Final - Issacs Flashcards
question to asks pts in pain?
PQRSTU palliative/precipitating quality region severity time U - impact on U....
what are the physiological changes seen in a patient who is in pain
dilated pupils (mydriasis) paleness sweating tachycardia tachypnea
wong baker pain scale is described how and is for who?
its the faces
and for young kids
FLACC scale stands for what? and is used for who?
FLACC = Face, legs, activity, cry, and consolability
is for infants or unconscious people
Non-Pharm Options for Pain
CORRECT UNDERLYING CAUSE!! (Surgery or avoidance) RICE (rest/ice/compression/elevation) Psychotherapy/behavioral modifications Massage Acupncture Physical Therapy
________ made an analgesic ladder for pharm treatment options
WHO - World health organization
how many steps are in the WHO analgesic ladder
3
what is step 1 in the WHO analgesic ladder
non opioid +/- adjuvant analgesic
what is step 2 in the WHO analgesic ladder
opioid for mild - moderate pain + non-opioid +/- adjuvant analgesic
what is step 3 in the WHO analgesic ladder
opioid for moderate to severe pain +/= adjuvant analgesic
PRN or Scheduled analgesics minimize exposure to limit toxicity
PRN (only treating when pain is above a threshold)
PRN or Scheduled analgesics may be a better option in chronic/continual pain
scheduled…
What are the non-opioid analgesics
NSAIDs and APAP
Adjuvants – aka for Neuropathic Therapies
- Gabapentinoids
- SNRIs
- TCAs
- Skeletal Muscle Relaxants
NSAIDs or APAP is the gold standard for OA in geriatric patients? and why?
APAP! because fewer side effects in geriatric patients
Patients with liver disease can or cannot take APAP?
can!
limit is < 2G/day though
APAP Peds dosing?
10 - 15 mg/kg PO Q4H prn
Ibuprofen doing for peds?
5 - 10 mg/kg PO Q6H prn
NSAIDs or APAP have a black box warning for increased cardiovascular events?
NSAIDs
NSAIDs or APAP?
leads to fluid retention
NSAIDs
increased CV events!!
NSAIDs or APAP?
causes hepatoxicity
APAP
If patient has hx of cardiac history, can you still use topical NSAIDs?
yes
topical is ok, systemic is less ok
why do we titrate gabapentinoids?
to limit sedation
ADEs of SNRIs
HTN
Sedation
HA
weakness
if CrCl is < 30 mL/min – what do you do for the SNRIs
NO duloxetine
Can do venlafaxine but decrease daily dose by 50%
list the drugs that are skeletal muscle relaxants
carisoprodol (Soma) Chlorzoxane (Lorzone) Cyclobenzaprine Metaxalone (Skelaxin) Methocarbamol (Robaxin)
what opioids are typically used in step 2 in WHO analgesic ladder aka for mild - moderate pain
tramadol
codeine
morphine
hydrocodone
what opioids are typically used in step 3 in WHO analgesic ladder aka for moderate - severe pain
oxycodone (+/- APAP) hydromorphone fentanyl methadone meperidine
codeine is used for pain and ?
for cough
codeine is an antitussive
how old does someone have to be to use codeine?
12 y.o +
because rate of metabolism is wack in kids under 12 for codeine
which opioid can lower seizure threshold?
tramadol
which opioid can cause itching/histamine release
morphine
what 2 opioids are save in renal impairment
fentanyl
and
methadone
which opioid can be used by certain prescribers for opioid detox
methadone
which opioid can cause neurotoxicty
meperidine
which drug comes in a patch and what is a note about giving the patch to patients?
fentanyl!
do not give the patch if the patient is “opioid naive”
also dont cut patches…
which drug is used for opioid reversal
naloxone
opioid antagonist
which drug is used for opioid dependence
buprenorphine/naloxone (Suboxone)
when naloxone is given does HR go up or down
up!!
which drugs may need to be avoid if patient has derm issues
fentanyl PATCH
and
morphine (bc itching side effect)
If a patient is experiencing acute pain —-
should pt use parenteral, IR, or CR?
parenteral and IR are appropriate
what patients are typically eligible for PCA (patient controlled analgesia)
post-op
pancreatitis
sickle cell crisis
for PCA dosing about how often are the opioids given?
about evert 4 - 10 minutes - aka hella often!!
Switching b/w Opioids: Drug: Parenteral: Oral: Fentanyl Hydrocodone Hydromorphone Morphine Oxycodone
Drug: Parenteral: Oral:
Fentanyl 0.1
Hydrocodone 30
Hydromorphone 1.5 7.5
Morphine 10 30
Oxycodone 20
Switching b/w Opioids:
Hydromorphone Conversion b/w parenteral and Oral
Morphine Conversion b/w parenteral and Oral
Morphone: Parenteral: 1.5 —-> Oral: 7.5 (5 x)
Morphine: Parenteral 10 —–> Oral: 30 (3x)
Opioid Conversion Steps?
1 - collect ALL opioid consumption from any route for 24 hour time frame
2 - convert each dose to oral morphine
3 - add all together to get total daily oral morphine dose
4 - reduce 25 - 50% due to cross tolerance
5 - determine appropriate agent for pt based on pt and med specific factors
Opioid Related Side Effects
Constipation N/V Itching Respiratory depression Sedation addiction/abuse tolerance overdose withdrawal
opioid induce N/V- how to manage?
take with food!!!
also consider is dose too high?
may add antiemetics— but try not to
3 main options for opioid induced constipation
Non-pharm: water + fiber + physical activity
OTC: STIMULANT laxative
(senna/bisacodyl)
Rx: Movantik or Relistor (the peripherally mu opioid antagonists) - $$$$$
When using a laxative for opioid induced constipation - use bulk or stimulant laxatives? (and examples)
stimulant
senna, bisacodyl
how to treat itching caused by opioids (usually morphine tho)
antihistamines!! (oral, topical, or parenteral)
or
reduce dose of opioid (because it is dose dependent)
switch to alternative opioid
Change route of administration
respiratory depression (An ADE of opioids) is usually defined by a RR < ____ BPM
8 BPM
Symptoms of opioid withdrawal
agitation anxiety increased sweating insomnia restlessness
What drugs can be used for symptom management in opioid withdrawal
clonidine - to decrease tachycardia
Methodone - for detoxification
CCD Guidelines for Prescribing Opioids:
- for chronic pain – start with ____ opioids and start with _______ dosage
IR
lowest effective
CCD Guidelines for Prescribing Opioids:
Avoid concomitant used of opioids with ______ if possible
BZDs
CCD Guidelines for Prescribing Opioids:
For chronic pain:
avoid titrating to > _____ mg of oral morphine equivs/day
AND
evaluate every ______ for opioid benefit/harm
90 mg
1 - 4 weeks
Indiana Opioid Law:
Initial Prescriptions for opioid therapies cannot be greater than _____ days UNLESS its for what 3 things?
7 days
Cancer, Palliative care, medication assisted tx of substance abuse
if pt is in hospice — opioids are used why?
well pain duhhh/providing comfort at end of life
and
decreasing respiratory drive (to aid in natural end of life processes)
