Pain

Question 1

Opioid side effects

Answer 1

• Nausea
• Constipation
• Dry mouth
• Sedation, Somnolence
• Slowed breathing, difficulty breathing
• Nodding off

Question 1

Opioid withdrawal symptoms

Answer 1

• N&V
• Insomnia
• Irritability
• Anxiety
• Flu-like symptoms (chills, myalgia)
• Craving

Question 2

Definition of opioid tolerant

Answer 2

Opioid tolerant:

• pt has been taking for a week or longer, at least 60mg of morphine daily / 30mg of oxycodone daily / 8mg hydromorphone daily

Question 3

What drug is used to rapidly reverse an opioid overdose?

Answer 3

Naloxone (opioid antagonist)

Question 4

Which opioid can be used for chronic pain?

Answer 4

Methadone

• Mu opioid agonist + NMDA antagonist
• Reduce opioid tolerance development

The higher the baseline opioid dose, the more potent methadone is, the less the methadone dose used

May be used for pt experiencing hyperalgesia or unrelieved pain with current opioid use

SEs to monitor for Methadone:
- less euphoric SEs
- may cause QTc prolongation

Question 5

What drugs are used for SUD treatment?

Answer 5

• Methadone (mu opioid agonist)
• Naltrexone (mu opioid antagonist)
• Buprenorphine (partial opioid agonist)

Question 6

Ketamine SE

Answer 6

nightmares, hallucinations, memory defects, psychosis, somnolence, impaired motor function, confusion, disorientation, addiction

Question 7

CDC guidelines

Non-opioid therapies are _________ as opioids for acute pain

Answer 7

Non-opioid therapies are AT LEAST AS EFFECTIVE as opioids for acute pain

Question 8

CDC guidelines

________________ are preferred for subacute and chronic pain

Answer 8

Nonopioid therapies are preferred for subacute and chronic pain

Question 9

CDC guidelines

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe ________

Answer 9

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting opioids

Question 10

CDC guidelines

Start opioids at the _________ dose

Answer 10

Lowest effective dose

And prescribe no greater quantities than that needed for the expected duration of pain

Question 11

CDC guidelines

Clinicians should evaluate benefits and risks with patients within _______ of starting opioid therapy for subacute or chronic pain

Answer 11

1-4 weeks

Question 12

CDC guidelines

Before starting opioid therapy, clinicians should evaluate ______

Answer 12

Risk for opioid-related harms

• Come up with management plan strategies to mitigate risk

Others:

• Also should review patient medication history (any controlled drug use etc.)
• Consider toxicology testing
• Caution w concurrent BZDs - CNS depressant

Question 13

What are some adjuvant pharmacologics for pain?

Answer 13

1. GABA acting anticonvulsants (Gabapentin, Pregabalin)
2. SNRIs (Duloxetine)

=> 1, and 2 are first line for neuropathic pain

3. Tramadol (mu agonist + serotonin reuptake inhibitor)
4. Corticosteroids
5. Local anaesthetics (lidocaine patch)
6. NSAIDs

Question 14

What are strong opioids?

Answer 14

• Buprenorphine
• Fentanyl
• Oxycodone
• Methadone
• Morphine
• Codeine >60mg TDS
• Tramadol >400mg/day