L23: Pain Meds I

Question 1

Side effects of opioids

Answer 1

Nausea/vomiting
Constipation
Pruritus
Dry mouth
Altered mental status
Respiratory depression
Tolerance
Dependence

Question 2

What’s a risk of long term opioid use?

Answer 2

Masks pain, as in the case of the old lady with hip pain who actually had a massive abscess

Question 3

Undertreated pain resulting in red flag behaviors

Answer 3

Pseudo-addiction

Question 4

3 types of pain etiologies

Answer 4

Nociceptive
Neuropathic
Psychogenic

Question 5

Withdrawal symptoms with abrupt discontinuation/decrease in opioid (usually chronic pain)

Answer 5

Physical dependence

Question 6

Need increased dose for pain relief/or reduced effect of constant dose over time

Answer 6

Tolerance

Question 7

Impaired control over drug use/craving, Compulsive and continued use despite harm

Answer 7

Addiction characteristics

Question 8

Nociceptive pain

Answer 8

Caused by injury to tissues:

Activation of peripheral pain receptors, somatic or visceral: 
Laceration or injury involving the skin
Fractures, strains, sprains
Surgery (post/op)
Tumors/cancer
Internal organ injury

Question 9

Neuropathic pain

Answer 9

Results from damage to or dysfunction of nerves, the spinal cord or brain:

Post-herpetic neuralgia
Cervical/thoracic/lumbar radiculopathy
Trigeminal neuralgia
Diabetic neuropathy
Phantom limb pain (post-amputation)
Central pain syndrome (CVA, traumatic spinal cord injury)

Question 10

Psychogenic pain

Answer 10

Patient with persistent pain typically w/evidence of psychological disturbance

No evidence of disorder that could account for the pain or its severity

Question 11

Neuropathic pain is treated with

Answer 11

Neurontin, lyrica
TCAs
Tramadol, Nucynta

Question 12

Opioids with some SNRI properties

Answer 12

Tramadol, Nucynta

Question 13

Interventional pain management for neuropathic pain may include

Answer 13

Epidural Steroid injection
Joint injections
Intrathecal Pump Implant
Spinal Cord Stimulator Implant
Peripheral Nerve Blocks
Sympathetic Nerve Blocks and Neurolysis

Question 14

Goals of psychogenic pain tx

Answer 14

improving comfort/ psychological function

Question 15

Psychogenic pain tx

Answer 15

Biofeedback/distraction techniques
Encourage exercise
Psychological/Psychiatric evaluation and therapy

Question 16

Probably don’t give opioids if…..

Answer 16

History of addictive behavior
Caring for small children at home
Teenagers in home

Question 17

Muscle relaxant + lower back pain + firefighter

Answer 17

Not ideal bc they sedate and probably don’t help that much

Question 18

Always _____ acute pain to prevent ____-

Answer 18

Treat it! Follow up! Can evolve into chronic pain

Question 19

Ongoing myofascial pain can be treated with _____

Answer 19

Transcutaneous electrical nerve stimulator (TENS) unit

Question 20

Muscle spasms may be treated with

Answer 20

Muscles relaxants vs trigger point injections

lecture seemed to favor trigger point injections

Question 21

Should imaging be done right away for the firefighter with low back pain?

Answer 21

Nah, maybe do it at follow up if he hasn’t improved

Question 22

Example RA medication regiment

Answer 22

Celebrex 200 mg daily
Prednisone 5mg daily
Long acting opioid

Question 23

Tolerance to opioids is faster with ______-

Answer 23

high dose short acting opioids

switch patients to long acting

Question 24

While a patient is converting from short acting to long acting opioids: do these things

Answer 24

Reduce daily dose by 50-75% when converting to a new pain medication
+/- lower dose opioid for breakthrough pain while converting→ no more than 20-25% of daily long acting dose

Question 25

RA adjunct therapies

Answer 25

topical compound cream for joint pain→ Lidocaine, ibuprofen or diclofenac TENs unit for myofascial pain Aqua therapy

Question 26

gradual onset of burning pain in feet bilaterally. | Worse at night/walking long distances

Answer 26

Diabetic neuropathy

Question 27

Fibromyalgia tx

Answer 27

ncourage physical activity (#1 in treatment of fibromyalgia!) Aqua therapy (often covered by insurance) Encourage them that they can work their way up to land exercise Support→ referral for counseling if depression is a concern Pregabalin (Lyrica) or gabapentin (Neurontin) Cymbalta for pain control and to help with mood

Question 28

Are opioids recommended for fibromyalgia?

Answer 28

NOT recommended, but many patients with fibromyalgia are on them

Question 29

Are opioids recommended for fibromyalgia?

