Module 5 Study Guide and Discussion board Flashcards
What is the reason some drugs are scheduled/controlled?
Because of their potential to be abused and dependency potential. They are classified I-V
What are the levels of drug scheduling and refill requirements?
For 2-4 RX with DEA# required (call in only in emergency)
1-No medical uses! No prescriptions
2-High risk of dependence (ex. fentanyl). No refills
3-Moderate Risk (ex. Tylenol with codeine). Refill up to 5 times within six months
4-Low Risk (ex. Xanax). Same as 3
5-May be gotten over the counter (ex. Cough syrup with codeine)
What is Nociceptive Pain caused by? Examples?
Caused by damage to the tissues.
Ex: Fractures, sprains, peritonitis, arthropathies, ischemic disorders, myalgias, skin and mucosal ulceration, superficial pain such as burns, and visceral pain such as appendicitis, pancreatitis, renal lithiasis.
What is Neuropathic pain caused by? Examples?
Damage to nervous system.
Ex: Neuropathies as in alcoholism and diabetes, cancer-related pain, regional pain syndromes, HIV, multiple sclerosis, phantom limb pain, postherpetic neuralgia, trigeminal neuralgia, post-CVA pain
What is mixed pain caused by? Examples?
Unexplained etiology
Ex: Chronic recurrent headaches, vasculitis
What is the difference between acute and chronic pain?
Acute: sudden onset and of short duration
Chronic: lasting 3-6 months or longer.
What is the first and second step in pain treatment for the elderly?
1st=non-pharm therapy
2nd=Non-opiod
Why can pain meds affect the elderly differently?
Kidneys and liver smaller, less saliva, less muscle mass, oral drugs absorbed differently
What are unique concerns about pain management in the elderly?
Cognitive impairment, dementia, comorbid conditions, and drug interactions can complicate effective communication and adequate pain assessment.
Most drug trials do not include older adults. NSAIDs often cannot be used in the elderly
Why should opioids be avoided in pregnancy?
All opioids are lipophilic and readily cross the placenta.
Chronic use can cause neonatal withdrawal symptoms, including difficulty with temperature regulation, feeding, hydration, seizures, and sudden infant death syndrome (SIDS).
What pain medicine is generally considered safe in pregnancy?
APAP (Tylenol)
What should be considered when family and friends request an opioid prescription?
A complete evaluation and medical record need to be generated. Anything otherwise really is poor care and risky. In many states, it is illegal. Most states forbid prescribers from writing for controlled drugs for themselves or close family members.
What are the QT prolongers discussed in Module 5?
Methadone, Cocaine, subutex
How do prostaglandins work in the body?
Prostaglandins sensitize pain receptors to bradykinin and other biochemical mediators, causing vasodilation and increased vascular permeability=analgesic, antipyretic, and anti-inflammatory. They also have protective functions, which is why blocking their action causes the many adverse effects seen with the use of NSAIDs.
What are the risks/adverse effects seen from blocking prostaglandins?
GI- lose protection of gastric mucosa and results in increased gastric acid
Renal- can cause decrease renal blood flow
When should a PPI be used with an NSAID?
Moderate GI risk due to one or two risk factors: 1) > 65 years of age, 2) daily ASA therapy, 3) previous uncomplicated ulcer, or 4) high-dose NSAIDs.
When should we avoid ASA?
Patients taking antiplatelets/anticoagulants, Under 19-years old during fever-inducing illness, pregnancy, MI hx (unless its daily low dose)
Why does ASA have a risk for GI bleed?
Aspirin has an irreversible effect on platelet aggregating properties and therefore increases the risk of bleeding for the life of the platelets it contacts.
Why should ASA not typically be used in pregnancy?
The use of high doses greater than 150 mg per day is associated with prolonged gestation and labor, maternal and neonatal bleeding, fetal growth restriction, and increased mortality during the perinatal period. Premature closure of DA if taken at the end of pregnancy.
What do all NSAIDs increase the risk of?
GI bleed, MI, and stroke.
Why is there less blood clotting with ASA use? Think Cox
ASA reduces Cox 1 more than Cox 2
Why are NSAIDs thought to increase the risk of clots? Think Cox.
NSAIDs block Cox 1 and Cox 2 (clotting and inhibition of clotting).
What is the role of Cox-1? Examples?
Involved with prostaglandins: protect gastric mucosal integrity, provide vascular homeostasis, platelet aggregation, kidney function
Examples: Ibuprofen, diclofenax, ketoprofen, indomethacin, meloxicam, toradol
What is the role of Cox-2? Examples?
Present in inflammation and vasodilation
Celecoxib (Celebrex)
Which NSAID poses the highest risk of MI?
Celecoxib (Celebrex)
What are the concerns with topical NSAIDs?
Can still cause GI bleeds, has little efficacy after 2 weeks, very expensive
Who should avoid acetaminophen?
Avoid in patients with hepatitis, dehydration, liver disease, cirrhosis, or those who are heavy drinkers.
What is the antidote to acetaminophen?
acetylcysteine
What is the maximum adult dose of acetaminophen per day?
What about got those with high risk of liver toxicity?
