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NAPLEX Content > Pain > Flashcards

Pain Flashcards

1
Q

Is physiological adaptation and addiction the same?

A

No!

All pts become physiologically adapted to opioid after repeated exposure

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2
Q

What’s addiction?

A

Involves a strong desire or compulsion to take the drug despite harm and is manifested by drug-seeking behaviors

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3
Q

What’s pseudo-addiction?

A

Pt may be anxious about running out of drug and may have used up the med too quickly - signs which can be mistaken for addiction, but may actually be due to poorly treated pain

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4
Q

Whats Tolerance?

A

Tolerance to opioids develops over time and necessitates a higher dose to produce the same analgesic response

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5
Q

What’s opioid hyperalgesia?

A

Chronic opioid use that actually worsens pain sensitivity

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6
Q

What’s breakthrough pain (BTP)?

A

Acute pain that occurs despite use of long-acting or scheduled opioid

It’s best treated with fast relief agent - such as immediate release opioid

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7
Q

Whats an essential component of chronic opioid regimen?

A

Constipation prophylaxis

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8
Q

What must inpatients on IV opioids be monitored for?

A

Sedation - most imp predictor of respiratory depression (usual cause of fatality with an opioid overdose)

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9
Q

Name agents for mild pain (rx and OTC)?

A

Acetaminophen (Tylenol, “non-Aspirin” pain relievers)

Acetaminophen + Hydrocodone (Vicodin, Norco, Lortab)

Acetaminophen + Oxycodone (Percocet, Endocet)

Acetaminophen + codeine (Tylenol #2, 3, 4)

Acetaminophen + tramadol (Ultracet)

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10
Q

Brand name of Acetaminophen?

A

Tylenol

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11
Q

Brand name of Acetaminophen + Hydrocodone?

A

Vicodin

Norco

Lortab

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12
Q

Brand name of Acetaminophen + Oxycodone?

A

Percocet

Endocet

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13
Q

Brand name of Acetaminophen + Codeine?

A

Tylenol #2, 3, 4

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14
Q

Brand name of Acetaminophen + Tramadol?

A

Ultracet

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15
Q

What’s the max daily dose of Acetaminophen in adults?

A

Keep below 4,000 mg/day (3,000-3,900 mg/day)

To prevent hepatoxicity

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16
Q

Children’s dosing of Acetaminophen? Max daily dose?

A

10-15 mg/kg Q4-6H

Max 5 doses/D

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17
Q

What’s the conc of Acetaminophen in infants and children’s suspension?

A

160mg/5mL

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18
Q

SEs of Acetaminophen use?

A

Hepatoxicity (with overdose)

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19
Q

What’s the DOC in pregnancy for pain?

A

Acetaminophen

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20
Q

Antidote for Acetaminophen overdose?

A

N-acetylcysteine (NAC, oral and IV)

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21
Q

Moa of N-acetylcysteine (Antidote for Acetaminophen overdose)?

A

Restores intracellular glutathione (acts as a glutathione substitute)

NAC should be admin IMMEDIATELY

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22
Q

MOA of Aspirin and other NSAIDs (not acetaminophen)?

A

Aspirin - irreversibly

Other NSAIDs - reversibly

Block the activity of thromboxane and prostaglandins

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23
Q

While cox-2 selective agents have lower bleeding risk, but what risk increases with their use?

A

Cardiovascular risk

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24
Q

List NSAIDs, Salicylates agents

A

Aspirin (Acetylsalicylic acid) - Bayer, Bayer “Advanced” aspirin, Ascriptin, Bufferin, Ecotrin, Excedrin

Salsalate

Mg Salicylate

Choline Mg Trisalicylate

Diflunisal

Salicylate salts

Topical ?Salicylates

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25
Q

Risk that increases with NSAIDs use. Grp with highest risk?

A

GI bleeding

Elderly
Previous bleed
Chronic or high dose use

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26
Q

CI to Aspirin (NSAIDs, Salicylates use)? And Ibuprofen (NSAIDs, others)?

A

Avoid with NSAID hypersensitivity

Avoid Aspirin (not other NSAIDs) in children < 16 y/o with any viral inf

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27
Q

SE to Aspirin (NSAIDs, Salicylates) use? And Ibuprofen (NSAIDs, others)?

A

Dyspepsia

Heartburn (more common with Aspirin - EC or buffered pdt can reduce dx) - take NSAIDs, salicylate with food to reduce nausea

BP may increase (monitor)

GI irritation/bleeding, renal

Severe skin rash (SJS/TEN) - rare (stop drug, seek immediate medical help)

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28
Q

List agents under NSAIDs, others

A

Ibuprofen (Motrin, Advil)

Naproxen Na

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29
Q

Brand name of Ibuprofen (NSAIDs, others)?

