IC6

Question 1

morphine excretion

Answer 1

active morphine-6-glucuronide is renally eliminated

Question 2

considerations when changing short to long acting

Answer 2

add 50% to 100% of prn usage to ard the clock doses
rescue prn doses = 10%-20% daily opioid requirements

Question 3

fentanyl pk

Answer 3

short half life but patches has longer - 72hrs

Question 4

ketamine uses

Answer 4

• anesthetic in OT
• opioid hyperalgesia
• reverse opioid tolerance(must reduce baseline when initiating by 50% or more) - its supercharges ur opioid

Question 5

opioid tolerance

Answer 5

occurs when a person using opioid begins to experience a reduced response to medication, requiring more opioids to experience the same effect

Question 5

ketamine ADR

Answer 5

hallucinations, insomnia, nightmares

Question 6

opioid dependence

Answer 6

when the body adjusts its normal functioning around the regular opioid use.
unpleasant physical symptoms occur when medication is stopped

Question 7

DDi of opioids

Answer 7

benzodiazepines and other CNS depressants

Question 8

opioid addiction

Answer 8

oud - opioid use disorder
- when attempts to cut down or control use are unsuccessful or when use results in social problems
- generally comes after patient has developed tolerance and dependence, making it physically challenging to stop opioid use and increasing risk of withdrawal.

Question 9

adjuvants for pain relief

Answer 9

1. gaba acting anticonvulsants (gabapentin, pregabalin)
2. SNRIs
3. tramadol
4. lidocaine patches

Question 10

early palliative care benefits

Answer 10

1. survival benefit
2. improve qol, mood, depression score
3. decrease proportion of aggressive EOL(ICU admission, intubation)

Question 11

EOL syndromes

Answer 11

1. Dyspnea
2. secretions
3. anorexia
4. n/v
5. constipation
6. diarrhea
7. delirium
8. bowel obstruction

Question 12

EOL syndromes: secretion

Answer 12

Glycopyrrolate, 0.2-0.4 mg IV or SC every 4 h PRN (less sedating)

Scopolamine, PRN/1.5-mg
patches, 1-2 patches every 72 h

Atropine, 1% ophthalmic solution 1-2 drops SL every 2 h PRN (caution in asthma),

Hyoscyamine, 0.125-0.25 mg PO or SL every 4 h with max dose of 1.5 mg daily

Question 12

EOL syndromes: Dyspnea

Answer 12

Opioids in low doses, with titration as appropriate, can be used to treat dyspnea that is resistant to other therapies.
Base dosing on patient’s opioid requirement. If patient’s opioid requirement is unkhown, start with low doses and titrate up as appropriate.

Fluid overload: Furosemide, PRN dosing as per clinical situation

Question 13

EOL syndromes: anorexic

Answer 13

Counsel family and patients about risks (eg, thrombosis), benefits, and options for cachexia treatment (eg, stopping
therapy if ineffective)

Gastroparesis (early satiety): Metoclopramide 5-10 mg PO QID 30 min before meals and QHS

Low/no appetite (avoid in setting of complete bowel obstruction):
Megestrol acetate, PO

Olanzapine, 2.5-5 mg/d PO

Dexamethasone 3-8 mg/d

Question 14

EOL syndromes: aggitation/delirium

Answer 14

Mild/Moderate Delirium
Haloperidol, 0.5-2 mg PO BID/TID
Alternatives: Risperidone, 0.5-2 mg PO BID;
olanzapine, 5-20 mg PO daily; or
quetiapine fumarate, 25-200 mg PO/SL BID

Severe Delirium (agitation)
Haloperidol, 0.5-2 mg IV every 1-4 h PRN
Alternatives: Olanzapine, 2.5-7.5 mg PO/SL every 2-4 h PRN (maximum = 30 mg/d);

chlorpromazine, 25-100 mg PO/PR/ V every 4 h PRN for-patients who are bedbound.

For direct IV injection, administer diluted solution slow V at a rate not to exceed 1 mg/minute. To reduce the risk of hypotension, patients receiving IV chlorpromazine must remain lying down during and for 30 minutes after the injection.

Question 15

Opioids ADR

Answer 15

1. constipation
2. nausea
3. pruritus
4. delirium
5. motor and cognitive impairment
6. respiratory depression
7. Sedation

Question 16

EOL syndromes: bowel obstructions

Answer 16

• pancreatic enzymes + Sodium bicarbonate

Metoclopramide, 5-10 mg PO QID 30 min before meals an QHS; avoid in the setting of complete obstruction

Dexamethasone, 4-12 mg IV daily, discontinue if no improvement in 3-5 days

Scopolamine (patch or V); hyoscyamine, 0.125 mg PO/ODT/SL every 4 h PRN; glycopyrrolate, 0.2-0.4 mg IV every 4 h PRN

Octreotide, 100-300 mcg SC BID-TID or 10-40 mcg/h continuous SC/IV infusion; if prognosis >8 weeks, consider long acting release (LAR) or depot injection

Question 17

Opioid tolerant

Answer 17

more than 1 week of daily use
- at least 25mcg/hr of fentanyl patch
- at least 60mg of morphine
- at least 30mg of oxycodone
- at least 8mg of hydromorphone

Question 17

renally cleared opioids

Answer 17

• morphine
• codeine
• hydromorphone
• oxymorphone
• hydrocodone

Question 18

transdermal fentanyl

Answer 18

• use only in opioid tolerant
• use only when well controlled pain
• 8-12hr prior, may need other opioids, steady state after 2-3d

Question 18

methadone pk

Answer 18

long, variable 1/2 life: 15-120 hr
time to steady state: 5-7 days

Question 19

methadone uses

Answer 19

hyperalgesia
unrelieved with opioids
heroin detox
cost effective option

Question 21

ketamine MOA

Answer 21

noncompetitive NMDA receptor antagonist that block glutamate