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Pharmacy 255 > Pain > Flashcards

Pain Flashcards

1
Q

Which gender experiences more chronic pain?

A

females especially >65 years old

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2
Q

What ethnicity has the highest rate of chronic pain in Canada?

A

FN

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3
Q

What time frame is acute pain?

A

<3 months

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4
Q

What is nociceptive pain?

A

sharp aching or throbbing pain,

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5
Q

What is somatic pain?

A

Skin bone joint

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6
Q

What is visceral pain?

A

internal organ- more dull cramping pain

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7
Q

What is neuroplastic pain?

A

damage to nervous system, burning or shooting pain

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8
Q

What is nociplastic pain?

A

sensitization of pain to nervous, chronic

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9
Q

What are the steps of nociceptive pain?

A

Transduction-stimulus found
conduction-action potential
transmission- up spine
perception-becomes conscious
modulation- if needing to heighten pain

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10
Q

What is difference between noxious and innocuous?

A

noxious= harmful

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11
Q

What nerve fiber is fast conduction? What is slow?

A

Fast- A gamma
Slow- C fiber

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12
Q

What type of pain is felt by each fiber?

A

A- sharp localized
C- achy

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13
Q

What neurotransmitters are released when in spine?

A

glutamate and substance P

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14
Q

What neurotransmitters are needed to inhibit pain?

A

endorphins, GABA, NorE, Serotonin

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15
Q

What tool can we use to assess pain?

A

Wong baker faces
PQRSTU

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16
Q

What are red flags for back pain?

A

bladder dysfunction, lax anal sphincter, motor weakness in lower body

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17
Q

What is some nonpharm for pain?

A

cold if less than 48 hours
heat after 48 hours
move!!!

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18
Q

How does acetaminophen work?

A

stop prostaglandins and stop pain impulse generation

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19
Q

What is dosing for acet?

A

1000mg q4-6 max of 4 grams

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20
Q

How does NSAIDs work?

A

stop COx1+2

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21
Q

When is NSAIDs contraindicated?

A

under 40 ml/min, HF, MI

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22
Q

Which COX is good for heart and which is good for stomach?

A

Heart-CoX 2
GI- Cox 1

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23
Q

Which options are more cox 2 selective? Which are COX 1?

A

2- Diclofenac, ketorolac
1-Ketoprofen and aspirin

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24
Q

What is dose for ASA?

A

max 4 grams a day

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25
Q

What is ibuprofen dose?

A

max 2400 mg a day

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26
Q

What is most neutral NSAID?

A

naproxen

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27
Q

When will you have Gi risk for NSAIDs?

A

2 risk factors= high risk
greater than 60, history of bleed, on anticoag

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28
Q

What can we do if risk of gi from NSAIDs?

A

misoprostol or PPI

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29
Q

What factors make you at risk of renal issues with NSAIDs?

A

greater than 70
renal disease,
HF
diuretics

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30
Q

What is pros of Celecoxib?

A

selective for COX 2= less gi risk and minimal platelet interactions

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31
Q

What are issues with Celecoxib?

A

CYP 2C9 and renal issues

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32
Q

What is dosing for celecoxib?

A

400 mg on first day then 200 the next 5 days

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33
Q

IN regards to pregnancy, what is process for NSAIDs?

A

dont recommend
ASA low dose maybe
Issues with ductus arteriosus

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34
Q

How long can you use muscle relaxants for?

A

1-2 weeks

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35
Q

S/e of relaxants

A

drowsy, falls,

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36
Q

What are the muscle relaxants?

A

methocarbamol
baclofen
cyclobenzaprine

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37
Q

What do muscle relaxants actually do?

A

sedation then maybe relax?

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38
Q

True or false Acet has anti inflam?

A

False

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39
Q

When should you refer after using NSAIDS or acet?

A

exceeding 10 days in adult

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40
Q

Why does cyclobenzaprine so anticholinergic?

A

similar structure to TCA

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41
Q

What is chronic secondary pain?

A

pain originates as a symptoms from a different condition

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42
Q

What is chronic primary pain?

A

persist longer than 3 months, not caused by another condition

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43
Q

What is a tuning fork used for in pain?

A

for neuropathic pain

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44
Q

What is. first line for pain?

A

non-pharm

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45
Q

What is first line DRUG for low back pain?

A

NSAIDs

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46
Q

What are some back up meds for low back pain?

