs when sensory nerves identify tissue namage
Nociceptive
Which drug classes can be given for mild pain (score 1-3)
Non-opioid +/- adjuvant
Which drug classes can be given for moderate pain (score 4-6)
Opioid for mild-moderate pain
+/- non-opioid
+/- adjuvant
Which drug classes can be given for severe pain (score 7-10)
Opioid for moderate-severe pain
+/- non-opioid
+/- adjuvant
Acetaminophen does not provide ____ effect
anti-inflammatory
Mechanism of APAP
inhibits PG synthesis in the CNS
APAP brand names
Tylenol, FeverAll, Ofirmev
FeverAll drug formulation
rectal suppository
APAP
Ofirmev drug formulation
Injection
APAP
APAP + hydrocodone brand names
Lorcet, Lortab, Norco, Vicodin
APAP + oxycodone brand names
Endocet, Percocet
APAP + codeine brand names
Tylenol #2, #3, #4
APAP + caffeine brand name
Excedrin Tension Headache
APAP + ASA + Caffeine brand names
Excedrin Extra Strength, Excedrin Migraine
APAP + caffeine + pyrilamine brand name
Midol Complete
Max APAP per day for adults
< 4000 mg/day
APAP dosing for children < 12 yrs
10-15 mg/kg Q4-6H
APAP infants and childrens suspension concentration
160 mg/5 ml
APAP BW
Severe hepatotoxicity with doses > 4 g/day or use of multiple APAP-containing products
Antidote for APAP overdose
NAC, Acetadote
How is NAC administered for APAP overdose
IV or PO (using the solution for inhalation or injectable formulation)
How does NAC help with APAP overdose
restores hepatic glutathione
Non-selective NSAIDs block the synthesis of
both COX enzymes
COX-2 selective NSAIDs block the synthesis of
COX-2 only, which decreases GI risk (b/c COX-1 protects the gastric mucosa)
Aspirin MOA
irreversible COX-1 & 2 inhibitor
makes it an effective antiplatelet
All Rx, non-aspirin NSAIDs require a MedGuide with the following info
- GI risk including bleeding and ulceration
- CV risk (MI and stroke)
- CABG surgery: NSAID use is CI after surgery. Antiplatelet therapy is recommended (commonly ASA)
NSAID side effects
- Caution in renal failure
- Can increase BP
- Can cause premature closure of the ductus arteriosus (do not use in 3rd trimester)
- Nausea (take with food)
- Photosensitivity
If the ductus arteriosus does not close after birth, which NSAIDs can be used
IV NSAIDs (indomethacin, ibuprofen) can be used within 14 days of birth
to close a patent ductus arteriosus
Ibuprofen brand name
Advil, Caldolor, Motrin
Which NSAIDs are COX-1 & COX-2 non-selective
Ibuprofen, indomethacin, Naproxen, Ketorolac
(NIKI)
Adult OTC dosing for Ibuprofen
200-400 mg Q4-6H
Max Rx dose of ibuprofen
3.2 g/day
OTC: 1.2 g/day
Pediatric dosing for Ibuprofen
5-10 mg/kg/dose Q6-8H
OTC self-treatment with ibuprofen should be limited to
< 10 days
Indomethacin brand name
Indocin
Indomethacin has a high risk for which side effects
CNS (avoid in psych conditions)
Naproxen brand name
Aleve
Naproxen + esomeprazole brand name
Vimovo
Ketorolac brand name
Toradol
How often is naproxen dosed
BID
How is Ketorolac nasal spray administered in patients < 65 years
1 spray in each nostril
How is Ketorolac nasal spray administered in patients 65+ years
1 spray in one nostril
Max combined duration IV/IM and PO/nasal for ketorolac is __ days in adults
5
Ketorolac warnings
acute renal failure, liver failure
How should ketorolac nasal spray be used
Prime 5x before use
Which NSAIDs have increased COX-2 selectivity
Celecoxib, diclofenac, meloxicam, nabumetone, etodolac
(C, D, E….M, N)
Benefit of COX-2 selective NSAIDs
lower risk for GI complications (but increased risk of MI/stroke), same renal risk
Diclofenac brand name
Voltaren
Voltaren gel total body max dose
32 g/day
Celecoxib CI
sulfonamide allergy
Which COX-2 selective NSAID has the most COX-2 selectivity
celecoxib
Diclofenac + misoprostol (Arthrotec) boxed warning
Avoid in women of childbearing potential
Why is misoprostol used with diclofenac
Used to replace the gut-protective PG to decrease GI risk
Meloxicam brand name
Mobic
ASA + omeprazole brand name
Yosprala
ASA dose for cardioprotection
81-162 mg once daily
ASA side effects
Dyspepsia, heartburn, bleeding
What may be used to protect the gut with chronic NSAID use
PPIs
Salicylate overdose can cause
tinnitus
What ingredient is found in Bengay, Icy Hot and Salonpas
Methyl salicylate
How should ASA and ibuprofen be used if taken together
Take ASA one hour before or 8 hours after ibuprofen
NSAIDs can increase the levels of which drug
Lithium
and methotrexate
Aspirin/acetylsalicylic acid brand names
Ascriptin, Bufferin, Ecotrin
all EC/buffered
Opioid MOA
Mu receptor agonists
What components of REMS do opioids have?
