Nurs 605 Module 4 Flashcards
What is acute pain?
Acute pain: most common experience by patients, short term and temporary, lasting minutes or weeks
What is chronic pain?
Chronic pain: pain that lasts beyond tissue healing time or pain that lasts > than 3 months
What is nociceptive pain?
pain of the muscles, can be divided into somatic and visceral pain
somatic is localized where visceral is deep organ pain
What is neuropathic pain?
pain described by a compression of the nerves
What is the mechanism of action of acetaminophen and what is the maximum adult dose? what is the max dose for chronic pain?
anti-pyretic analgesic no anti-inflammatory effects max dose in adults 4000mg/day max dose with chronic pain 3200mg/day
What is the mechanism of NSAIDS?
antipyretic
analgesic
anti-inflammatory affects
inhibits prostaglandins, causes GI side effects
equally potent to opioids
inihibits COX pathways that decreases pain
What are some classes of NSAIDS and what are the common NSAIDs/
salicylates-ASA COX 2 inhibitors-celecoxib proprionic-ibuprofen, naproxen indoles-indomethacin others-ketoralac, diclenofonac
Describe COX 1 and why is it important? How do NSAIDS work on COX 1?
COX 1- inhibits prostaglandins; decreased platelet aggregation = increased GI side effects and thinning of blood most adverse effects are from COX 1
What is COX 2?
another production of prostaglandin
increased platelet aggregation-better GI symptoms buit increased cardiovascular risk
What are some adverse effects of NSAIDs?
CNS: tinnitus, headache
Renal: renal insufficiency
GI: abdo pain, nausea/vomiting, ulcers
How would you manage the GI side effects of NSAIDs?
stop the drug if needed misoprostol-decreases risk of GI ulcers PPIs antacids rantidine
Why can you not take lithium with NSAIDs?
medication interaction, lithium levels can increase in the serum levels with use of NSAIDs
Opioid vs. opiate
opiate- natural derivative of the opium poppy
opioid- synthetic creation of opiates such as hydromorphone
How is codeine made?
derived from morphine in the opium poppy
Describe the mechanism of action of opioids
works on the Mu receptor in the brain
gives the morphine like effects: sedation, analgesia, respriatory depression, bradycardia, euphoria
What dosage would you start on someone who is opoioid naive?
morphine2.5mg-10mg PO q 4 hours
What is incident pain?
predictable pain that may worsen with activity or movement
short in duration, acute and severe
What can you provide prior to incident pain?
fentanyl or sufentanil transmucosal
very potent, very quick acting
What can you provide prior to incident pain? What is the suggested dose?
fentanyl or sufentanil transmucosal
fentanyl 25-50mcg SL
sufentanil 12.5mcg SL
very potent, very quick acting
A patient is not responding to pain, what may be some factors contributing to this?
pain is greater than estimated not adherent genetics-low levels of CYP 2D6 which cannot activate codeine into morphine=no levels of analgesic interactions intolerative
What are some adverse effects with opioids?
resp depression pruritis constipation nausea/vomiting sedation
Describe how to manage respiratory depression in a patient taking opioids?
could be opiate naive
could be increasing in metabolites because of decreased renal clearance
excessive doses
stop offending drug, nalaxone if needed
Why does nausea and vomiting occur in individuals taking opiiods?
decreased gastric motility
tolerance develops in 3-4 days
can take antiemetics
Describe neurotoxicity and How would you manage neurotoxicities?
increased metabolites in the system
causes CNS changes-confusoin, hallucinations
incresaing pain despite increasing opioid
discontinue or lower the opiod dose
Why does constipation happen with opioids and how would you manage it?
opioids causes decreased peristalsis and increased water absorption
not a tolerance
needs to give laxatives such as senna or lactulose with opioids
Which opioid most commonly causes pruritis and how woul dyou manage it?
morphine
can take hydroxyxine or diphenhydramine for relief
Opiods cause sedation, why does this happen?
may be a successful analgesic dose
persistent sedation may indicate another concern
tolerance builids in 3-4 days
Describe some adjuvant analgesics
adjuvant analegesics used alongside the opioid for pain
What would you use in bone pain as an adjuvant analgesic?
NSAIDs
just as good as opioids, may be able to decrease the opioud dose
use lower risk medications such as ibuprofen, naproxen
When would you use trycylcic analgesics as an adjuvant analgesic?
neuropathic pain
amytriptyline, nortryptyline
What are some tools used to manage opioid use?
UDS, questionnaires
limited prescribing
using a contract, goal setting with patient
Describe the process in an opioid trial?
opiiouds should only be prescribed short term
assess for benefit-will be noticed early in 2-6 weeks
risks of addiction
How would you evaulate an opioid trial?