A

Duloxetine= FOR CHRONIC
TCA= not alot of evidence

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47
Q

How good is placebo generally in pain studies?

A

40% improvement

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48
Q

How often should NSAID trial be reassessed?

A

every 6-12 months

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49
Q

For neuropathic pain what is our go to drugs?

A

Duloxetine
Pregab
Gabapentin

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50
Q

WHat is the recommended dosing for duloxetine for Low back pain?

A

60 mg/day

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51
Q

What is the recommended dosing for duloxetine for neuropathic pain?

A

40-120mg/day

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52
Q

What is recommended dosing of pregabalin for neuropathic pain?

A

usually 300 mg/day
divided BID-TID

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53
Q

What is recommended dosing of gabapentin for neuropathic pain?

A

1800mg/day divided TID-QID

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54
Q

What are back up drugs for neuropathic pain?

A

TCA

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55
Q

What is the drug given for trigeminal neuralgia?

A

CBZ-200 QID

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56
Q

What is dosing for TCA for neuropathic pain?

A

Amitriptyline= 25-100mg/day
Nortriptyline= 25-100 mg/day

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57
Q

What is stepwise approach for neuropathic pain?

A

Gabapentins, SNRI,
TCA
Tramadol/Opiods
Cannabinoids

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58
Q

What is the main issue with cannabinoids for neuropathic pain?

A

HIGH NNH

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59
Q

What is a non RX measure for neuropathic pain?

A

capsaicin

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60
Q

Why do studies have issues coming up with quality evidence in pain studies?

A

pain is subjective= bias, confounding
some outcomes arent clinically significant
short trials so we dont know longterm benefit

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61
Q

Why arent other anticonvulsants (topiramate and oxcarbazepine) used more for neuropathic pain?

A

More D/C from side effects

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62
Q

Main S/e of gabapentinoids?

A

Sleepy, dizzy

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63
Q

Which gabapentinoid may have better tolerability?

A

Pregabalin

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64
Q

Why is CMZ such a shitty drug?

A

Lots of cyp interactions- 2C9, 3A4, 1A2

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65
Q

How long does it take to see benefits of medication for neuropathic pain?

A

weeks

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66
Q

WHat is MOA of gabapentinoids?

A

block release of excititory transmitters by binding to calcium channels

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67
Q

Where are gabapentinoids cleared?

A

renally only

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68
Q

Which TCA is a pro drug?

A

amitriptyline

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69
Q

WHen should you take TCA?

A

before bed

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70
Q

MOA of TCA?

A

stop reuptake of serotonin and Norepinephrine

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71
Q

What drug interaction are we worried about with TCA?

A

2D6

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72
Q

Which TCA is more tolerated?

A

Nortriptyline

73
Q

What are symptoms of withdrawl?

A

Flu like
Insomnia
Nausea
Imbalance
Sensory distrubance
hyperactivity

74
Q

What is fibromyalgia?

A

diffuse body pain for 3 months, nociplastic pain

75
Q

Who usually gets fibromylagia?

A

early 20-30s

76
Q

What is the most effective treatment for FM?

A

exercise= better than any drug
and CBT

77
Q

What drugs for FM?

A

same as neuropathic
fluoxetine can be used as well

78
Q

What are the opiates?

A

morphine, opium, codeine

79
Q

What are the receptors opiods act on?

A

mu
delta
kappa

80
Q

What does mu receptors do?

A

addiction, analgesia, resp depression, sedation, constipation, euphoria

81
Q

What does delta receptors do?

A

analgesia, euphoria, addiction

82
Q

What does kappa receptors do?

A

analgesia, sedation

83
Q

Where do opiods act?

A

central and peripherally

84
Q

For acute pain what is max dose and duration

A

no more than 50 MEQ and 5 days

85
Q

Why are opioids shit?

A

Bad S/e
dependence
no good study evidence
no change in functional outcomes
pain intensity was worse for opoids

86
Q

Should you start opioids if addiction?

A

NO

87
Q

What should be max opioid dose?

A

<90 MEQ

88
Q

WHat is duration of immediate release opioids?

A

4-6 hours

89
Q

What are some immediate release opioids?

A

hydromorphone,

90
Q

What indicates it is continuous release?

A

contin

91
Q

How much more potent is IV opioids compared to oral?

A

2 times

92
Q

Should you ever use a CR opioid for acute pain?

