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Therapeutics > exam 5 lecture 6 > Flashcards

exam 5 lecture 6 Flashcards

1
Q

clinical pearls for opioids

A

Consider starting stool softener or laxative
Potential for tolerance, dependence, addiction
Schedule II

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2
Q

Side effects of opioids

A

Respiratory depression
Orthostatic Hypotension
Antitussive
constipation
N/V
Itching

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3
Q

Codein brand name

A

Tylenol #3

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4
Q

Codeine available formulations

A

Tabs and cough syrup

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5
Q

What is codeine metabolized into? What enzyme does that?

A

Codeine is turned into morpheine by 2D6

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6
Q

What can poor metabolizers expect from codeine? What can ultra rapid metabolizers expect from codeine

A

Poor- get no effect from codeine
Ultra rapid- Experience OD, resulting in death (especially children)

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7
Q

Tramadol brand name

A

ultram, Qdolo

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8
Q

Tramadol available formulations

A

Capsule
oral
solution
combo products

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9
Q

what warnings does tramadol have? Boxed warning?

A

warning- risk of serotonin syndrome when used with other substances

black box warning- Use of CYP 450 3A4 inducers, 3A4 inhibitors, and 2D6 inhibitors with tramadol requires careful consideration of the effects on the parent drug and metabolite

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10
Q

morphine available formulations

A

IV
long acting
suppository
inj
tab
capsule

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11
Q

What side effect is more prominent in morphine than other opioids

A

Itching

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12
Q

How is morphine eliminated

A

Renally excreted

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13
Q

When to avoid use of morhine

A

AKI or ESRD

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14
Q

boxed warning for morphine

A

avoid aclcohol use while taking ER capsules

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15
Q

Hydromorphone generic name

A

dilaudid

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16
Q

Hydromorphone available formulations

A

IR/ER
oral solution
injection
suppository

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17
Q

boxed warning for hydromorphone

A

dosing errors common in prescribing and dispensing. DO not confuse with high potency solution.

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18
Q

hydrocodone+acetaminophen drug naes

A

Norco
lortab
vicodin

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19
Q

Norco boxed warning

A

3A4 inhibitors may increase blood plasma levels of hydrocodone

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20
Q

Oxycodone available formulations

A

tabs
capsules
oral solutions

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21
Q

boxed warning for oxycodone

A

Use with CYP 3A4 inhibitors may
increase oxycodone plasma concentrations

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22
Q

fentanyl available formulations

A

Buccal tablet
sublingual liquid
lozenge’solution
patch

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23
Q

boxed warning for fentanyl

A

Monitor patients receiving CYP 3A4 inhibitors or inducers

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24
Q

can we use fentanyl in renal impairement

A

Monitor patients receiving CYP
3A4 inhibitors or inducers

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25
Q

When can we use non injectable forms of fentanyl

A

When the patient are opioid tolerant

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26
Q

opioid tolerant is defined as

A

taking morphine 60mg per day (or equivalent) for at least 1 week

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27
Q

Can we convert from fentanyl to another product? Can we coonvert from another product to fentanyl?

A

We can only covert other products to fentanyl.

Never fent to other products

28
Q

Why do we never switch from transdermal fent to oral morphine

A

will cause OD

29
Q

fentanyl patch counseling

A

1 patch x 3 days
do not cut
avoid hot things (sauna, hottub)
not on broken skin
showers ok

30
Q

What is the use of methadone

A

last line for chronic pain
opioid detox

31
Q

boxed warning for methadone

A

US Boxed Warning:

1.Monitor patients receiving CYP
3A4 inhibitors or inducers

2.QTc prolongation
check baseline ECG before tx

32
Q

What are potential adverse effects of taking opioids

A

Serotonin activity could cause serotonin syndrome
Seizure threshold is lowered

33
Q

Which opioid is never used in pts with seizures

A

Tramadol

34
Q

intial dosing for opioid naive pts

A

Codeine 15-60mg PO Q4H PRN

Tramadol 25-50mg PO Q4-6H PRN

Morphine 5-10mg PO Q4H PRN
2.5-5mg IV Q3-4H PRN

Hydromorphone 2-4mg PO Q4-6H PRN
0.2-1mg IV Q2-3H PRN

Hydrocodone 2.5-10mg PO Q4-6H PRN

Oxycodone 5-15mg PO Q4-6H PRN

Fentanyl 25-50mcg Q30-60min PRN

35
Q

which opioid options would you recommend for someone who doesnt swallow

A

Morphine- IV
Dilaudid- IV
Duragesic- fentanyl IV solution
Fentanyl patch- Not for opioid naive

36
Q

Options for long acting opioids

A

Tramadol- ER capsure 24 H or ER tab
Morphine- ER capsule 34 H or ER tab
hydromorphone- ER tab
hydrocodone- ER tab
oxycodone- ER tab and capsule

37
Q

Name the natural opiates

A

Morphine
Codeine

38
Q

Name the semi synthetic opiates

A

Hydromorphone
oxycodone
oxymorphine
hydrocodone
buprenorphine

39
Q

Name the synthetic opiates

A

Fentanyl
methadone
meperidone
tramadol

40
Q

What is the allergic cross reaction present in opiates

A

Avoid natural and semi synthetic opiates due to allergy as there is cross reaction.

no cross reaction in synthetic opioids

41
Q

Do we switch to synthetic opioid for itching? Nausea? Anaphylaxis?

