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NAPLEX 2022 > Pain > Flashcards

Pain Flashcards

1
Q

Define nociceptive pain.

A

Pain that occurs when sensory nerves (nociceptors) identify tissue damage.

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2
Q

Pain that does not result in tissue injury or damage but from damage or malfunction of the nervous system is commonly referred to as?

A

neuropathic pain

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3
Q

Examples of Neuropathic pain

A

Fibromyalgia

Diabetic neuropathy

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4
Q

What analgesic regimen is indicated for mild pain (1-3)?

A

Non-opioid +/- adjuvant

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5
Q

What analgesic regimen is indicated for moderate pain (4-6)?

A

Opioid for mild-moderate pain +/- Non-opioid +/- adjuvant

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6
Q

What analgesic regimen is indication for severe pain (7-10)?

A

Opioid for moderate-severe pain +/- Non-opioid +/- adjuvant

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7
Q

Acetaminophen -

Brand/Drug Class/MOA/MDD/Dosing <12 yoa/Boxed Warning

A

Brand: Tylenol

Drug Class: antipyretic

MOA: inhibit prostaglandin synthesis

MDD: < 4g/day

Dosing in pediatrics: 10-15 mg/kg Q4-6H using 160mg/5mL

Boxed Warning: hepatotoxicity if > 4g/day

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8
Q

Antidote for acetaminophen overdosage

A

N-acetylcysteine (NAC)

based on serum level and time since ingestion

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9
Q

NSAIDs MOA

A

1) Non-selective NSAIDs blocks both COX enzymes
2) COX-2 selective NSAIDs blocks COX-2 only - decreasing GI risk (b/c COX-1 protects the gastric mucosa)
3) Aspirin is an irreversible COX-1 and 2 inhibitor and is an effective antiplatelet - cardioprotection

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10
Q

NSAID use is contraindicated after what type of surgery?

A

Coronary Artery Bypass Graft (CABG) but only aspirin is recommended due to the antiplatelet effects

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11
Q

Side effects of all NSAIDs

A 
Increase BP (avoid in uncontrolled HTN)
Photosensitivity
Premature closure of the ductus arteriosus (if used in 3rd trimester)
Nausea/dyspepsia (take with food)
Abdominal pain ~ likely due to GI bleed
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12
Q

What NSAIDs can be used within 14 days after birth to close a patent ductus arteriosus (PDA)?

A

IV indomethacin or ibuprofen

in most cases the PDA closes on its own

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13
Q

What is ductus arteriosus (DA)?

A

It’s a duct that connects the pulmonary artery to the aorta, allowing oxygenated blood to flow to the baby, bypassing the immature lungs.

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14
Q

Ibuprofen dosing in adults & pediatrics

A

Adults: MDD 3.2g/day

Pediatrics: 5-10 mg/kg Q6-8H

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15
Q

How often is Naproxen dosed?

A

BID

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16
Q

Which NSAIDs increase COX-2 selectivity and have a lower risk for GI complications but still have a high risk for MI/stroke, as well as the same risk for renal complications?

Generic/Brand

A

celecoxib (Celebrex)

diclofenac (Voltaren)

meloxicam (Mobic)

nabumetone

etodolac

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17
Q

What drug is used to replace the gut-protective prostaglandins to decrease GI risk?

A

Misoprostol

Also used to increase uterine contractions (terminate pregnancy) and causes cramping and diarrhea

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18
Q

Which NSAID has the highest COX-2 selectivity and should be avoided if patient has a sulfa allergy?

A

celecoxib (Celebrex)

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19
Q

Name the salicylate NSAID and what’s the dosing?

A

Aspirin (Acetylsalicylic acid)

Cardioprotection dosing: 81-162 mg/day

**Avoid in children & teenagers due to Reye’s Syndrome (sx: somnolence, N/V, lethargy, & confusion)

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20
Q

Yosprala contains what agents?

