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Pharmacotherapy > Chronic Pain > Flashcards

Chronic Pain Flashcards

1
Q

What is the common cause for chronic pain

A

Cause may not be identifiable

Or result from changes in nerve function and transmission

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2
Q

What are the two classification for chronic pain

A

Cancer pain and non-cancer pain

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3
Q

When using opioids for non-cancer pain what should you consider?

A

Risk of substance abuse/ Comorbid mental health issues

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4
Q

What are the symptoms of chronic pain

A

Occurs without relation to noxious stimuli and generally has no obvious signs

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5
Q

What is the goal for managing chronic pain

A

Improve functional status

Decrease pain perception

Reduce the use of medication

Improve overall quality of life

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6
Q

Why should comprehensive care be used during management of chronic pain

A

To address fear, anxiety, fatigue, depression etc should include emotional and mental support

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7
Q

Beside the Assessment tools studied in acute pain what are the other pneumonics for assessing chronic pain - OLDCARTS

A 
O - onset
L-location
D-Duration
C-characteristics
A- aggravating factors
R- relieving factors
T-Timing
S-severity
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8
Q

Beside the Assessment tools studied in acute pain what are the other pneumonics for assessing chronic pain - SOCRATES

A 
S-site
O-onset
C-characteristics
R-radiation
A- associated sx
T-Time
E- exacerbating factors
S-severity
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9
Q

Adjunctive agents to opioid therapy are administered as

A

Co-analgesics to address neuropathic pain

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10
Q

Which antidepressants are used as adjunctive

A

TCA: amitriptyline

SNRI: duloxetine, venlafaxine

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11
Q

Amitriptyline side effect

A

Sedation

Dry mouth

Constipation

Urinary retention

Cardiac events

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12
Q

Duloxetine or venlafaxine side effect.

A

Serotonin syndrome

Somnolence

Constipation

HTN

Yenlafaxine: QT prolongation

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13
Q

Anticonvulsants used as adjunctive agents

A

Gabapentin

Pregabalin

Carbamazepine

Oxcarbazepine

Lamotrigine

Topiramate

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14
Q

Gabapentin dose

A

100-300mg TID and titrate to max dose as patient can tolerate

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15
Q

Pregabaliclosen

A

150mg daily divided as TID or BID

Max: 300mg daily

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16
Q

Gabapentin / pregabalin side effect

A

Sedation/CNS

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17
Q

Carbamazepine side effect

A

CNS and GI

Steven Johnson syndrome (rare)

Cardiac

Hematologic rxn

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18
Q

Oxcarbazepine side effect

A

CNS and GI

Serious Dermatologic or Hematologic (rare)

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19
Q

Lamotrigine side effect

A

Steven Johnson Syndrome

Blood dyscrasias

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20
Q

Topiramate is mainly used for?

A

Prophyleris migraine

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21
Q

Antispacity skeletal muscle relaxant adjunctive agent

A

Baclofen

Dantrolene

Diazepam

Tizanidine

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22
Q

Antispasmodic adjunctive agents

A

Carisoprodal

Chlorzoxazone

Cyclobenzaprine

Orphenadrine

Tizanidine

Diazepam

Methocarbamol

Metaxalone

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23
Q

What are the side effects of antispasmodic and antispacity adjunctive agents

A

Sedation

With-drawl with abrupt discontinuation

Respiratory depression when administered with opioids

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24
Q

How are antispasity or antispasmodics dosed to reduce additive side effects

A

Short term use as needed

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25
Q

What other agents can be used adjunctive agents

A

Corticosteroids

Lidocaine or Topical capsaicin for local pain

Cannabidol

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26
Q

Why should we be cautious with using sleep- aids, anxiolytics or antispasmodic as adjunctive agents

A

Sedation

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27
Q

Non-pharmacologic intervention: Physical/occupational rehabilitation (PT/OT)

A

Ergonomic considerations

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28
Q

Non- Pharmacologic interventions: Complementary and alternative medicine

A

Chiropractic

acupuncture

hypnotherapy/mind-body therapy

massage

other holistic methods

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29
Q

Non-pharmacologic intervention: Interventional pain management techniques

A

Local corticosteroid injections

Nerve/spinal block via anesthesiology

Implanted intraspinal pump/catheter

Implanted nerve stimulators; Electroanalgesia (TENS/PENS)

