Pain 3

Question 1

T or F: Pain is an objective phenomenon that requires careful measurement and tx.

Answer 1

F

Pain is completely subjective and is whatever the pt says it is

Question 2

List all therapeutic alternatives for chronic non-cancer pain:

Answer 2

Opioids, NSAIDs, acetaminophen, TCAs, SNRIs, anticonvulsants

Question 3

Patient is on hydromorphone 10mg po daily. What’s their total daily morphine equivalents?

Answer 3

50mg MEQ

Question 4

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?

Answer 4

81mg MEQ

Question 5

Current inpatient medication administration record for Patient A:
-Hydromorphone 1 mg subcut q4h scheduled-

What is Patient A’s total daily MEQ?

Answer 5

60mg MEQ

Question 6

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?

Answer 6

82.5 mg MEQ

Question 7

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)

Answer 7

20mg hydromorphone/d

10mg bid (q12h) (just like prev dosing regimen)

and 2mg q4-6h (10% of total daily dose)

Question 8

Before turning to opioids, what must we do for pain tx?

Answer 8

Optimize non-opioid interventions first! > non-pharm and non-opioid tx FIRST!

Question 9

T or F: Opioids are trialed and are not often intended to be used indefinitely

Answer 9

T

Question 10

How long should an opioid trial be?

Answer 10

3-6 mths

Question 11

Which opioids are first line for mild-mod pain?

Answer 11

codeine

Question 12

Which opioids are first line for severe pain?

Answer 12

morphine, oxycodone, hydromorphone

Question 13

Which opioids are second line for mild-mod pain?

Answer 13

morphine, oxycodone, hydromorphone

Question 14

Which opioids are second line for severe pain?

Answer 14

fentanyl

Question 15

Which opioids are third line for mild-mod pain?

Answer 15

No alternatives - stick w/ second-line and optimize non-pharm and non-opioid options

Question 16

Which opioids are third line for severe pain?

Answer 16

methadone

Question 17

How should the optimal opioid dose for a pt be determined?

Answer 17

By starting w/ a low dose and slowly titrating up in small qty’s

Question 18

Maximum opioid dose for new pts?

Answer 18

50 MEQ/day

Question 19

For all pts on opioids, what is the max opioid dose?

Answer 19

90 MEQ/day

Question 20

What should we do if a pt is on > 90 MEQ/day?

Answer 20

Switch or taper down

Question 21

Which population should be careful when using codeine?

Answer 21

Breast-feeding women > some may be fast-metabolizers and convert codeine rapidly to morphine, which may place the infant at risk of morphine tox

Question 22

Which opioid increases risk of seizure?

Answer 22

tramadol

Question 23

Which opioid should we avoid during renal dysfn?

Answer 23

morphine

Question 24

Which opioids have a higher abuse potential?

Answer 24

oxycodone and hydromorphone

Question 25

What should we ensure before switching an ind to fentanyl?

Answer 25

that they've been on a total daily SCHEDULED dose of at least 60 MEQ/day for ≥ 2 weeks

Question 26

What opioid can we NEVER switch to an opioid from?

Answer 26

codeine

Question 27

What should we counsel a pt on when dispensing fentanyl patches?

Answer 27

1. be alert for signs of overdose (slurred speech, ataxia, nodding off during conversation or activity, emotionally labile) 2. don't use >1 patch at a time, nor change more often than directed 3. avoid any sources of heat 4. dispose patches carefully

Question 28

How often should we titrate methadone?

Answer 28

titrate no more frequently than q5d

Question 29

Why is methadone titrated in such long intervals?

Answer 29

due to its long t1/2

Question 30

Max daily acetaminophen dose when using it chronically?

Answer 30

3.2g

Question 31

Optimal opioid dose is reached when these three factors are balanced:

Answer 31

1. effectiveness (at least 30% pain reduction) 2. plateauing (increased doses aren't beneficial) 3. AEs are manageable

Question 32

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.

Answer 32

F

Question 33

A person's pain goes from 8 to 3. What is the percent change of their pain?

Answer 33

8-3 = 5 5/8 * 100 = 62.5% reduction in pain

Question 34

Common AEs of opioids

Answer 34

N/V, constipation, drowsiness, dizziness, dry skin/pruritus

Question 35

Medical complications of opioid use:

Answer 35

neuroendocrine abnormalities (HPO and HPA axis probs), erectile dysfn, sleep apnea, hyperalgesia

Question 36

What kinds of pts should we consider starting at lower doses of opioids?

Answer 36

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