A

Omeprazole + Aspirin

*PPIs used to protect the gut with chronic NSAID use**

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21
Q

Counseling point if patient is taking both aspirin and ibuprofen

A

If aspirin is used for cardioprotection and ibuprofen for pain, take aspirin 1 hour before or 8 hours after ibuprofen.

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22
Q

Concurrent use of NSAIDs with Lithium and MTX can do what to which levels?

A

NSAIDs can increase the levels of Lithium & MTX

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23
Q

Name a non-salicylate drug.

A

magnesium salicylate (Doan’s Extra Strength)

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24
Q

Name the topical products that contains methyl salicylate.

A

Bengay, IcyHot, & Salonpas

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25
Q

When a higher opioid dose is needed to produce the same level of analgesia, this is due to what?

A

Tolerance

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26
Q

When physical withdrawal symptoms occur when an opioid is stopped or a dose is missed, this is called?

A

Dependence

27
Q

Sharp spikes of severe pain that occur despite the use of an ER opioid such as transmucosal immediate-release fentanyl (TIRF) drugs, is called?

A

Breakthrough pain and only indicated for cancer patients

28
Q

MOA of opioid analgesics

A

mu receptors agonists that produce pain relief but can also cause euphoria and respiratory depression

29
Q

What scheduled classes are the different formulations of codeine?

A

C-II: codeine tablet

C-III: tablet/capsule combination products (ex: Tylenol #2/3/4)

C-IV: oral solution combination products (Cheratussin AC)

30
Q

Boxed warnings of opioids & Side effect

A

Respiratory depression & death

Avoid use in ultra-rapid metabolizers of codeine due to a CYP450 2D6 polymorphism

SE: constipation

31
Q

What is the brand name of fentanyl oral transmucosal lozenge on a stick “lollipop?”

A

Actiq

32
Q

fentanyl dosing

A

1 patch Q72H

33
Q

When can a patient start fentanyl patches?

A

A patient who has been using equivalent to morphine 60 mg/day or more for at least 7 days can be converted to fentanyl patches.

34
Q

Duragesic patches can be covered ONLY with what 2 permitted adhesive film dressings?

A

Bioclusive or Tegaderm

35
Q

What is the dose acetaminophen in hydrocodone IR?

A

325 mg APAP

36
Q

Dilaudid

Generic/Dosing

A

Generic: hydromorphone

PO: 2-4 mg Q4-6H PRN

IV: 0.2-1 mg Q2-3H PRN

  • *potent, start low and titrate due to high risk of overdose
  • *med error w/ high potency, use in opioid-tolerant patients only
37
Q

What opioid agent (brand/generic) is a major CYP3A4 substrate that has a life-threatening boxed warning for QT prolongation and can decrease testosterone and contribute to sexual dysfunction?

A

methadone (Dolophine)

38
Q

Which opioid is no longer recommended as an analgesic due to its short duration and its serotonergic effects?

(generic/brand)

A

meperidine (Demerol)

39
Q

What are morphine brand names & side effect.

A

ER: MS Contin, Kadian

Injection: Duramorph, Infumorph

SE: Pruritus (diphenhydramine can be given to block histamine-induced pruritus)

40
Q

Which opioids are CYP3A4 substrates?

A

Fentanyl
Hydrocodone ER
Oxycodone
Methadone

41
Q

Which oxycodone brand is taken on an empty stomach?

A

Opana

42
Q

Brand names of oxycodone formulations

A

IR: Roxicodone

CR: OxyContin

+ acetaminophen: Endocet or Percocet

43
Q

Opioid Drug Interactions

A

Avoid concurrent use with BZDs & Etoh

Do not use in patients with COPD or sleep apnea (increase risk of hypoxemia)

Avoid use with CYP3A4 inhibitors

44
Q

Opioid Dosing Conversion

A

**round down to reduce risk of overdose

Morphine - 10mg (IV/IM) - 30 mg (PO)
Hydromorphone - 1.5 mg (IV/IM) - 7.5 mg (PO)
Oxycodone - 20 mg (PO)

45
Q

Opioid allergy

A

Common drugs in the same chemical class that cross-react with each other have “cod,” “morph,” or “norph” in the name.

