L 77-79 Rogers- Non-malignant pain Flashcards
what is the PQRSTU acronym for? list it after you answer that.
subjective questions to ask pt to assess pain.
- Palliative or Precipitating Factors
- Quality of pain
- Region of pain
- Severity of pain
- Time-related nature of pain
- U- impact on yoU
5 physio changes for assessment of pain slide
dilated pupils (mydriasis)
paleness
sweating
tachycardia
tachypnea
4 pain intensity scales, which one is special
verbal
numeric
visual
wong-baker (for kids*)
step 1 of WHO treatment approach *
non-opioid with or without adjuvant analgesic
step 2 of WHO treatment approach *
Opioid for mild-moderate pain, + non-opioid, with or without adjuvant analgesic
Step 3 of WHO treatment approach *
Opioid for moderate-severe, +non-opioid, with out without adjuvant analgesic
what meds/med classes are considered adjuvant therapies to opioids
(6)
gaba
snris
tca
skeletal muscle relaxants
antiepileptics
topical agents
Recommended dosing tylenol:
Adult: (regimen) (max dose)
Kids: (regimen) (max dose)
Adult: 325-1000mg po q4-6h, max dose 3-4 g/day
Kids: 10-15 mg/kg po q4h, max 75 mg/kg/day or 3-4 g/day
if a pt has liver disease, what is the max dose of tylenol?
2 or less g/day
1 side effect listed on tylenol slide
hepatotoxicity (most likely doses above 10g)
2 clinical pearls listed with tylenol *
injection is super expensive
gold standard for osteoarthritis
4 side effects listed with NSAIDs
GI bleed
nephrotoxicity
fluid retention
increase CV events
4 clinical pearls listed with NSAIDs
take with food
caution in old farts
avoid in pts with cardiac history
avoid in liver and kidney disease
aspirin adult dosing with max dose
325-1000mg po q4-6h prn
max - 4g/day
aspirin pediatric dosing with max dose
sike, dont give it to kids dumbass (bc of reye’s)
2 clinical pearls on aspirin slide
avoid in pts taking blood thinners
some formulations available OTC (no shit)
Ibuprofen adult dosing with max
200-800mg po q6-8h prn
max- 3200 mg/day
Ibuprofen pediatric dosing with max (under 6 months)
5-10 mg/kg po q4-6h prn
max - 40mg/kg/day or 2400 mg
2 interesting/different formulations of diclofenac that might catch you off guard
ophthalmic solution
patch
adult dosing of diclofenac
50 mg po q8h or 2-4 g applied topically 4 times/day
2 clinical pearls for diclofenac
minimal systemic side effects with gel (duh)
some available OTC (duh)
Naproxen adult dosing with max
220-500 mg po q6-12hr
max - 1,000mg/day
two weird formulations of ketorolac
nasal spray
ophthalmic
ketorolac adult dosing
15-30 mg IV q6h or 10 mg po q6h
ketorolac pediatric dosing
0.5mg/kg dose IM/IV q6h
2 clinical pearls for ketorolac (first one is underlined)
- maximum duration is 5 days ** bc increased risk of GI bleed
- oral dosing is continuation of IM or IV
Celecoxib adult dosing
200 mg po bid
clinical pearl celecoxib
Cox 2 selective -> less GI toxicity
3 uses of gabapentinoids
fibromyalgia
neuropathies
post-op pain
gabapentin recommended dosing and max
100-300 mg po tid
max - 3600 mg/day
pregabalin recommended dosing and max
75 mg po bid
max - 600mg/day
3 side effects listed with gabapentinoids
sedation
dizziness
peripheral edema
4 clinical pearls for gabapentinoids
- renally dose adjusted
- titrate up to limit sedation
- use in combo to lower requirements of other analgesics