A

Motrin

Advil

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30
Q

Brand name of Naproxen-Esomeprazole?

A

Vimovo

PPI used to protect gut from damage caused by NSAID

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31
Q

Howz all forms of Naproxen dosed?

A

All given BID

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32
Q

Advantage of Naproxen formulations?

A

Relatively lower cardiac risk

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33
Q

Agents under other non-selective NSAIDs?

A

Diclofenac (Cataflam, Voltaren XR)

Indomethacin (Indocin IR, CR)

Piroxicam (Feldene)

Ketorolac (Toradol)

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34
Q

Brand name of Diclofenac (non-selective NSAIDs)?

A

Cataflam

Voltaren XR

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35
Q

Brand name of Indomethacin (non-selective NSAIDs)?

A

Indocin

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36
Q

Brand name of Piroxicam (non-selective NSAIDs)?

A

Feldene

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37
Q

Brand name of Ketorolac (non-selective NSAIDs)?

A

Toradol

Sprix NS

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38
Q

SEs unique to indomethacin (Indocin)?

A

High risk for CNS SEs (avoid in psych conditions)

GI toxicity

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39
Q

SEs unique to Piroxicam (Feldene)?

A

High risk for GI toxicity and severe skin rxns (including SJS/TEN)

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40
Q

SEs unique to Ketotolac (Toradol)?

A

GI bleeding and perforation

Acute renal failure

Liver failure

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41
Q

Max duration of Ketorolac (Toradol) use?

A

Max 5 days in adults

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42
Q

COX-2 selective agents?

A

Celecoxib (Celebrex)

Meloxicam (Mobic)

Etodolac (Lodine)

Nabumetone (Relafen)

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43
Q

Brand name of Celecoxib (COX-2 selective agents)?

A

Celebrex

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44
Q

Brand name of Meloxicam (COX-2 selective agents)?

A

Mobic

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45
Q

Brand name of Etodolac (COX-2 selective agents)?

A

Lodine

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46
Q

Brand name of Nabumetone (COX-2 selective agents)?

A

Relafen

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47
Q

Which COX-2 selective agent has highest COX-2 selectivity and is CI with Sulfonamide allergy?

A

Celecoxib (Celebrex)

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48
Q

How do u mitigate upset stomach from NSAID use?

A

Take with food

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49
Q

Which meds shouldn’t NSAIDs be used with (to reduce ulcers and bleeding in stomach)?

A

Steroids

Anticoagulant

Antidepressant, including 
Fluoxetine
Paroxetine
Sertraline
Citalopram
Venlafaxine
Others
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50
Q

When should NSAIDs be avoided?

A

If you’ve experienced breathing problems or allergic-type rxns after taking aspirin or other NSAIDs

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51
Q

Effect of NSAIDs on BP?

A

NSAIDs can raise BP

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52
Q

NSAIDs and photosensitivity?

A

Limit sun exposure; use broad spectrum sunscreen (blocks both UVA and UVB)

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53
Q

Which opioids are classified as pure opioid receptor agonists?

A

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Methadone

Morphine

Oxycodone

Oxymorphone

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54
Q

What’s the primary receptor for pain relief?

A

Mu receptor

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55
Q

While full agonists don’t have a true ceiling effect, how should high doses be used!

A

Rotated with other opioids to reduce risk of tolerance

56
Q

Brand name of morphine (long-acting brands)?

A

MS Contin

Avinza

Kadian

Oramorph SR

Roxanol

57
Q

How should long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol) be used?

A

Don’t crush or chew any of these

58
Q

Avinza and alcohol use?

A

No alcohol - can shorten long-acting duration

Can sprinkle on applesauce, soft food (Kadian too)

59
Q

SEs of long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol)?

A

Constipation

N/V

60
Q

Tolerance develops to all SEs except?

A

Constipation

61
Q

What’s used for constipation from opioids?

A

Stimulant laxatives (senna, bisacodyl)

Osmotic laxatives (MOM)

Methylnaltrexone (Relistor) - last line

62
Q

Brand name of Fentanyl patch?

63
Q

Brand name of Fentanyl pills?

A

Abstral

Fentora SL

64
Q

How’s Duragesic (fentanyl patch) used?

A

12 (delivers 12.5 mcg/hr), 25, 50, 75, 100 mcg/hr

Change transdermal patch Q3 days

65
Q

If pain is controlled, but short-lived with Duragesic (Fentanyl patch), how should they be treated? (As u would do with any long-acting opioid)?

A

Don’t increase dose, reduce freq

From Q72h => Q48h

66
Q

Role of Fentanyl, in any form, in therapy?

A

Chronic pain management only

67
Q

How do adjust oral opioid when starting fentanyl?

A

Reduce dose by 50% at first of oral opioid

68
Q

Which form of fentanyl is a REMS drug?

