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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
opioids with highest amount of histamine reaction
morphine codeine meperidine
26
buprenorphine, fentanyl, methadone, oxycodone DDI that increase plasma levels of opioids
CYP 3A4 antibiotics antifungals
27
methadone and buprenorphine DDI that cause QtC proglation
metoclopramide ondansetron citalopram
28
dexamethasone DDI that decrease plasma levels of what
buprenorphine methadone fentanyl oxycodone
29
Drugs that are metabolized CYP 2D6 potently
fluoxetine | paroxetine
30
drugs that metabolized CYP 2D6 moderately
bupropion duloxetine sertraline
31
TCAs
amitriptyline | nortriptyline
32
when to use SSRIs for neuropathic pain
if they also have major depressive disorder
33
SSRIs
fluoxetine paroxetine citalopram
34
gabapentin may cause
weight gain
35
tramadol and SSRIs
possible serotonin syndrome
36
possible advantage of tapentadol over other opioids
less GI ADRs
37
methadone duration
5-130 hours | takes several days to get to steady state
38
methadone CI
QT interval >500 m/s
39
methadone DDI
``` antiarrhythmics antipsychotic antibiotics antidepressants anticonvulsants ```
40
methadone metabolized by
3A4 mostly | 2D6
41
monitoring for methadone
obtain ECG for all patients
42
lidocaine application
- 12 hours on 12 hours off - can have up to 3 at a time - can cut - *must be applied in medical office*
43
capsaicin application
- use gloves | - most benefit after 4-6 weeks
44
capsaicin patch
- on for 60 minutes every 3 months | - only physicians and health care professionals can apply qutenza patch
45
signs of opioid induced respiratory depression
- slow breathing - pinpoint pupils - unusual sleepiness - mental confusion - fingernails turn blue
46
treatment steps of an opioid overdose
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
physical dependence
state of adaptation manifested by withdrawal symptoms
48
addiction
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
pseudoaddiction
condition that outwardly mimics addiction but is driven by a desire for pain relief
50
tolerance
state of adaptation that results in the diminution of opioid effects over time
51
risk factors for opioid misues/abuse
- history of any substance abuse - history if binge drinking - family history of substance abuse - anxiety, depression, ADHD - history of secual abuse victimization
52
opioid withdrawal symptoms
- N/V/D - hyperactivity, restlessness - severe back pain - rhinorrhea, lacrimation
53
opioid withdrawal symptoms duration
7-14 days
54
opioid withdrawal treatments
1. opioid substitution (methadone, buprenorphine) 2. symptom treatment (clonidine, prochlorperazine, loperamide) 3. rapid detox (opioid antagonist under anesthesia) 4. NSAID for pain
55
methadone substitution therapy treatment steps
1. start 20-30 mg 2. uptitrate by 5mg every 3 days until stable 3. slowly start down taper
56
buprenorphine substitution therapy steps
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
benefits of buprenorphine substitution over methadone
- similar effectiveness | - symptoms resolve more quickly
58
who is naltrexone best for
motivated patients who desire total abstinence and are currently opioid free

PT2 Pain 5-10 (6 decks)

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