Neuroablative procedures

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30
Q

Non-pharmacologic intervention: Surgical interventions

A

Kyphoplasty

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31
Q

What is the general opioids principles

A

Start at low doses and go slow

Consider previous opioid exposure and patient preference

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32
Q

Who might need immediate-release and short acting opioid

A

Opioid naive

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33
Q

Pho might need higher dose

A

Non-opioid naive

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34
Q

Which opioids are good for renal failure patient

A

Oxycodone

Fentanyl

Methadone

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35
Q

Which is not safe for use in renal failure

A

Morphine

Hydromorphone

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36
Q

Which is not safe for hepatic failure

A

Oxycodone

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37
Q

Which cytochrome converts codeine, hydroco done and tramadol to active form

A

CYP2D6

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38
Q

CYP2D6 inhibitors

A

Fluoxetine

Paroxetine

Haloperidol

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39
Q

Which medication is a central acting analgesic with low affinity for the mu receptor

A

Tramadol

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40
Q

Which medication inhibits reuptake of norepinephrine and serotonin

A

Tramadol

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41
Q

Tramadol has less of these side effects compared to opioids

A

Nausea

Constipation

Drowsiness/Dizziness

Headache

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42
Q

How is immediate release tramadol dosed

A

25-100mg every 4-6 hours

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43
Q

Max dose of immediate release tramadol

A

400mg daily

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44
Q

What is the extended release dose of tramadol

A

100 mg daily

45
Q

What is the max dose of extended release tramadol

A

300 mg daily

46
Q

What are the long acting opioids for chronic pain

A

Morphine

Oxycontin (oxycodone)

47
Q

What is the frequency of dosing for long acting oxycontin and morphine

A

Every 12 hours

But morphine can be giving at every 8 hours if needed

48
Q

How is long acting oral opioid morphine and oxycontin administered

A

Swallow whole. Do not crush, chew or open

49
Q

Which opioid is active at the mu receptors and NMDA receptors

A

Methadone

50
Q

How is methadone better than other opioids

A

Reduced tolerance and improved responsiveness to pain

51
Q

Why is methadone a long acting medication

A

Half life: 128hours and very lipophilic

Titrate slowly

52
Q

True/ false: methadone is available as a tablet which can be chewed or crushed and as an oral solution

A

True

53
Q

Is renal adjustment needed for methadone

A

No

54
Q

What should be monitored in patients taking methadone

A

EKG: check QT baseline on day 30 followed by an annual check up due to arrhythmia risk

Drug interaction

55
Q

What are the strength of fentanyl transdermal patches

A

12.5,25,50,75,100 mg

56
Q

How often can transdermal fentanyl patch be replaced

A

Every 72 hours or 3 days

57
Q

When can fentanyl transdermal patch be changed every 48 hours

A

If patient is tolerating every 72 hours but pain returns at the end of 72 hours

58
Q

How often should fentanyl transdermal patch be titrated

A

No faster than 3-6 days

59
Q

What are the important counseling point when initiating fentanyl transdermal patch

A

Take last oral long acting dose when placing first patch

When taking off patch give half of longacting oral dose at every 12-18 hours

Do not ever cut patch

Always dispose properly

60
Q

How is fatalities from dose overestimation of fentanyl transdermal patches avoided

A

Double check conversions

Never round up and always provide breakthrough medication

Titrate patch size if needed

61
Q

What is a Patient controlled analgesia (PCA)

A

It is a process that uses an individualized computerized system program to administer analgesics for institutionalized patients needing IV therapy

62
Q

What and who is involved in pla therapy

A

Requires regular monitoring and dosage adjustment

Nurse, patient, pharmacist and prescriber

63
Q

What are the components of a PCA order

A

Drug chosen

Basal rate

Bolus dose and dose interval

Lockouts

Prn orders for side effect

Naloxone prn order

Nursing assessment

64
Q

What should a nurse assess when using PCA

A

RR

O2

Pain score

65
Q

How is the opioid side effect of constipation managed

A

Bowel regimen: Stool Softener +/- Stimulant

Docusate 1-4 caps/day +/- senna 2 tabs/day to start

66
Q

The/False: patient develop tolerance to constipation side effect

A

False

May need to add more laxatives (miralax, milk of mag, lactulose)

67
Q

Other constipation relievers

A

Methylnaltrexone

Lubiprostone

Movantik (naloxegel)

68
Q

Reverses GI mu receptor to help with constipation

A

Methylnaltrexone

69
Q

Should laxative be used with methylnaltrexone

A

No. D/C all laxative upon initiation

70
Q

How are non-cancer patient dosed with methylnaltrexone

A

450mg by mouth daily

Or

12 mg SubQ daily

71
Q

How are advanced ill patient dosed with methylnaltrexone

A

Weight based

72
Q

Methylnaltrexone dose for patient weighing < 38kg

A

0.15 mg/kg

73
Q

Methylnaltrexone dose for patient weighing 38 to <62 kg

A

8 mg

74
Q

Methylnaltrexone dose for patient weighing 62 to 114 kg

A

12 mg

75
Q

Methylnaltrexone dose for patient weighing > 114kg

A

0.15 mg/kg

76
Q

What is the mechanism of action for the constipation relieving agent lubiprostone