Answer 29

NOT recommended, but many patients with fibromyalgia are on them

Question 30

Cancer pain management

Answer 30

May need to consult with palliative care, pain management, hospice Can include management of symptoms other then pain (anxiety) Often involves optimization of opioid therapy + analgesic adjuncts Consider interventional pain management strategies

Question 31

Cancer patients should def get

Answer 31

PCA to control their pain

Question 32

Adjuncts to PCA for cancer patients could include

Answer 32

``` NSAIDs – Toradol (ketorolac) IV/IM/PO Acetaminophen IV/PO Lidoderm patch Antidepressant - Cymbalta (duloxetine) Neurontin (gabapentin)/Lyrica (pregabalin) Heat packs/ice packs ```

Question 33

Describe the PCA system

Answer 33

Short term→ Chronic, high dose opioids pt who is NPO IV + delivery system→ Managed by anesthesiologist or surgeons

Question 34

Indications for PCA

Answer 34

Severe post-op pain or intractable cancer pain

Question 35

PCA dosing

Answer 35

Demand dose q__ minutes Continuous dose Continuous + Demad dose

Question 36

Benefits of PCA

Answer 36

control, do not use while sleeping leads to less use overall, gets pain under control quickly

Question 37

Risks of PCA

Answer 37

Family members pushing demand dose when pt is a sleep, overdose if not monitored and titrated

Question 38

Considerations for PCA

Answer 38

``` Continuous pulse oximetry Orders for naloxone(narcan) prn Discuss with RN, make note that she/he is to monitor for mental status changes, respiratory distress New PCA→ follow up again within 12hrs Titrate PCA if needed Once dosage stable, patient should be monitored at least every 12-24hrs by Anesthesia/Surgery Wean as soon as tolerable ```

Question 39

IV to PO morphine conversion is typically ____

Answer 39

3:1 | aka the oral dose is three times the IV dose

Question 40

Converting from PCA to IV

Answer 40

Calculate amount of medication patient was receiving in 24hrs Convert to oral opioids while reducing PCA/IV pain medication dose PCA is for short term use only Consider for “pain emergencies”

Question 41

Converting from IV to PO (concepts)

Answer 41

Convert to long acting pain medication plus something for breakthrough pain Convert while still inpatient to evaluate for tolerance prior to home

Question 42

***Contraindications to opioids***

Answer 42

Hepatic disease | Increased intracranial pressure

Question 43

DOCs (2) for ESRD opioid

Answer 43

Fentanyl (patch or parenteral) | Methadone

Question 44

Caution with these 2 opioids and ESRD

Answer 44

hydromorphone | oxycodone

Question 45

Avoid these opioids in ESRD

Answer 45

morphine demerol hydrocodone codeine

Question 46

In whom is a fentanyl patch less effective, and why?

Answer 46

Cacehctic patients bc fentanyl is lipophilic

Question 47

Buprenorphine patch

Answer 47

Can cause QT prolongation | Is NOT for use with opioids

Question 48

Tramadol/Nucynta indications

Answer 48

Consider for neuropathic pain | Can consider in patients with fibromyalgia if absolutely necessary (but don't)

Question 49

Tramadol/Nucynta contraindications

Answer 49

Relative: fibromyalgia, antidepressants due to serotonin syndrome

Question 50

Is a fentanyl patch good for acute pain?

Answer 50

No, it takes 12 hours to reach therapeutic levels

Question 51

When converting IV opioids to fentanyl patch....

Answer 51

Two step taper (whatever that means)

Question 52

What increases fentanyl absorption and could even cause fatal OD?

Answer 52

Heat exposure! even sunbathing

Question 53

Before using methadone, ______

Answer 53

Baseline EKG/check renal/hepatic function EKG yearly thereafter Many drug interactions, get a good medication history

Question 54

Which drug has a 1⁄2 life up to 55 hours, so initiating requires a very SLOW titration, every 3-5 days

Answer 54

Methadone

Question 55

Benefits of methadone

Answer 55

Decrease neuropathic pain | Inexpensive

Question 56

Rx for controlled substances must include

Answer 56

Date of issue Patient's name and address Practitioner's name, address, telephone and DEA registration number Drug name, strength, form and quantity Directions for use Manual signature of prescriber (NOT in EMR) Don’t use shorthand, write out # of pills per day, quantity and refills in long hand.

Question 57

Always ask about

Answer 57

***constipation***

Question 58

Avoid ______ with other controlled substances

Answer 58

polypharmacy | idk which other substances are controlled for testing purposes though?

Question 59

ONLY diagnose an opioid if the following questions are all answered with a YES:

Answer 59

Does the patient have a definitive diagnosis? Has there been a documented work up with abnormal findings? Is the patient experiencing impairment in function? Have you evaluated for contraindications to opioid management? Has the patient tried adjunct treatments and failed?