Trial success? benefits noticed, improvements in function, decreased pain, safety maintained, little to no side effects
Failed: signs of misuse, harm or diversion, no reduction in pain, no increase in function, intolerance to opioids
What are some factors to consider prior to prescribing opioids?
patient safety efficacy of the drug goal setting drug interactions prepare to stop or change if not helping
Describe some considerations of codeine
weak Mu agonist
CYP 2D6 inhibitor and/or inducer
1-10% of population either rapid or slow metabolizers
slow metabolizers don’t get analgesic effect, cant conver to morphine; can lead to toxicity
rapid metabolizers - cant also get opioid toxicity as rapid metabolism
Descrive some considerations of oxycodone/oxycontin
mu, delta, kappa receptor
CYP 2D6/3A4 inhibitor or inducer (messy metabolism)
not tamperproof, addictive
considerations when taking-gels when gets wet, don’t lick
take with full glass of water
contraindicted in those who can’t swallow
Describe considerations of fentanyl
very potent
do not use in opoiod naive patients as can be difficult to convert
patches can have residual medication on them, handlw e with care
clean with water only, no alcohols or soaps as this can add to residual effect
renal and heptatotoxic-contraindicated and cautioned in elderly and renal/hepatotixc concerns
serotonin toxicity
How long does it take for fentanyl patchesto reach steady state?
6 days
What are some risks when prescribing buprenorphine patches?
can precipitate opiate withdrawl
morphine equivalen to <30mg if switching
qT prolongation
naloxone not effective to reverse overdose
increased drug interactions-can’t use if using MAOi’s in 14 days
Is tramadol an opioid? what are the adverse effects of tramadol?
yes! different prescribing rules
many mechanisms of action
nalaxone in OD may cause seizures
serotonin toxicity
What is serotonin toxicity and what drugs can cause this?
SCAN can be caused by increase of opioids plus other serotonin reuptake drugs
fentanyl, tramadol, bupenorphine
serotonin toxicity
consciousness- anxiety, agitation, delirium, hallucinations
autonomic- hypertension, nausea, vomiting, diaphoresis
neuromuscular-rigidity, tremors, jerks
What are the benefits of suboxone?
any NP can prescribe as long as they take a course=greater access
decreased risk of drug interactions
quicker to get to therapeutic dose
decreased risk of respiratory depression
Describe the mechanism of action of suboxone
split into bupenorphine and naloxone
bupenorphine: partial opioid agonist; ceiling effect; higher affinity to receptors; binds to the mu receptors to prevent withdrawl but also maintain comfort
naloxone: specially as a deterrant for aberrant behaviours; injection can cause full withdrawl; opooid antagonist
What is the route of administration of suboxone and why?
SL route only, needs to activate through the mucousal membrane
cannot inject as nalaxone is in it as a deterrent
oral route of this drug means no therapeutic effect
What are the indications for use of suboxone
opooid use disorder only
What assessment is required for suboxone initiation?
health and medical assessment UDS substance use history drugs labs
What are the contraindications for use of suboxone?
respiratory depression
liver dysfunction
ETOH use
delirium tremens
What are the drug interactions when using suboxone?
ETOH
benzos, CNS depressants
MAOIs esp within 14 days
herbal, st johns wort
What are the doses of suboxone available in Canada?
subxone 2mg/0.5mg
8mg/2mg
12mg/3mg
16mg/4mg
You want to start a suboxone induction on a patient; why do patients have to be in moderate withdrawl prior to starting suboxone?
must be in withdrawl 12-24 hours
can be put into precipitated withdrawl if lots of opioids are still in their system
What tool do you use in clinic to start suboxone on a patient?
COWs scale
measures their state of withdrawl
What score on a COWs scale warrants a suboxone start? what dose would you give them? What if their score is greater than 24?
> 12 can start suboxone
start with 2mg/0.5mg or 4mg/1mg (if at risk of precipitated withdrawl, start with 2mg)
24 give 6mg/1.5mg dose
What is the maximum amount of suboxone you can give on day 1 of induction? day 2? day 3?
day 1: 12mg/3mg
day 2: 16mg/4mg
day 3: 24 mg/6mg
Your patient has taken their maximum dose of suboxone on day 1 but is still having withdrawl symptoms; what would be your next step?
can’t give anymore
attempt to give medications to make them more comfortable until next day
clonidine, antiemetics, antidiarrheals, analgesics etc
What is the dosage of suboxone used to titrate patients up?
2mg/0.5 or 4mg/1mg
You and a patient agree to do a home induction of suboxone; what score must the patient be at for their SOWs prior to starting suboxone?
> 17
start with 2mg/0.5mg
What dose of suboxone will you give your patient if they missed their 16mg/4mg suboxone 4 days ago?
same dose if 5 days or less
if greater than 7 days cut by half or consult