prescriber education and counseling requirements
Which opioids cannot be taken with alcohol
Kadian, Nucynta ER, Oxymorphone ER & Zohydro
can increase plasma levels and cause fatal overdose
What drug class (DEA) is codeine solution combination products (e.g, cough syrups)
C-V
Respiratory depression and death have occurred in children following tonsillectomy and/or adeoidectomy found to have evidence of being ultra-rapid metabolizers of codeine due to what polymorphism
2D6
Codeine should be avoided in children < __ years for any indication & < __ years following tonsillectomy/adenoidectomy surgery
12
18
Brand name of fentanyl oral transmucosal lozenge (“lollipop on a stick”)
Actiq
How often is fentanyl patch applied
Q72H
Fentanyl should be avoided with CYP450 ____
3A4 inhibitors
A patient who has been using morphine ___ mg/day or equivalent for at least ___ days can be converted to fentanyl patch
60
7
Similar drug (IV) to fentanyl
remifentanil
Fentanyl patch can be covered with
Only the permitted adhesive film dressings: Bioclusive or Tegaderm
How should fentanyl patch be disposed
In toilet
Hydrocodone should be avoided with CYP450 ____
3A4 inhibitors
Hydromorphone oral dose
2-4 mg Q4-6H PRN
Hydromorphone IV dose
0.2-1 mg Q2-3H PRN
Hydromorphone should only be used in:
Opioid-tolerant patients only
high potency
Hydromorphone has a high risk for
overdose
very potent
Methadone brand name
Dolophine
Methadone BW
QT prolongation (life-threatening)
Which C2 opioid has a variable half-life and is hard to dose safely
Methadone
Which C2 opioid can decrease testosterone levels and lead to sexual dysfunction
Methadone
Methadone is a major ____ substrate
3A4
Meperidine brand name
Demerol
Meperidine warning
Renal impairment/elderly at risk for CNS toxicity
Which C2 opioid is no longer recommended as an analgesic
Meperidine
Which C2 opioid has a short duration of action
Meperidine
controls pain for max 3 hours
What is the metabolite of Meperidine and how is it cleared
Normeperidine
Renally (can accumulate and cause seizures)
Whch opioid, when combined with other drugs, can be serotonergic
Meperidine
Morphine ER brand name
MS Contin, Kadian
Morphine injection brand name
Duramorph, Infumorph
Morphine SE
pruritis
What can be given to block histamine-induced pruritis with morphine
Diphenhydramine
Oxycodone IR brand name
Roxicodone
Oxycodone CR brand name
OxyContin
Oxycodone initiation with CYP450 ____ can cause fatal overdose
(Boxed warning)
3A4
Oxycodone side effect
Pruritis
How should oxymorphone be taken
On empty stomach
Which opioids are 3A4 substrates
Hydrocodone, fentanyl, methadone, and oxycodone
How should opioid conversions be rounded
Round down to reduce risk of OD
opioid conversions
(morphine, hydromorphone, oxycodone)
Morphine: 10 mg (IV); 30 mg (PO)
Hydromorphone: 1.5 mg (IV); 7.5 mg (PO)
Oxycodone: 20 mg (PO)
If an exam question says to reduce the dose of an equivalent opioid, how much do you reduce it by
25%
don’t.do this if question does not say to reduce dose
If using opioids, which formulation should be started first
IR
What should be done in a true opioid allergy
Use an agent in a different chemical class
Conversions to and from fentanyl and methadone
fentanyl: dosing table in PI
methadone: highly variable due to patient tolerance
methadone t1/2 varies
The common drugs in the same chemical class that cross-react with each other have which words in their names
cod or morph (or norph)
T/F: Opioids are first line for chronic pain
False
goal might be low pain rather than no pain
What is the first line laxative for OIC
Stimulant laxatives (like Senna)
All opioids should be taken (with or without) food except ____
with (to lessen nausea)
oxymorphone
If laxatives are not sufficient for OIC, what can be used
PAMORAs
If PAMORAs are not effective for OIC, what can be used
Lubiprostone
PAMORA MOA
block opioid receptors in the gut to reduce constipation without affecting analgesia
Which meds are PAMORAs
Methylnaltrexone, Naloxegol
Methylnaltrexone brand name
Relistor
