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PT2 Pain 5-10 > chronic pain therapeutics and toxicity > Flashcards

chronic pain therapeutics and toxicity Flashcards

1
Q

treatments for breakthrough pain

A
  1. IR opioids
  2. morphine sulfate IR
  3. any shorter onset opioid
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2
Q

opioids analgesic ceiling

A

opioids have no ceiling, can always give more of have increased effect

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3
Q

what to prescribe with opioids

A

laxatives and metoclopramide

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4
Q

potential additional agents for opioid induced constipation

A
  • magnesium hydroxide
  • lactulose
  • sorbitol
  • magnesium citrate
  • PEG
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5
Q

metoclopramide use

A

-use for a max of 3 months due to neurologic complications (psychosis)

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6
Q

peripheral antagonists for opioid constipation

A
  • use if laxatives are not sufficicent
  • methylnaltrexone
  • naloxegol
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7
Q

opioid induced nausea

A
  • usually occurs with initiation and resolves soon

- gives antiemetic before opioid to prevent

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8
Q

emetics to use

A

prochlorperazine

metoclopramide

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9
Q

opioid induced sedation

A
  • occurs with initiation
  • prevent by starting with lower doses
  • minimize other sedating drugs
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10
Q

dosage form that has a higher rate of histamine reaction

A

IV

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11
Q

signs of histamine reaction

A
  • local wheal
  • burning
  • itching
  • erythema
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12
Q

adjuvant analgesics

A
  • antidepressants

- anticonvulsants

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13
Q

non-opioid for chronic low back pain

A

APAP

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14
Q

opioid use in chronic low back pain

A

short term use for mild-moderate flare-ups

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15
Q

other medications for chronic low back pain

A

tramadol
TCAs
AEDs

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16
Q

strategy for chronic low back pain

A
  • APAP first
  • tramadol or opioid
  • AED/TCA if neuropathic in origin
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17
Q

non-opioid for neuropathic pain

A

APAP or NSAIDs

not really effective

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18
Q

opioids for neuropathic pain

A

considered second line

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19
Q

other medications for neuropathic pain

A

TCAs
AEDs
SNRIs
tramadol

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20
Q

strategy for neuropathic pain

A
  • first line TCAs, SNRIs, AEDs, gabapentin, pregabalin, lidocain patch
  • 2nd tramadol, opioids
  • 3rd capsaicin
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21
Q

treatment for mild pain

A
  1. APAP and/or NSAID
  2. if not controlled consider adding opioid or non-opioid analgesic
  3. consider titrating opioid with bowel regimen
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22
Q

treatment of moderate pain

A
  1. weak opioids +/- NSAIDs or APAP

2. titrate short acting opioid w/ bowel regimen

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23
Q

treatment of severe pain

A
  1. first choice is oral morphine
  2. if renal impairment fentanyl and buprenorphine
  3. rapidly titrate short acting opioid w/ bowel regimen
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24
Q

safest options for renal impairment

A

fentanyl
buprenorphine
both either TD or IV

25
Q

opioids with highest amount of histamine reaction

A

morphine
codeine
meperidine

26
Q

buprenorphine, fentanyl, methadone, oxycodone DDI that increase plasma levels of opioids

A

CYP 3A4
antibiotics
antifungals

27
Q

methadone and buprenorphine DDI that cause QtC proglation

A

metoclopramide
ondansetron
citalopram

28
Q

dexamethasone DDI that decrease plasma levels of what

A

buprenorphine
methadone
fentanyl
oxycodone

29
Q

Drugs that are metabolized CYP 2D6 potently

A

fluoxetine

paroxetine

30
Q

drugs that metabolized CYP 2D6 moderately

A

bupropion
duloxetine
sertraline

31
Q

TCAs

A

amitriptyline

nortriptyline

32
Q

when to use SSRIs for neuropathic pain

A

if they also have major depressive disorder

33
Q

SSRIs

A

fluoxetine
paroxetine
citalopram

34
Q

gabapentin may cause

A

weight gain

35
Q

tramadol and SSRIs

A

possible serotonin syndrome

36
Q

possible advantage of tapentadol over other opioids

A

less GI ADRs

37
Q

methadone duration

A

5-130 hours

takes several days to get to steady state

38
Q

methadone CI

A

QT interval >500 m/s

39
Q

methadone DDI

A 
antiarrhythmics
antipsychotic
antibiotics
antidepressants
anticonvulsants
40
Q

methadone metabolized by

A

3A4 mostly

2D6

41
Q

monitoring for methadone

A

obtain ECG for all patients

42
Q

lidocaine application

A
  • 12 hours on 12 hours off
  • can have up to 3 at a time
  • can cut
  • must be applied in medical office
43
Q

capsaicin application

A
  • use gloves

- most benefit after 4-6 weeks

44
Q

capsaicin patch

A
  • on for 60 minutes every 3 months

- only physicians and health care professionals can apply qutenza patch

45
Q

signs of opioid induced respiratory depression

A
  • slow breathing
  • pinpoint pupils
  • unusual sleepiness
  • mental confusion
  • fingernails turn blue
46
Q

treatment steps of an opioid overdose

A
  1. if unresponsive give naloxone
  2. call 911
  3. assess airway (rescue breathing if witnessed, chest compressions if not witnessed)
  4. consider 2nd dose of naloxone if not response after 2-3 minutes
  5. put patients on their side until EMS arrives
47
Q

physical dependence

A

state of adaptation manifested by withdrawal symptoms

48
Q

addiction

A

primary, chronic, neurobiological disease that is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and cravings

49
Q

pseudoaddiction

A

condition that outwardly mimics addiction but is driven by a desire for pain relief

50
Q

tolerance

A

state of adaptation that results in the diminution of opioid effects over time

51
Q

risk factors for opioid misues/abuse

A
  • history of any substance abuse
  • history if binge drinking
  • family history of substance abuse
  • anxiety, depression, ADHD
  • history of secual abuse victimization
52
Q

opioid withdrawal symptoms

A
  • N/V/D
  • hyperactivity, restlessness
  • severe back pain
  • rhinorrhea, lacrimation
53
Q

opioid withdrawal symptoms duration

A

7-14 days

54
Q

opioid withdrawal treatments

A
  1. opioid substitution (methadone, buprenorphine)
  2. symptom treatment (clonidine, prochlorperazine, loperamide)
  3. rapid detox (opioid antagonist under anesthesia)
  4. NSAID for pain
55
Q

methadone substitution therapy treatment steps

A
  1. start 20-30 mg
  2. uptitrate by 5mg every 3 days until stable
  3. slowly start down taper
56
Q

buprenorphine substitution therapy steps

A
  1. DAY 1: 2-4 mg q2-4h until withdrawal symptoms do not appear, max 8 mg
  2. DAY 2: increase titration in 2-4mg increments
  3. outpatient: continue up titrate until stable on daily dose
  4. down-titrate over 10-14 days
57
Q

benefits of buprenorphine substitution over methadone

A
  • similar effectiveness

- symptoms resolve more quickly

58
Q

who is naltrexone best for

A

motivated patients who desire total abstinence and are currently opioid free

PT2 Pain 5-10 (6 decks)

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