4000 mg in 24 hours
3,000 for those with a higher risk of liver toxicity
What is the concern with combination products?
Accidental overdose
What is a common side effect of local anesthetic lidocaine?
Vaso-vagal response
What patient teaching is indicated when prescribing capsaicin (Qutenza)
Do not take it orally. Instruct the patient to be very careful not to get topical capsicum in their eyes.
What conditions does medical marijuana have FDA approval for?
Epidiolex (cannabidiol) [CBD]: two rare and severe forms of epilepsy, Lennox-Gastaut syndrome, and Dravet syndrome, in patients two years of age and older
What is the process for recommending medical marijuana?
The patient obtains a recommendation from their provider, which they can present to a dispensary and legally obtain the marijuana.
What medications are made from marijuana and have FDA approval?
Epidiolex (cannabidiol) [CBD]-Epilepsy
Marinol (dronabinol)-chemo/HIV
Cesamet (nabilone)-chemo
Which NSAID has the highest risk of GI bleed? How should it be prescribed?
Ketorolac-do not use for more than five days
What are the pain recommendations for pt with MI hx?
APA->ASA->Tramadol->opiods
What are the special concerns regarding pain management in the elderly?
Physiological change in aging (renal, liver) , Cognitive impairment , Comorbid condition and drug to drug interaction. Avoid anticolinergics.
What are the special concerns regarding pain management in children?
In infants due to their immature organs the drug can be delayed or last longer in their system so we have to be cautious of toxicity. Children 1 year and older may need an increase in dosage due to their faster metabolism compared to an adult or they may need an adjustment in the dosing interval. Because of this variability in age with the pediatric population, faster drug metabolism and higher water concentration, the dosing is based on body weight in kg.
What do you know about Cox1 and cox 2 medications?
Cox 1 is around all the time and is the COX responsible for stimulating prostaglandin production in the stomach.
This prostaglandin protects gastric mucosal integrity, vascular homeostasis, platelet aggregation and kidney function (vasodilation of the kidneys). these drugs are ibuprofen, diclofenac, ketorolac (Toradol), Indomethacin, Meloxican, Ketoprofen.
COX 2
Cox 2 is produced by gene transcription in the presence of tissue injury. it then produces the vasodilating prostaglandins that cause swelling, erythema, pain. COX 2 inhibitor is Celebrex. Vioxx and Brextra was taken off the market for causing Cardiac abnormalities
What schedule drug is medical marijuana?
So, Federally, it is illegal. But depending on your state, a NP may be allowed to write a recommendation card- not a prescription.
After completing your reading what are your thoughts on the use of muscle relaxants for the treatment of acute back pain? Risks benefits?
they are not the first line, they may have a role in acute back pain, but really should not be prescribed for chronic back pain. They do have significant potential side effects. There is not a lot of good evidence that shows they make much of a difference in recovery.
Discuss the FDA approved treatment of Fibromyalgia. What are some off label treatments of Fibromyalgia and what is the evidence on those treatments?
FDA approved medications for use in fibromyalgia are: SNRIs duloxetine (Cymbalta) and milnacipran (Savella) and anticonvulsant pregabalin (Lyrica) with evidence grade A.
Off label treatment from best to worst evidence grade are:
TCA Amitriptyline (Grade A)
SSRIs fluoxetine and paroxetine, anticonvulsant gabapentin, and muscle relaxant cyclobenzaprine (Grade B)
opioids, tramadol, benzodiazepines, NSAIDs, magnesium, guaifenesin, DHEA, melatonin, and calcitonin (Grade C-have not demonstrated effectiveness)
SSRI citalopram (Grade D-not effective)
What are the benefits and limitations of Prescription Monitoring Systems (PDMS- PDMP)?
PDMS is a database for controlled substance prescriptions, so you will not see the abx history. Only statewide.
What medications from this module prolong QT interval?
Methadone, cocaine, buprenorphine
What drugs from this module have significant drug-to-drug interactions?
Tylenol- increases Warfarin
Marijuana- CYP 450 inhibitor
Cox-2 - Decreases Digoxin clearance, ACEI (potential renal damage)
Cox 1-2- Steroids, spironolactone, and SSRIs increase the risk for bleeding.
ASA- Anticoags (increases risk for bleeding), glucocorticoids, ACEI, NSAIDs (increase risk for GI bleed, MI, and stroke), and alcohol
Cyclobenzaprine- MAOI
Colchicine- do not give with PGP and CYP 3A4 inhibitors, Statins (rabdo)
Lyrica- Alcohol, benzos, or any CNS depressant
Antabuse- metronidazole and of course alcohol
tramadol- MAOI and SSRIs (cause Serotonin syndrome)
Ergot Alkaloids- Cyp 3A4 inhibitor, triptans
Are there any drugs from this module that should be avoided in children?
Aspirin, codeine, tramadol,
Strengthened Warning to mothers that BF not recommended when taking codeine or tramadol due to serious adverse rxns in BF infants. (sleepiness, difficulty breathing, serious problems that result in death)
What is the difference between acute/abortive versus prophylactic treatment of migraines?
