Pain 3 Flashcards
T or F: Pain is an objective phenomenon that requires careful measurement and tx.
F
Pain is completely subjective and is whatever the pt says it is
List all therapeutic alternatives for chronic non-cancer pain:
Opioids, NSAIDs, acetaminophen, TCAs, SNRIs, anticonvulsants
Patient is on hydromorphone 10mg po daily. What’s their total daily morphine equivalents?
50mg MEQ
Patient with chronic back pain is taking Tylenol #3s (300mg acetaminophen/30mg codeine/15mg caffeine) 3 tabs po q4h for chronic back pain.
What is the patient’s total daily MEQ?
81mg MEQ
Current inpatient medication administration record for Patient A:
-Hydromorphone 1 mg subcut q4h scheduled-
What is Patient A’s total daily MEQ?
60mg MEQ
Current inpatient medication administration record for patient B: • Morphine 5mg IV intermittent q4h scheduled
• Oxycodone 5mg po q4h prn
• Used 3 x 5mg doses in last 24 hours
What is Patient B’s total MEQ in the last 24 hours?
82.5 mg MEQ
Patient C has is taking M-Eslon (morphine) SR 100 mg po q12h
• Patient C has declining renal function and her family physician is worried about CNS adverse effects of morphine and would like to change to hydromorphone
• What is the equivalent dose of hydromorphone that you would recommend for Patient C? (give dosing interval and prn dosing too)
20mg hydromorphone/d
10mg bid (q12h) (just like prev dosing regimen)
and 2mg q4-6h (10% of total daily dose)
Before turning to opioids, what must we do for pain tx?
Optimize non-opioid interventions first! > non-pharm and non-opioid tx FIRST!
T or F: Opioids are trialed and are not often intended to be used indefinitely
T
How long should an opioid trial be?
3-6 mths
Which opioids are first line for mild-mod pain?
codeine
Which opioids are first line for severe pain?
morphine, oxycodone, hydromorphone
Which opioids are second line for mild-mod pain?
morphine, oxycodone, hydromorphone
Which opioids are second line for severe pain?
fentanyl
Which opioids are third line for mild-mod pain?
No alternatives - stick w/ second-line and optimize non-pharm and non-opioid options
Which opioids are third line for severe pain?
methadone
How should the optimal opioid dose for a pt be determined?
By starting w/ a low dose and slowly titrating up in small qty’s
Maximum opioid dose for new pts?
50 MEQ/day
For all pts on opioids, what is the max opioid dose?
90 MEQ/day
What should we do if a pt is on > 90 MEQ/day?
Switch or taper down
Which population should be careful when using codeine?
Breast-feeding women > some may be fast-metabolizers and convert codeine rapidly to morphine, which may place the infant at risk of morphine tox
Which opioid increases risk of seizure?
tramadol
Which opioid should we avoid during renal dysfn?
morphine
Which opioids have a higher abuse potential?
oxycodone and hydromorphone
What should we ensure before switching an ind to fentanyl?
that they’ve been on a total daily SCHEDULED dose of at least 60 MEQ/day for ≥ 2 weeks
What opioid can we NEVER switch to an opioid from?
codeine
What should we counsel a pt on when dispensing fentanyl patches?
- be alert for signs of overdose (slurred speech, ataxia, nodding off during conversation or activity, emotionally labile)
- don’t use >1 patch at a time, nor change more often than directed
- avoid any sources of heat
- dispose patches carefully
How often should we titrate methadone?
titrate no more frequently than q5d
Why is methadone titrated in such long intervals?
due to its long t1/2
Max daily acetaminophen dose when using it chronically?
3.2g
Optimal opioid dose is reached when these three factors are balanced:
- effectiveness (at least 30% pain reduction)
- plateauing (increased doses aren’t beneficial)
- AEs are manageable
T or F: If an opioid’s dose is completely effective at dealing w/ pain, that is considered to be the optimal dose despite AEs that reduce quality of life.
F
A person’s pain goes from 8 to 3. What is the percent change of their pain?
8-3 = 5
5/8 * 100 = 62.5% reduction in pain
Common AEs of opioids
N/V, constipation, drowsiness, dizziness, dry skin/pruritus
Medical complications of opioid use:
neuroendocrine abnormalities (HPO and HPA axis probs), erectile dysfn, sleep apnea, hyperalgesia
What kinds of pts should we consider starting at lower doses of opioids?
older, reduced wt, sleep apnea, impaired renal/hepatic fn, interacting drugs/concurrent CNS depressants, pulmonary dz/conditions that cause decreased pulmonary drive, seizure pts, risk of developing GI obstruction
