Pain Flashcards
Chronic pain
Pain that last more than 3 months.
Pain scales
Assess severity of pain.
A Joint committee standard.
Pain is the “5th Vital sign”
Analgesic Regimen for pain
Start low and stop at the lowest dose needed to control pain. Using meds with multiple MOA is ideal
Pain scale of 1-3: Non-opioid. +/- 2 agents
Pain scale of 4-6: Opioid for mild pain. +/- non-opioid or opioid.
Pain scale of 7-10: Opioid for severe pain. +/- non opioid or opioid.
Apap
Brand, BBW, Peds dosing, antidote (4)
Brand: INJ; ofirmev, Supp; FeverAll
BBW: do not exceed 4g/day
Peds: 10-15mg/kg q 4 to 6 h
antidote: NAC, Mucomyst, Acetadote, Cetylev (Use Rumack-Matthew Nomogram)
NSAIDS
BBW (3), SE (3), C/I, Med guides?
Med guide is required for all RX NSAIDs
BBW: GI Bleeding Risk, Cardiovascular risk (MI or Stoke), and CABG (only aspirin is recommended)
SE: reduce renal clearance, increase BP, nausea (take with food)
Contraindication: third trimester
ASA
Brand, Avoid, EC, Notes
Brand: Bufferin, Ecotrin
Avoid ASA in children and teens with viral infections due to reyes syndrome
EC: is used to decrease nausea.
Durlaza and yosprala are not used when immediate effect is needed (MI) due to low aspirin
Non-ASA salicylates
Salsalate, Mag salicylate, Difunisal,
Ibuprofen brand (3), peds dose
Brand: Motrin, Advil, caldolor
peds dose: 5-10mg/kg q 6 - 8 h max 40mg/kg/day
Indomethicin
Brand, SE
Indocin
High risk for CNS SE
Naproxen Branded Combo (2), dosing
Treximet (+sumatriptan), Vimovo (+Esomeprazole)
Can be dosed bid
NSAIDs (Rare counseling point)
Photosensitivity
*Ketorolac
Brand (2), BBW, Warnigs
Brand: Sprix, Toradol
BBW: Use no more than 5 days regardless of dosage forms*
Warnings: Renal (Volume depletion)* and Liver failure
decrease dose in 65 yo or more or less than 50kg or increase SCr.*
Piroxicam; Brand?
Feldene
Sulindac
CLinoril
Celecoxib
brand, C/I, selectivity?
Celebrex
C/I: Sulfonamide allergy
HIGH COX 2 Inhibition
Diclofenac
Brand((3), BB,
Volaren, Dyloject, Antrotec(+Misoprostol)
BBW: Avoid in women childbearing potential
Misoprostol is used to replace gut-protective prostaglanins and can terminate pregnancy
Do not use more than 32 grams and use dosing card. 2g for hands wrist elbows
4g for feet ankles or knees
Meloxicam
Mobic
Nabumetone
Relefan
MOA: NSAID
Etodolac
Lodine
Opioid Hyperanalgesia
When an increase dose occurs and makes the pain worse. Try different opioid.
Centrally acting opioid antagonist
Naloxone is used to reverse respiratory depressin
Naltrexone is used in combo to prevent rhe use of another opioid inapporiately.
Opioids concerns
REMS for all ER and LA meds including methadone
Opiod BBW
BBW: Addiction leading to death
Respiratory depression
avoid use with BZD and alcohol
Codeine
Brand, BBW, CS categorization
Brand: Tylenol #2,3,4
BBW: 2D6 Ultra metabolizers avoid due to respiratory depression
CII: Codeine (itself)
CIII: capsule/tablet combination products
CIV: Oral solutions
Fentanyl
BBW, Brand, Notes, disposal, Similar
Duragesic, Sublimaze, Onsolis (buccual)
BBW: avoid 3A4 inhibitors
Start on pt using more than 60 morphine equiv per day for 7 days
Disposal: in toilet
Alfentanil (Alfenta) , Remifentanil (Ultiva) Sufentanil (Sufenta)
Hydrocodone IR
Brand (4), warning
Brand: Norco, Lorcet, Lortab, vicodin
Warning: poor 2d6 metabolizers
Hydrocodone ER
Vantrela ER
BBW: 3a4 inhibitors
Hydromorphone
Dilaudid
BBW: use in opiod tolerant pt (High risk for OD)
Methadone
Brand, BBW, Notes (3)
Dolophine, Methadose
BBW: QT prolong
Notes: Variable half-life, serotonergic agents and major 3A4 substrate
Morphine
MS Contin, Kadian, Roxanol, Arymo ER
If renally impaired start at lower dose.
SE: Dizziness CNS Effects, N/V pruritis
Oxycodone
IR, ER, BBW,
IR: Roxicodone, RoxyBOnd
ER: Xtampza, Endocet, percocet, Roxicet, (all 3 with apap)
BBW: 3A4 inhibitor or stoping inducer can cause fetal OD
Oxymorphone
Opana
Take on empty stomach
Tramadol
Brand, MOA
Ultram, Conzip (Ultracet +apap)
MOA: Centrally acting analgesic
Tapentadol
Brand, MOA, C/I
Nuncyta
C/I avoid MAOi
MOA: Centrally acting analgesia
Fentanyl Counseling points
Do not heat patch
apply to hairness skin or short hair and press for 30 secs
dispose in toilet
keep away from animals or children
Opioid management
If medications is effective but runs out to fast increase frequenct and NOT strength
If ineffectivie increase dose
Opiod conversion
Calc 24 hr dose, use ration,
then reduce dose by 25% (if the exam dose not specifiy to reduce then do not reduce)
Fentanyl
Convert to mcg then divide by 24 to get the mcg/her dosing
OIC
Methylnaltrexone (Relistor), Naloxegel (Movantik), Lupiprostone (Amitzia), Naldemedine (Symproic)
Opioid allergy
Drugs in the same chemical class has COD or MORPH in the name.
Buprenorphine is still apart of the MORPH class. + heroin
Patient needs Naloxone if:
Hx of previous OD, more than 50mg morphine equiv substanse abuse concurrent use of BZD respiratory illness or psych
Naloxone
Brand (2) notes
Narcan, Evzio
may repeat dosing,
will cause acute pain, tachy
Buprenorphine
Brand: Butrans, Belbucca, suboxone, Zubsolv (+naloxone)
Prescribers need an X in their DEA to prescribe it
Neurological pain
Diabetes, spinal chord injury, fibromyalgia, Postherpatic pain.
Gabapentin
Neurontin, Fanatrex, Gralise (PHN), Horizant (PHN + RLS)
Pregabalin
Lyrica
Baclofen
Lioresal
MOA: Antispasmodic with anagesic effects
Cyclobenzaprine
Fexmid, Amrix, Flexeril
MOA: Antispasmodic with anagesic effects
Tizanidine
Zanaflex
MOA: Alpha 2 agonist for muscle spasm
SE: Hypotension, dry mouthm weakness
Carisoprodol
Soma
poor 2c19 will have higher conc
MOA: Antispasmodic effect with sedation
MEthocarbomal
Robaxin-750
MOA: Antispasmodic effect with sedation
Metexalone
Skelaxin
MOA: Antispasmodic effect with sedation
Milnacipran
Brand, MOA, BBW
Savella
MOA: SNRI
BBW psychatric events
Amitriptyline
Elavil
Duloxetine
Cymbalta
lidocaine 5% patch
Lidoderm
Can cut patch.
Do not use more than 3 at one time
Casaicin 0.025% and 0.075%
Zostrix and Qutenza 8% (given in health care office due to burning. pretreat with lidocaine)