- pregab is schedule V, gaba is not scheduled
2 SNRIs used in pain
venlafaxine and duloxetine
2 uses for SNRIs in pain
fibromyalgia
neuropathy
venlafaxine rec dosing and max
37.5-75 mg po qd
max - 225 mg/day
duloxetine rec dosing and max
30 mg po qd x 1 week, then up to 60 mg po qd daily
max- 60 mg/day
5 side effects with SNRIs
nausea
headache
htn
sedation
weakness
2 clinical pearls with SNRIs
- start low dose and titrate up
- renally dose adjust venlafaxine and avoid duloxetine w/ CrCl <30 * (might come up on exam tbh)
2 TCAs used in pain
amitriptyline and nortriptyline
3 uses of TCAs in pain (all off label btw)
fibromyalgia
neuropathy
migraine prophylaxis *
amitriptyline/nortriptyline rec dose and max
10 mg po qhs
max- 150 mg/day
2 side effects on TCA slide
anticholinergic
sedation
1 clinical pearl under TCAs for pain
last line option for neuropathy and fibromyalgia bc of bad side effects
5 muscle relaxants used in pain management
cyclobenzaprine
baclofen
methocarbamol
carisoprodol
tizanidine
1 use listed for muscle relaxants
musculoskeletal pain/ spasms
cyclobenzaprine rec dosing with max
5 mg po tid
max - 30 mg/day
baclofen rec dosing with max
5 mg po tid
max - 80mg/day
carisoprodol rec dose and max
250-350 mg po tid
max- 1050 mg/day
methocarbamol rec dose and max
1.5 g po 3-4 times/day
max- 8g/day
tizanidine rec dosing and max
2-4 mg po q8-12hr
max - 24 mg/day
4 side effects listed under muscle relaxants
sedation/drowsiness
dizziness
dry mouth
vision changes
2 clinical pearls for muscle relaxants
short term use (3 or less weeks)
carisoprodol is schedule IV
1 antiepileptic used for pain management
carbamazepine
1 use of carbamazepine for pain
neuropathic pain
carbamazepine rec dosing and max
200-400 mg po qd in 2-4 divided doses (tf)
max- 1200 mg/day
2 clinical pearls with carbamazepine
- increased risk of hypersensitivity reaction in patient with HLA-B*1502
- Autoinduction of hepatic enzymes
rec dosing of lidocaine patch
apply 1 patch daily and remove 12 hours later
2 side effects with lidocaine patch
hypotension
arrhythmia (but minimal risk with patch)
3 clinical pearls with topical lidocaine
tachyphylaxis with continuous use
12 hour break between patches
local effect- apply to site of pain (no fucking way bro fr?)
2 uses for capsaicin topical
muscle/joint pain
neuropathic pain (how tf)
1 side effect listed on capsaicin slide
skin irritation/pain
3 clinical pearls with capsaicin
- dont get in eyes (ok)
- wash hands after applying
- some otc options
what are the primary pain management options you should aim to use in elderly?
tylenol
topicals
SNRis
gabapentinoids
what are the two weak opioid agonist
codeine and tramadol
Medication becomes less effective over time and it takes a higher dose of the drug to achieve the same effect
A. Tolerance
B. Dependence
C. Addiction
a
When a patient stops using a drug, their body goes through withdrawal
A. Tolerance
B. Dependence
C. Addiction
b
Continued use of a drug despite negative consequences
A. Tolerance
B. Dependence
C. Addiction
c
Overdose or Withdrawal?
insomnia/agitation
withdrawal
Overdose or Withdrawal?
pinpoint pupils
overdose
Overdose or Withdrawal?
dilated pupils
withdrawal
Overdose or Withdrawal?
tachycardia
withdrawal
Overdose or Withdrawal?
bradycardia
overdose
Overdose or Withdrawal?