69
Q

How do u dispose of Duragesic (fentanyl patch)?

A

Dispose in toilet

Or

Cut up and put in coffee grounds

70
Q

Brand name of Hydromorphone?

71
Q

Brand name of Oxycodone CR?

A

OxyContin

OxyContin OP

72
Q

Brand name of Oxycodone + Acetaminophen?

A

Endocet

Percocet

Roxicet

73
Q

BBWs of Oxycodone (OxyContin; OP - CR Oxycodone) +

Oxycodone + Acetaminophen (Percocet, Endocet, Roxicet)?

A

Report abuse

Avoid with 3A4 inhibitors (eg Amiodarone, Fluconazole, Grapefruit, Verapamil etc)

74
Q

Brand name of Oxymorphone?

A

Opana

Opana ER

75
Q

What’s unique about use of Oxymorphone (Opana; Opana ER)?

A

Take on empty stomach (most others are use with food to avoid stomach upset)

No alcohol with Opana ER

76
Q

Brand name of Methadone?

A

Dolophine

Methadose - liquid

77
Q

Concern with using Methadone (Dolophine, Methadose) and Meperidine (Demerol)?

A

Serotonergic, when used in combo with other drugs

78
Q

Brand name of Meperidine?

79
Q

Role of Meperidine (Demerol) in therapy?

A

Short duration so action (pain control for max 3 hrs)

Avoid as agent for chronic pain management

80
Q

Brand name of Hydrocodone + Acetaminophen?

A

Lorcet

Lortab

Vicodin

Norco

81
Q

Brand name of Hydrocodone + Acetaminophen - referred to as safer combo?

A

Norco (325mg APAP)

82
Q

What’s concern with Hydrocodone + Acetaminophen (Lorcet, Lortab, Vicodin, Norco)?

A

Watch for APAP max dosing (combo with APAP higher than 325mg is been phased out)

83
Q

Brand name of Codeine + Acetaminophen?

A

Tylenol #2, 3, 4

84
Q

List combination opioid agonists/norepinephrine uptake inhibitors and Tramadol also inhibits 5 Reuptake

A

Tramadol (Ultram, Ultram ER, Conzip IR/ER)

Tramadol + Acetaminophen (Ultracet)

Tapentadol (Nucynta, Nucynta ER)

85
Q

Brand name of Tramadol + Acetaminophen?

86
Q

Brand name of Tramadol?

A

Ultram

Ultram ER

Conzip IR/ER

87
Q

Brand name of Tapentadol?

A

Nucynta

Nucynta ER

88
Q

Whats warning associated with Tramadol use?

A

Increased seizure risk (serotonin syndrome)

89
Q

SEs of Tapentadol (Nucynta, Nucynta ER)?

A

Dizziness

Drowsiness

Nausea

But lower GI than stronger opioids

90
Q

What should be avoided with Tapentadol (Nucynta, Nucynta ER)?

A

No alcohol

91
Q

All opioids have a no alcohol use warning, but which ones have a special warning to avoid alcohol use?

A

Opana ER (Oxymorphone ER)

Nucynta ER (Tapentadol ER)

Avinza

92
Q

Which opioid has a take on empty stomach direction (almost all others are use with food)?

A

Opana (Oxymorphone)

93
Q

Morphine and renal insufficiency?

A

If switching to morphine and pt has renal insufficiency, reduce dose by 50% of TDD

(Morphine has an active metabolite that’s renally cleared)

94
Q

When converting from 1 opioid to another, what should always be considered?

A

Always Use breakthrough med, as-needed, when converting

95
Q

Converting to Fentanyl patch?

A

Find TDD in mg

Convert to mcg (multiple by 1,000)

Divide by 24 (to get patch dose)

Fentanyl is dosed mcg/hr

96
Q

When converting 1 opioid to another, do u round up?

A

No! Never!

Round down (use breakthrough doses for compensation)

97
Q

What changes do u make if medicine works well to control pain, but runs out too fast?

A

Shorten dosing interval (don’t increase dose, this will cause a risk of respiratory depression)

98
Q

How to convert from 1 opioid to another?

A

Calculate total 24h dose req of current drug

Use ratio-conversion to calc dose of new drug (make sure numerators & denominators match in both drug & route of admin)

Calculate 24h dose of new drug & reduce dose at least 25% (Note: if problem on exam says to find equivalent dose, the don’t reduce it)

Divide to attain appropriate interval and dose for new drug

Always have breakthrough pain (BTP) med available while making changes (BTP dose ranges from 5-17% of total daily baseline opioid dose)

99
Q

Role of Naloxone (as a single agent) in therapy?

A

Used for Opioid overdose

100
Q

Whys repeat dosing of Naloxone required?

A

Opioid may last longer than blocking agent

101
Q

Effect of Naloxone in pts physically dependent on opioids?