A

NEVER

93
Q

Does morphine have active metabolites

A

yes

94
Q

When is renal failure contraindicated for opioids?

A

<20-30 ml

95
Q

What is Codeine’s MEQ?

A

0.15

96
Q

What is special about codeine?

A

pro drug, needs CYP 2D6

97
Q

What are bad inhibitors of CYP 2 D6?

A

clarithromycin and ketoconazole

98
Q

At what dose is codeine maybe antitussive?

A

> 15 mg q4-6

99
Q

What is MEQ of Oxycodone?

A

1.5 times

100
Q

Which is better, adding naloxone or laxative for opioid constipation?

A

neither

101
Q

What is MEQ of hydromorphone?

A

5 times

102
Q

What is special about hydromorphone?

A

good in renal impairment

103
Q

What is effects of morphines metabolites?

A

6= analgesic
3= CNS stim

104
Q

WHat is codeine metabolized into?

A

Morphine

105
Q

What is special about tramadol MOA?

A

not just mu, also serotonin and norepinephrine, PRODRUG

106
Q

What are the cons of tramadol?

A

more seizures, Qt prolongation, serotonin syndrome, 2D6, dont know proper dose

107
Q

What do you need to know about tapentadol?

A

same as tramadol but less nausea

108
Q

What is MEQ of fentanyl?

A

100 x`

109
Q

When is fentanyl used?

A

if cant take oral, it is a patch, and for renal impairment

110
Q

Who is fentanyl not for?

A

obese, ascites, super sweaty

111
Q

Counseling points for fentanyl patch?

A

every 3 days, different site, dispose dont touch sticky

112
Q

How does methadone work?

A

on mu and NMDA=prevent tolerance and potentiate analgesic

113
Q

How is methadone cleared?

A

hepatic

114
Q

WHat are the risks of methadone?

A

long half life= potential for overdose
Qtc prolongation and serotonin syndrome

115
Q

What exam should you do if giving methadone?

A

baseline ECG

116
Q

How do you dose methadone?

A

chart to do it. the higher the dose you need for methadone the more morphine it ‘counteracts’

117
Q

How frequently should you increase dose of methadone?

A

every 5 days

118
Q

Is it ok to abruptly stop methadone?

A

NO

119
Q

Why is there a risk of resp depression with methadone?

A

slow onset so you dont know when it happens

120
Q

For opioid naive patients, what should you start buprenorphine dose at?

A

5 mcg/hr q7 day patch up to 20

121
Q

What opioids can you switch to buprenorphine for pain?

A

Only if under 90 MEQ because max dose is low

122
Q

True or false: Oral naloxone is better than IM?

A

NO ORAL DOES NOTHING

123
Q

MOA of naloxone?

A

mu partial agonist= saturate so cant overdose
delta and kappa antagonist

124
Q

Is naloxone safe in renal or hepatic impairment?

A

YES

125
Q

What is sx of a pseudo allergy of opioids?

A

flush, itch, hives because histamine release side effect

126
Q

Do opioids or opiates have more pseudoallergies?

A

Opiates more

127
Q

What are sx of true allergy to opioids?

A

severe hypotension, skin reaction other than flush, itch or hives, breathing issues and swelling of face

128
Q

S/E of opioids?

A

Sedate
resp depression
constipation
nausea
miosis
itching

129
Q

Which s/e of opioids will tolerance develop?

A

All except miosis and constipation

130
Q

What is the issue with tolerance to resp depression with opioids?

A

quickly lost if increase dose or no opioids for a few days

131
Q

How long to get tolerance to sedation?

A

3-10 days or NEVER

132
Q

What are chronic s/e of opioids?

A

hypogonad
sleep apnea
pain

133
Q

What are drug drug interactions with opioids?

A

CNS depressants
MAO
QT
CMZ

134
Q

How does hypogonadism happen from opioids?

A

influence hypo and pit axis which can lower cortisol and increase prolactin and decrease other sex hormones

135
Q

Is hypogonadism dose related or duration?

A

duration

136
Q

Does methadone also cause hypogonadism?

A

YES

137
Q

Regarding sleep apnea and opioids, what is important?

A

called central sleep apnea
more severe and longer in NREM
makes CPAP less effective

138
Q

What is suggested MOA of hyperalgesia of opioids?

A

on NMDA sensitize= more glutamate released

139
Q

What is a good option if opioid hyper algesia?

A

methadone and naloxone

140
Q

Who is at risk of opioid use disorder?