Acute: include analgesics such as acetaminophen, NSAIDS, opioid analgesics, selective serotonin 1B/1D receptor agonist agonists (Triptns), ergots, caffeine, and adjunctive antiemetics
Prophylactic: Reduce frequency, intensity, and duration
What is the difference between acute/abortive treatment of gout and prophylactic treatment of gout?
The IL-1 inhibitors potentially have a role as anti-inflammatory agents in refractory gout or for patients who are unable to tolerate conventional therapy, such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or glucocorticoids. These are used for acute attacks.
Colchicine may also be given for prophylaxis when urate-lowering therapy is started, as this is the time that flare-ups occur.
Can you list the three FDA-approved drugs for the treatment of Fibromyalgia?
milnacipran, duloxetine, and pregabalin
What is the APRN’s ethical role in treating opioid addiction?
primary prevention
How does naloxone hydrochloride (Narcan) work to reverse opioid overdose?
Naloxone is an opioid antagonist.Works in the brain to block opioid-induced pleasurable effects.
What would happen if someone was given naloxone hydrochloride (Narcan) and had not overdosed?
Nothing. They need to be treated for their medical condition
Who can/should receive a prescription of naloxone hydrochloride (Narcan)?
Public health workers, family of those with addiction and patients with addiction
What is CARA, and what is its significance?
Comprehensive Addiction and Recovery Act (CARA) of 2016. This new law expanded the authority of APRNs to treat opioid addictions with buprenorphine in office-based settings. This is an expansion of APRNs’ ability to be on the front line in drug treatment.
What is MAT?
Medication-Assisted Treatment
What is the difference between Suboxone and Subutex?
Suboxone is a combination of Naloxone and Buprenorphine. This has buprenorphine a partial-agonist and naloxone an antagonist. Subutex is buprenorphine alone.
Discuss the Mu receptor effects and examples of meds that activate
○ Demonstrates the classic effects associated with opiates:
■ Analgesia
■ Respiratory Depression
■ Euphoria
○ Examples = morphine (Kadian), meperidine (Demerol® ), fentanyl (Sublimaze®), sufentanil (Sufenta® ), and hydromorphone hydrochloride (Dilaudid®)
Discuss the Kappa receptor effects and examples of meds that activate
○ Analgesia
○ Sedation
○ Examples = Nubain and Stado
Discuss the Delta and Sigma receptors effects
○ Dysphoria
○ Hallucinations
Discuss full agonist opioids
opioids that bind to mu-opioid receptors in the brain. This produces endorphins and gives pain relief.
Discuss partial agonist opioids
bind primarily to mu-opioid receptors and cause them to produce endorphins to a much lesser extent than full agonists. Increasing dose of partial agonists results in a much smaller increase in endorphin release, if any. *Giving a partial agonist to someone who is addicted and using a full agonist can trigger withdrawal.
Discuss opioid antagonists
Bind to the mu-opioid receptors but don’t stimulate the production of endorphins. Prevent other opioids from stimulating the mu receptors.
What is the difference between affinity and activation of receptors?
Affinity- the binding strength with which a drug physically binds to a receptor. Subutex has a strong affinity and it will displace full agonists such as heroin.
Activation of the receptor is based on the agonist or antagonist properties of the medication.
Can you list important patient education for patients being treated with opioids?
● alcohol with opiates (increased risk of respiratory depression)
● Sharing is illegal
○ Sharing opiates with opiate naive individuals could be fatal
● S&S of overdose
● non-opiate meds can increase risk of overdose
● dosing schedule & expected onset of action
● Sedation effects
○ work & school
● child & safety storage
What is the CDC’s recommendation for the length of treatment for acute pain with opioids to prevent addiction?
<7 days (ideally ≤3 days) of medication when initiating opioids could mitigate the chances of unintentional chronic use
What is a prescription drug monitoring system (PDMS), a prescription drug monitoring program (PDMP), and how does it help combat drug misuse?
This database contains information regarding all
scheduled medications prescribed to a patient, including who prescribed them and the amount prescribed. State-specific databases
What are pain contracts, and how do they impact primary care?
Patients in pain management will have contracts that state if they get controlled substances from any other provider, they are discharged from care.
How is it possible that giving an opioid-addicted person an opioid receptor partial agonist can trigger withdrawal?
Partial agonists have a greater affinity for the receptor sites than full agonists. Giving a partial agonist to someone who is addicted and using a full agonist can trigger withdrawal.
What are the effects of opioid use in the preconceptual period?
Opioid use in the periconceptional period appears to be associated with a 2.2-fold increased risk of neural tube defects.
What are the FDA’s recommendations on using codeine and tramadol in children?
FDA is restricting the use of codeine and tramadol medicines in children.These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years
Explain how codeine affects breastmilk and the breastfed infant in an ultrarapid metabolizer.
Codeine is a prodrug that must be metabolized to become active. There are case reports where the infants of ultrarapid metabolizers who breastfed died.
What is the level of evidence for the three medications FDA approved for fibromyalgia?
Grade A
What is the level of evidence for opioids and muscle relaxants for fibromyalgia?
Muscle relaxants: B
Opioids: C