A

Will cause acute withdrawal syndrome (pain, anxiety, tachypnea)

102
Q

Acute overdose s/sx to watch out for when using Naloxone?

A

Somnolence

Respiratory depression with shallow breathing

Cold and clammy skin

Constricted (pinpoint, miosis) pupils

Can lead to coma and death

103
Q

What’s the role of Suboxone (Buprenorphine + Naloxone) in therapy?

A

Used as alternative for methadone (so pts can get from regular doctor and filled at any pharmacy and can get over opioids since withdrawal sx are reduced)

Used daily for addiction

104
Q

SEs of Buprenorphine + Naloxone (Suboxone)?

105
Q

Buprenorphine and QT interval?

A

Prolongs QT interval (avoid in pts at risk of arrhythmia)

106
Q

List Antispasmodics with analgesic effects

A

Baclofen (Lioresal)

Cyclobenzaprine (Flexmid)

Tizanidine (Zanaflex)

107
Q

Brand name of Baclofen (Antispasmodics with analgesic effects)?

108
Q

Brand name of Cyclobenzaprine (Antispasmodics with analgesic effects)?

109
Q

Brand name of Tizanide (Antispasmodics with analgesic effects)?

110
Q

SEs of all skeletal muscle relaxants?

A

Excessive sedation, dizziness, confusion

111
Q

SEs of Cyclobenzaprine (Flexmid)?

A

Xerostomia (may have efficacy with fibromyalgia)

112
Q

SEs of Tizanidine (Zanaflex)?

A

Central alpha-1-agonist => Hypotension, dizziness, xerostomia,
weakness

113
Q

List drugs that exert their effects by sedation

A

Carisoprodol (Soma)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin, Robaxin-750)

114
Q

Brand name of Carisoprodol (drugs that exert effects by sedation)?

A

Soma

C IV (due to dependence, withdrawal sx and diversion and abuse)

115
Q

Brand name of Metaxalone (drugs that exert effects by sedation)?

116
Q

Poor CYP 2C19 metabolizes and Carisoprodol (Soma)?

A

Poor CYP 2C19 metabolizes will have higher Carisoprodol (Soma) conc (up to 4-fold)

117
Q

What meds is Tizanidine (Zanaflex) CI with?

A

Ciprofloxacin & Fluvoxamine (due to elevated Tizanidine levels)

118
Q

List common neuropathic pain agents

A

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Gabapentin (Neurontin)

Amitriptyline (Elavil)

119
Q

Brand name of Pregabalin (Neuropathic pain agents)?

120
Q

Brand name of Duloxetine (Neuropathic pain agents)?

121
Q

Brand name of Gabapentin (Neuropathic pain agents)?

122
Q

Brand name of Amitriptyline (Neuropathic pain agents)?

123
Q

SEs of Pregabalin (Lyrica) and Gabapentin (Neurontin)?

A

Dizziness

Somnolence

Peripheral edema

Weight gain

Ataxia

Diplopia

Blurred vision

Xerostomia

Mild euphoria

124
Q

SE of Amitriptyline (Elavil) - mostly uncommon with low doses used for neuropathic pain

A

Anticholinergic

125
Q

List Fibromyalgia agents

A

Milnacipran (Savella)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

126
Q

Brand name of Milnacipran (Fibromyalgia agent)?

127
Q

SEs of Milnacipran (Savella)?

A

Nausea

HA

Constipation

Dizziness

Insomnia

Hot flashes

128
Q

Topical pain agents, for localized pain

A

Lidocaine 5% patches (Lidoderm)

Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)

Diclofenac topical (Voltaren gel, Flector patch)

Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)

129
Q

Brand name of Lidocaine 5% patch?

130
Q

Brand name of Capsaicin 0.025% and 0.075%?

A

Zostrix

Zostrix HP

131
Q

What’s Lidoderm (Lidocaine 5% patch) approved for?

A

Postherpetic neuralgia (shingles)

132
Q

Can Lidoderm (Lidocaine 5% patch) be cut into smaller pieces?

A

Yes! B4 removing backing

133
Q

Max number of Lidoderm (Lidocaine 5% patch) that can be applied at one time? Duration of applied patch use?

A

Max of 3 Lidoderm (Lidocaine 5% patch) at one time

12 hrs on and 12 hrs off

134
Q

SEs of Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)?

A

May cause 1st to 3rd degree burns (mostly in patients with neuropathic damage)

135
Q

How do u obtain best results on Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)?

A

Best results typically occur after 2 to 4 wks of continuous use

Don’t use PRN, since freq, long-term use is required for benefit

136
Q

SEs of Ibuprofen?

A

May cause acute kidney problems

May cause increase in BP (codeine and APAP doesn’t cause BP rise)

137
Q

T/F? It’s preferable to treat severe pain at initial onset?

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