pale/clammy skin
overdose
3 treatments for opioid withdrawal
clonidine -> helps w/ sxs such as htn, sweating, vomiting
buprenorphine -> duh
methadone -> interesting
3 clinical pearls for opioids
- consider starting a stool softener and/or stim lax
- potential for tolerance, dependence and addiction
- schedule II (except tramadol and codeine)
4 clinical pearls for tramadol
- risk of serotonin syndrome
- renally dose adjusted
- box warning for use of 3A4 and 2D6 shit
- schedule IV
3 clincial pearls for morphine
- itching more prominent **
- morphine and its metabolites are renally excreted and accumulate in renal dysfxn
- box warning for avoiding alcohol while taking ER formulation bc of possible fatal overdose
1 clinical pearl for hydromorphone
box warning about dosing errors when prescribing:
oral solution -> do not confuse mg and mL
IV solution -> do not confuse high potency solution (10mg/mL) with other solutions (lower strengths)
2 clinical pearls for hydrocodone/acetaminophen
counsel patient on tylenol use
box warning for use with 3A4 inhibitors may increase plasma concentrations
3 clinical pearls oxycodone/acetaminophen
- counsel pts on tylenol use
- ER capsule/tabs are abuse-deterrent
- box warning for use with 3A4 inhibitors may increase plasma concentrations
4 box warnings fentanyl
- box warning to monitor pts receiving 3A4 interacting meds
- CAN use in renal impairment
- less hypotension than morphine or hydromorphone
- non-injectable forms are ONLY indicated for pts who are opioid tolerant
- (defined as taking morphine 60 mg/day for at least 1 week)
how often to apply fentanyl patch
every 3 days
where can you apply fentanyl patch?
chest
back
flank
upper arm
can you cut the fentanyl patches
no
2 uses of methadone in pain management
last line tx of chronic pain
opioid detox
3 clinical pearls of methadone
box warning for QTc prolongation
box warning for 3A4 interactions
long half-life (8-59 hours)
Meperidine (demerol) 5 clinical pearls
- avoid in elderly, renal impairment, caution in hepatic
- box warning for 3A4
- box warning for not using within 14 days of MAOi ***
- metabolized by liver into active metabolite (accumulation can cause delirium and seizures)
- not commonly used bc of adverse effects
what are the 4 synthetic opioids that can be used that avoids allergic cross reaction
fentanyl
methadone
meperidine
tramadol
opioid equivalents:
fentanyl
parenteral and oral
p: 0.1
o: —
opioid equivalents
hydrocodone
parenteral and oral
p: —
o: 30
opioid equivalents
hydromorphone
parenteral and oral
p: 1.5
o: 7.5
opioid equivalents
morphine
parenteral and oral
p: 10
o: 30
opioid equivalents
oxycodone
parenteral and oral
p: —
o: 20
do we need to know the naive dosing?
hopefully theres two options and we just think to hit the lower one
T or F: One of the CDC Recs for prescribing opioids is to prefer ER formulations over IR ones
false, they want to prescribe IR
what are the 4 exceptions to the 7 day prescribing limit opioid law?
cancer
medication assisted tx for a substance-abuse disorder
palliative care
professional judgement with documentation supporting it
Michigan law thing with opioid prescribing after procedures:
how many oxycodone 5 mg tablets for each of the following?
Dental extraction:
Thyroidectomy:
Caesarean Section:
Total Hip Arthoplasty:
0
0-5
0-20
0-30
In the tx of acute pain, you can only have one med order for each severity of pain**, what is the regimen for each severity?
mild:
moderate:
severe:
mild: tramadol 25 mg po q6h
moderate: oxycodone 5 mg po q4h
severe: fentanyl 25 mcg IV q1h
first line for lower back pain
tylenol or NSAIDs
2nd line for lower back pain
SNRis and TCAs
first line for osteoarthritis pain
tylenol, NSAIDs
second line for osteoarthritis
intra-articular hyaluronic acid
capsaicin
2 FDA approved meds for fibromyalgia **
pregabalin and duloxetine
first line for neuropathic pain
snris and gabapentinoids
second line for neuropathic pain
topical lidocaine and TCAs