A

Not for itching and nausea, only for anaphylaxis

42
Q

What are the scenarios we use different synthetic opiatesq

A

Fentanyl- IV for severe pain
Tramadol- oral and weak opioid
Methadone- not for acute pain

43
Q

EXAM
What are the steps to follow when switching between opioids

A
  1. calculate consumption of each opioid per day
  2. convert each opioid to oral morphine
  3. Add morphine doses together to get total daily morphine dose
    4.Due to cross tolerance, reduce dose by 25-50%
44
Q

Breakdown the types of recommendations in the 2022 clinical practice guideline

A

1,2- determining whether or not to initiate opioids for pain
3,4,5- selecting opioids and determining opioid dosages
6,7- deciding duration of initial opioid prescription and scheduling follow up
8,9,10,11,12- Assessing risk and addressing potential harms of opioid use

45
Q

Describe recommendations 1 and 2

A

Recommendation 1- Non opioid therapies are at least as effective as opioids for many types of acute painn(NSAIDs, antidepressant, acetaminophen)

recommendation 2- Non-opioids preferred for subacute and chronic pain

46
Q

Describe recommendations 3, 4, 5

A

3- When starting opioid therapy acute, subacute or chronic pain, clinicians should start IR opioids and not ER opioids

4- Use lowest effective dose

5- Carefully weigh risks and concerns when changing opioid dosage. Gradually taper to lower dose if benefits do not outweigh risk

47
Q

Describe recommendations 8, 9, 10, 11, 12

A

8- strategies to mitigate risk (offer nakixone)
9- Clinicians should review patients history of controlled substance prescriptions to determine if patient is receiving opioid dosages that put them at risk for OD
10-toxicology testing to assess for prescribed medications as well as other prescribed and non prescribed controlled substance
11- use caution when prescribing opioids and BZDs concurrrently
12- Clinicians should offer or arrange treatment with evidence based medication. Detox on its own is not recommended

47
Q

Describe recommendations 6 and 7

A

6- when pt is in acute pain, clinicians should prescribe no greater quantity than needed for expected duration of pain severe enough to require opioids

7- Evaluate benefit and risk with it within 1-4 weeks.

48
Q

When to consider reducing/tapering doses of opioids

A
  • no better pain control
    -patient asks
  • larger doses or concurrent BZDs
    -signs of OD/substance use
49
Q

How to reduce and taper opioid doses

A

-Avoid abrupt discontinuation
-decrease dose by 10% per month if patient has taken opioids for more than 1 year
- Decrease dose by 10% per week for pts that have taken opioids for shorter time (weeks/months)
-once lowest available dose is reached, interval between doses can be extended. May be stopped when taking < once per day.

50
Q

What patients do Opioid laws apply to

A

-patients taking >60 opioid pills/month >3 months
- using a transdermal patch > 3 months
- tramadol >399 mg/day for > 3 months
-taking any dose of an ER med

51
Q

Who has exemptions from these opioid laws

A

Terminal condition, Palliative/hospice,

52
Q

Describe the 2017 opioid 7 day law? Exemptions?

A

prescriber may not prescribe more than a 7 day supply

except for cancer, MAT (medication assisted treatment), substance abuse disorder, palliative, professional judgement

53
Q

Describe the 2019 inspect law

A
  • requires checking INSPECT each time before prescribing an opioid or a BZD for pt
    NO EXCEPTIONS
  • check inspect every 90 days
54
Q

Describe what a pain contract is

A

Agreement between patient and prescriber that says they wont get opioids from anyone else.

Does not legally prevent another provider from prescribing opioids or pharmacy from filling.

55
Q

for treatment of acute pain, can hospitals have multiple different medications for just one type of severity?

A

No, you can only have one for each level of pain.

56
Q

What is PCA? When is it used?

A

Patient controlled analgesia.

For patients in severe pain in hospital. (post OP, pancreatitis, sickle cell disease)

57
Q

Recommend treatments for lower back pain

A

1st line- Acetaminophen
NSAIDs

2nd- SNRI
TCA

Non- pcol- CBT, exercise, limit bed rest

58
Q

Recommend treatments for osteoarthiritis

A

1st- Acetaminophen
Oral NSAIDs

2nd- intra-articular hyaluronic acid
Capscasin

59
Q

Recommended treatments for fibromyalgia

A

Pregabalin
Duloxetine

60
Q

Recommended treatments for neuropathic pain

A

1st
SNRIs
Gabapentin/pregabalin

2nd- topical lidocaine
TCAs

61
Q

Treatment for pain relief and air hunger in hospice

A

-Morphine IV or sublingual (fentanyl/hydromorphone could also be used)

62
Q

Treatment for anxiety/agitation in hospice pts

A

Lorazepam

63
Q

Tx for N/V in hospice pts

A

Ondansetron ODT

64
Q

How to treat secretions in hospice pts

A

Atropine
Scopolamine
Glycopyrollate

65
Q
A

Therapeutics (38 decks)

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