A

Calcium channel activator

77
Q

How is lubiprostone dosed

A

24 mcg twice daily by mouth

78
Q

What are side effects associated with lubiprostone

A

GI

Hypotension/syncope

Dyspnea

79
Q

What is the mechanism of action for the constipation relieving agent movantik

A

Mu opioid receptor antagonist

80
Q

Should laxative be D/C/ when starting movantik

A

Yes. But can restart if needed

81
Q

How is movantik dosed and administered

A

25 mg daily by mouth on empty stomach

82
Q

Should movantik be really adjusted

A

Yes.

83
Q

What are the side effects of movantik

A

GI

Risk of perforation or withdraw

84
Q

How do opioids induce nausea and vomiting

A

Stimulates chemoreceptor trigger zone, decreases GI motility

85
Q

How is nausea and vomiting managed and what are therapeutic side effects

A

Antiemetics:

Prochlorperazine/promethazine
– Side effect: EPS, dizziness/drowsiness

• Ondansetron
– Side effect: constipation, headache

• Dronabinol
– Side effect: increased appetite, CNS disturbances (particularly in elderly)

86
Q

How is nausea inducing early satiety managed

A

Metoclopramide

Side effect: Diarrhea

87
Q

How is nausea inducing vertigo managed

A

Scopolamine, meclizine

Side effect: impaired eye accommodation, anticholinergic

88
Q

How is sedation side effect managed

A

Dose-related, consider hepatic/renal function

Change to alternative opioid; tolerance

89
Q

How does opioid induce puritus

A

Central action versus histamine release

90
Q

Why is antihistamine such as diphenhydramine or hydroxyzine not always effective against opioid induced puritus

A

Can be sedating

Consider alternative opioid

91
Q

How is unsay retention side effect managed

A

Change to alternative opioid because tolerance does not develop

92
Q

True/False: opioids can cause respiratory depression

A

True

93
Q

What is risk mitigating strategies

A

Check board to lower risk of inducing respiratory depression or over dose

94
Q

What are the risk mitigating strategies

A

1) establish realistic goals
2) identify risk prior to initiating opioids

       history of substance abuse /comorbidities/ mental health disorders

       close monitoring, including random regular urine drug screen

       contracts: pill count or prescription monitoring program
95
Q

What medication is used incase of opioid overdose

A

Naloxone

96
Q

How is naloxone available

A

IM, IV, nasal spray

97
Q

When should naloxone be used according to CDC guidelines

A

If ≥ 50mg morphine equivalent per day or if concurrent benzodiazepine

98
Q

What is the counsel point for naloxone use

A

. Signs/symptoms of overdose

  • Importance of seeking medical care (call 911)
  • How to use device

• Availability of drug treatment
programs

99
Q

What is one general opioid counseling point you would forget

A

Do not restart opioid at same dose if there is a period
of abstinence as overdose is possible due to lowered
tolerance

100
Q

What is step 1 of the five step approach to opioid conversion

A

Assess of uncontrolled is worsening or development of new type of pain.

use assessment tools

101
Q

What is step 2 of the five step approach to opioid conversion

A

Determine total daily usage of current opioid

102
Q

What is step 3 of the five step approach to opioid conversion

A

Decide which opioid analgesic would be used for the new agent and use conversion table for proper dosage

103
Q

What is step 4 of the five step approach to opioid conversion

A

Individualize dosage base on assessment from step 1 and ensure adequate access to breakthrough medication (short acting opioids usually 5-20% of dose for chronic pain )

104
Q

In step 4: when is 25-50% dose reduction considered

A

For cross tolerance in controlled patient

At risk of respiratory depression or sedation

If no side effect and pain is adequately controlled

105
Q

In steps: when is dose increase considered

A

If patient is tolerating but ineffective baseline analgesia

If in severe pain

Closely monitor

106
Q

What is step 5 of the five step approach to opioid conversion

A

Patient follow up and continual reassessment during the first 7-14 days

107
Q

What is special about methadone conversion

A

ALWAYS triple check the math with peer evaluation

  • Always reduce calculated dose (up to 90%) to avoid overdose
  • Divide dose into q8h

• Monitor closely, titrate slowly
– Do NOT titrate any faster than every 3-5 days (may need to only
titrate every 1-2 weeks)

– Delayed effect: steady state after 3-5 days

– Duration analgesia shorter than half-life

• In general, max starting dose is 40mg/day

108
Q

Read slide about palliative care

A

Onto it

Pharmacotherapy (12 decks)

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