pain

Question 1

mild pain with and without liver damage

Answer 1

Acetaminophen: NTE 3-4 g.
If cirrhosis, 1.5-2 g.

NSAIDs, ASA,

Question 2

moderate pain meds in order of less potent to most potent

Answer 2

1. Codeine + acetaminophen
2. Tramadol- mu agonist, SSRI, NE uptake inhibitor (risk of serotonin syndrome)
3. Hydrocodone + acetaminophen (norco, vicodin, hycet, lortab)
4. Oxycodone + acetaminophen (Percocet)

Question 3

severe pain meds

Answer 3

• Morphine
• Hydromorphone (dilaudid)
• Fentanyl – routes: transdermal patch, IV, transmucosal (need to get extra license for this- stick, lozenges, intranasal)
• Methadone- long half life, QTC needs to be <500
• Oxycodone

Question 4

use Immediate release opioids for…

Answer 4

acute pain- start with short-acting when you start opoioids

Question 5

PK of po opioids

Answer 5

onset at 30 min, peak at 60-90 min, go away at 4 hrs

Question 6

PK of IV opioids

Answer 6

onset 5-10 min, peak at 15-30 min, go away at 2-3 hrs

Question 7

how much should you titrate for mild vs moderate pain

Answer 7

If mild pain, titrate by 25-50% at peak.

If moderate pain, titrate up by 50-100% at peak effect

Question 8

Long-acting opioids good for …

Answer 8

unrelenting chronic pain (months-years)

Question 9

names of long acting opioids

Answer 9

• Morphine- MS contin, kadian, avinza- q12 hrs
• Oxycodone- oxycontin q 12 hrs
• Fentanyl trans-derm patch

Question 10

dose options for fentanyl patch

Answer 10

o Dose options: 12, 25, 50, 75, 100 mcg/hr

o patches changed q72 hrs

Question 11

onset of action of fentanyl patch

Answer 11

18-24 hrs

Question 12

how does fentanyl reach body through patch

Answer 12

lipid soluble – diffuses thru epidermis subq adipose tissue blood vessels (doesnt work well for cachetic pts)

Question 13

Levy’s principle:

Answer 13

if on 50 mg morphine po for 24 hrs, equivalent to 25 mcg/hr patch

2:1; 50mg morphine/24hrs = 25mcg/hr fentanyl

Question 14

can you give long acting opioids through NG tube or peg?

Answer 14

No • because too big and you cant crush it because that’d make it short-acting

Question 15

what should you also remember to prescribe in addition to long acting opioids

Answer 15

bowel regimen

break through pain: pain that is really severe short-term- immediate release agents

Question 16

how much breathrough immediate release pain meds should you order

Answer 16

• 10-15% of the 24 hr dose can be used as breakthrough

Question 17

Adjuvant pain meds:

Answer 17

• Gabapentin: originally an anticonvulsant
• Pregabalin/lyrica- anticonvulsant
• Amitryptiline- TCA
• Duloxetine- SNRI
• Baclofen- for muscle spasms

Question 18

4 C’s of addiciton

Answer 18

• craving, compulsive use, continued use despite harm, consequences d/t use of drug

Question 19

concentration of morphine PCA

Answer 19

♣ 1 mg/ml of morphine in 30 ml IVF solution called TKO (to keep open- the tubing)

Question 20

o Demand: How much they get when the press the button

Answer 20

♣ 1 mg morphine (50-100% of the basal rate)

Question 21

o Lockout: max dose of how much they get-

Answer 21

♣ Q15 min
♣ 4 hr max- 16 mg in this example
♣ reevaluate after 4 hrs whether to adjust the dose

Lock-out at 10-15 minutes. Four hour lock-out 150mg

Question 22

o Basal rate- continuous infusion

Answer 22

♣ Don’t give if opioid naïve

♣ Equivalent to long acting opiate

Question 23

Loading dose- to saturate mu receptors-

Answer 23

o IV bolus of demand or 2x demand dose

♣ 2 mg q30 min (peak effect)
♣ if in acute pain
♣ puts it in to IV directly- faster than thru PCA tubing

Question 24

what to do if someone vomiting up meds?

Answer 24

Convert home opioids dose to IV and make it basal rate.

50-100% of basal rate is demand dose (as breakthrough).

Question 25

tramadol MOA

Answer 25

Mu & 5-Ht/NE uptake inhibitor activity

Question 26

safest drug in liver & kidney failure” –Dr. K

Answer 26

fentanyl

Question 27

Demerol (Meperidine) Rx

Answer 27

postop rigors,

Hem-Onc post-transfusion, not for pain

Question 28

PO morphine pca dose →

Answer 28

660 mg PO/ 24 hrs

Question 29

PCA basal dose = patient’s 24hrs morphine equivalent

Answer 29

660mg PO morphine divided by 3 = 220 mg morphine

divided by 24 ~ 10 mg/hr for basal infusion

Question 30

PCA Demand Dose & lockout

Answer 30

5 mg q 10 mins

Question 31

Gold standard morphine dose

Answer 31

10 mg IV

Question 32

V morphine → to PO drugs

Answer 32

PO form of morphine is 3x higher than IV form. 2/3rds of the total (24hr dose) given via extended release and 1/3 used for breakthrough pain. 24 hr dose IV was 15 mg → 45 mg PO. Would give morphine XR 15 mg BID with Morphine IR 15 mg PO PRN q 4 hrs.

Question 33

PO morphine to Fentanyl patch

Answer 33

PO morphine 24hr total dose divided by 2 → XXX mcg/hr fentanyl patch dose

Question 34

Which type of patient can tolerate meperidine?

Answer 34

young/healthy and not on MAOIs or elderly)

Question 35

Side Effects of demerol (meperidine)

Answer 35

Renally excreted → do not use in renal insufficiency
Can ↑ CNS excitability → Seizures

Atropine derivative → tachycardia → difficulty in determining if meds or something else is causing patient to be tachy

Question 36

In the elderly or individuals w/ diminished renal function, consider starting at ____ morphine b/c morphine is cleared renally

Answer 36

0.5mg (instead of 1-2 mg)