CODeine
hydroCODone
oxyCODone
MORPHine
hydroMORPHone
oxyMORPHone 
bupreNORPHine
46
Q

What drug is first-line for opioid-induced constipation?

A

Stimulant laxatives, including senna with or without a stool softener.

bisacodyl tablet - prophylaxis
suppository - treatment

47
Q

If patients failed therapy with stimulant laxatives +/- stool softeners. What is an alternative treatment?

A

Peripherally-acting mu-opioid receptor antagonists “PAMORAs”

       - methylnaltrexone (Relistor) 
       - naloxegol (Movantik)

Chloride channel activators - lubiprostone (Amitiza)

48
Q

Name the centrally-acting analgesics

A

tramadol (Ultram) - C IV
- do not use w/ concurrent MAOIs or within 14 days

tapentadol (Nucynta) - C II
- increase risk of seizures

49
Q

Opioid-induced respiratory depression (OIRD) risks

A

Hx of previous overdose
Substance abuse
Using large doses (> 50 morphine mg equivalent dose)
Using with BZDs, gabapentin or pregabalin
Comorbid illness, like respiratory & psychiatric disease

50
Q

Opioid Abuse Agents

A

buprenorphine is a partial mu-agonist (agonist at low doses & antagonists at higher doses).

naloxone is an opioid antagonist; it replaces the opioid on the mu receptor.
- given alone (nasal or injection) is used for OD

buprenorphine/naloxone combination is used as alternatives to methadone.

   - buprenorphine suppresses withdrawal symptoms
   - naloxone helps prevents misuse
51
Q

Opioid overdose management

A
  1. s/sx of OD: extreme sleepiness, shallow breathing, blue/purple fingers/lips, pinpoint pupils, slow
    HR/BP
  2. Give naloxone & call 911.
  3. opioids last longer than naloxone so multiple doses may be needed, CPR may be needed
52
Q

Naloxone is available in 3 options (what are they?)

A
  1. Evzio (auto-injector): easy to administer with visual and voice instructions, each auto-injector = 1 dose (no longer available but available up to expiration date)
  2. Narcan (nasal spray): onset of action is slower than injection, a single-use nasal spray is 4 mg administered in 1 nostril, repeat PRN
  3. Naloxone (injection): multiple size vial, separate syringe will be needed, may need to repeat doses Q2-3 minutes until medical emergency arrives.
53
Q

To prescribe for opioid dependence: prescribers need what?

A

Drug Addiction Treatment Act (DATA 2000) waiver; the DEA will issue a unique identification number to the prescriber “starts with an X”

54
Q

An injectable adjuvant can be added to opioids in intrathecal (epidural) pain infusion pumps for patients with cancer pain. What drug is used?

A

Clonidine

55
Q

Which drug was approved for osteoarthritic knee pain and is administered by injection into the knee joint (intra-articular) to provide 12 weeks of pain relief without opioids?

A

triamcinolone acetonide ER (Zilretta)

56
Q

What scheduled class is gabapentin?

A

C VI

57
Q

What scheduled class is pregabalin?

A

C IV

58
Q

What scheduled class is carisoprodol? Brand?

A

C IV

Soma

59
Q

Generic & Side effect of Zanaflex

A

tizanidine

SE: hypotension & xerostomia

60
Q

Generic & Side effect of Lioresal

A

baclofen

SE: all muscle relaxants: sedation, dizziness, confusion, asthenia (muscle weakness)

61
Q

What topical adjuvant is dosed TID-QID?

A

capsaicin

62
Q

Dosing of Lidoderm? and counseling?

A

Dosing: Apply to painful area 1-3 patches/day and worn up to 12 hours/day.

can be cut | no more than 3 patches at one time

63
Q

Diclofenac gel dosing

A

Dose for hands, wrists or elbows: 2 g QID (MDD 8 g/d)

Dose for feet, ankles, or knees: 4 g QID (MDD 16 g/d)

**do not wash or bathe treated areas for at least 1 hour after application*

NAPLEX 2022 (25 decks)

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