Naloxegol brand name
Movantik
Methylnaltrexone & Naloxegol warning
Risk of GI perforation
Methylnaltrexone & Naloxegol SE
Abdominal pain, flatulence
Lubiprostone brand name
Amitiza
Tramadol and tapentadol MOA
mu-opioid receptor agonists - inhibit NE reuptake (tramadol also inhibits reuptake of serotonin)
Tapentadol DEA drug class
C2
Tramadol DEA drug class
C-IV
Tramadol warnings
Seizure risk, risk of serotonin syndrome when used alone or with other serotonergic drugs or inhibitors of 2D6 or 3A4
Tramadol CI
Do not use in children < 12 years of age or in children < 18 years of age following tonsillectomy or adenoidectomy surgery
Do not use with MAOi or within 14 days
Tramadol & Tapentadol side effects
dizziness, constipation, nausea, somnolence
Tramadol requires conversion to active metabolite by which CYP enzyme
2D6
Tapentadol warnings
Can increase seizure risk
Risk of serotonin syndrome
Suboxone is formulated with which abuse deterrent medication
Naloxone
Which two opioids are manufactured using specific technology designed to deter crushing, dissolving or other modifications
OxyContin & Hysingla ER (hydrocodone)
Buprenorphine MOA
partial mu-opioid agonist (agonist at low doses and antagonist at high doses)
Given by itself, naloxone is used for
opioid overdose
Buprenorphine/naloxone combination products are used as alternatives to
methadone (buprenorphine suppresses withdrawal symptoms and naloxone helps prevent misuse)
Which 3 formulations does naloxone come in
IM/IV/SC
Narcan (nasal spray)
Naloxone (injection)
Naloxone SE
acute withdrawal symptoms (pain)
Buprenorphine drug schedule
C3
buprenorphine buccal brand name
Belbuca
buprenorphine patch brand name
Butrans
Buprenorphine + naloxone brand names
sublingual film: Suboxone
sublingual tabs: Zubsolv
Buprenorphine patch (Butrans) should be changed how often
weekly
How should Buprenorphine patch be disposed
fold sticky sides together and flush
side effects from Buprenorphine patch
dizziness, HA, application site reactions, nausea
To prescribe for opioid dependence, prescribers need a ____ waiver
Drug Addiction Treatment Act (DATA 2000)
If a prescriber has authorization from the DEA to prescribe for opioid dependence, what will the DEA number start with
X
Butrans patch can be covered with:
permitted adhesive film dressings: Bioclusive or Tegaderm
Gabapentin ER brand name for post herpetic neuralgia and RLS
Horizant
Gabapentin SE
Dizziness, somnolence, peripheral edema/weight gain
Pregabalin DEA drug class
C-V
Pregabalin SE
Dizziness, somnolence, peripheral edema, weight gain, mild anxiolytic
Pregabalin is approved for which conditions
fibromyalgia, post herpatic neuralgia, and neuropathic pain
What is the only FDA-approved medication for trigeminal neuralgia
Carbamazepine (tegretol)
Baclofen brand name
Lioresal
common adjuvants for pain management
gabapentin, pregabalin, carbamazepine, amitriptyline, duloxetine
milnacipran, desipramine
SE for all muscle relaxants
excessive sedation, dizziness, confusion, asthenia (muscle weakness)
Cyclobenzaprine brand names
Amrix, Fexmid, Flexeril
which muscle relaxant has serotonergic properties
cyclobenzaprine
Cyclobenzaprine side effect
dry mouth
Serotonergic
Tizanidine SE
Hypotension, dry mouth
tizanadine brand name
Zanaflex
Carisoprodol brand name
Soma
Carisoprodol DEA class
C-IV
Poor ____ metabilizers will have increased Carisoprodol concentrations
2C19
methocarbamol brand name
Robaxin
Which muscle relaxant is used for malignant hyperthermia
Dantrolene (Dantrium)
How long can lidoderm patches be used per day
12 hours/day
Which topical patch is approved for PHN (shingles) pain
Lidoderm
Which topical patch can be cut into smaller pieces
Lidoderm
Do not apply more than __ patches of Lidoderm at a time
3
How often can Capsaicin be used
TID-QID
Capsaicin brand names
Zotrix, Zostrix HP
Capsaicin counseling
Do not touch genitals, nasal area, mouth or eyes after application & wash hands after applying
how does capsaicin cream work?
decreasing substance P
Trolamine brand name
Aspercreme