A

if history of substances
>90 days or >120 MEQ

141
Q

How can we screen for OUD before opioids and during?

A

before: ORT
During: POMI and COMM

142
Q

What are signs of an overdose from opioids?

A

difficulty walking, talking or staying awake
blue lips
cold and calmmy
confused
drowsy
gurgling
no breathing

143
Q

If someone is overdosing what should be done?

A

give naloxone and call 911

144
Q

How does naloxone help with overdose?

A

binds more tightly than opioids to the same receptors
fix breathing in 2-5 min
effects wear off in 30-90 min

145
Q

What to do if acute exacerbation of chronic pain?

A

use short acting opioids, may need higher doses cause tolerance, adjunctives

146
Q

How does opioids effect sleep other than drowsy?

A

decrease mood and sleep quality

147
Q

Is naloxone only for OUD?

A

NO

148
Q

How long until tolerance to opioids will happen?

A

3 months

149
Q

For opioid Naive how much opioid do you give and what kind to start with?

A

5-10 MEQ for a single dose and use IR for easier adjustment

150
Q

When do harms of opioids (overdose/death) start to happen?

A

doses >50 MEQ

151
Q

What patients should start at an even lower dose

A

really old
really small
sleep apnea
impaired clearance
gi obstruction

152
Q

When is onset opioid analgesia?

A

15-30 minutes

153
Q

How is optimal dose of opioids reached?

A

at least 30% pain reduction, plateau point
adverse effects

154
Q

What is known about using opioids for breakthrough pain?

A

better to use other ways
leads to dose increases

155
Q

How frequently should you reassess opioids?

A

q2-4 weeks

156
Q

What can we do to limit OUD?

A

ask for a pill count, limit quantity
one opioid prescriber and one pharmacy
urine test q6 months

157
Q

What is considered a failed opioid trial?

A

not enough pain relief after 2-3 dose increases, bad s/e, medical complications, OUD,

158
Q

Which people should not enter taper of opioids?

A

Pregnant= withdrawal can induce labour/abortion
pysch unstable
OUD

159
Q

When is it needed to taper opioids?

A

if > 1 week of regular use

160
Q

What are symptoms of opioid withdrawal?

A

anxious, sweaty, pain, teary eyes, tremour, fever, nausea, irritable, low body temp

161
Q

How can we help with withdrawal sx?

A

Clonidine helps with insomnia, nausea, sweaty, anxiety
NSAIDS= pain
Loperamide= bowels
Gravol= Gi
Hydroxyzine= anxiety
Trazodone= Insomnia
Oxybutinin= sweaty

162
Q

What is MOA of clonidine?

A

alpha 2 agonist and has s/e that help with withdrawal

163
Q

What is the usual course of a taper with opioids?

A

decrease of 5-10% weekly and go slower at last 1/3 of dose

164
Q

What other strategies to taper opioids?

A

cross over rotation taper= go with a different opioid at 75% due to less tolerance

165
Q

What should be done if pain from withdrawal?

A

may stop usually 2 weeks before continuing

166
Q

Who would do a rapid taper of opioids?

A

done in 1-2 weeks
for people at high risk or highly motivated

167
Q

When doing cross rotation tapering what must be done?

A

after rotation pause for a month then do it again

168
Q

If the patient was on a dose of 250 mg total daily what should hes cross rotation dose be?

A

50% original because >200

169
Q

Why is cross roation not done?

A

confusing risk of two opioids

170
Q

Who should be on Opioid Agonist therapy?

A

if on for longer than 5 years, psych issues, OUD, hyperalgesia, pregnant

171
Q

What are the effects of THC?

A

euphoria, appetite, BP and anxiety too

172
Q

What are the effects of CBD?

A

potential antiinflammatory and anti anxiety

173
Q

If using cannabis what route?

A

ORAL

174
Q

Short term effects of cannabis?

A

anticholinergic
lower learning and memory, risk of MI 1 hour after smoking

175
Q

Long term effects of cannabis?

A

cog impairment
anxiety
dependence
hyperemesis

176
Q

DI with cannabis?

A

depressants, anticholinergic, CYP interactions

177
Q

What are Rx cannabis?

A

nabilone, nabiximols

177
Q

Is store bought cannabis okay?

A

NO use RX

177
Q

What type of pain is cannabis good for?

A

refractory neuropathic pain

Pharmacy 255 (16 decks)

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