Pain Flashcards
1
Q
Arthropathies, ischemic disorders, myalgias, skin and mucosal ulcerations, superficial pain such as burns, and visceral pain such as appendicitis, pancreatitis, renal lithiasis, etc.
**Cuts or Surgical incision
A
Nociceptive Pain
2
Q
Neuropathies as in alcoholism and diabetes, cancer-related pain, regional pain syndromes, HIV, multiple sclerosis, phantom limb pain, postherpetic neuralgia, trigeminal neuralgia, post-CVA pain
Shingles, neuropathy, fibromyalgia »_space;>
Difficult to manage over time, may benefit from adjuncts such as anti-depressants
A
Neuropathic Pain
3
Q
Chronic recurrent headaches, vasculitis
A
Mixed or Undetermined Etiology
4
Q
NSAIDs inhibit _________ formation.
A
prostaglandin (PG)
5
Q
__________ sensitize pain receptors to bradykinin and other biochemical mediators,causing vasodilation and increased vascular permeability.
A
prostaglandins (PG)
6
Q
Triple A effect of NSAIDs
A
analgesic, antipyretic, and anti-inflammatory
7
Q
Ibuprofen Diclofenac Ketoprofen Indomethacin Meloxicam Ketorolac (Toradol)... are all COX \_\_ Inhibitors
A
1
8
Q
Celecoxib (Celebrex) is a COX __ Inhibitor
A
2
9
Q
Celecoxib (Celebrex) as a COX-2 Inhibitor has a better track record with ____ symptoms and ________
A
GI; bleeding
10
Q
non-selective COX 1 + 2 Inhibitor intended for short-term use (<5 days) and used for moderate/severe pain; risks are GI bleed and renal deficiency
A
(Ketorolac) Toradol
11
Q
the drug most commonly used for chronic pain in persons with past history of bleeding or GI problems, or ASA hypersensitivity
A
Acetominophen
12
Q
drug class used for mild to moderate pain and soft tissue injury
A
NSAIDs
13
Q
6 Items that must be on written Rx for scheduled drug
A
Date of Issue Patient’s name & Address NP Name, Address & DEA # Drug Name Drug Strength Dosage Form
14
Q
No refills + No telephone orders unless true 911 (electronic orders OK) on Schedule ____ drugs
A
II
15
Q
Up to 6 months or 5 refills + telephone/fax/electronic orders OK on Schedule ___ or ___
A
III or IV
16
Q
Schedule ___ is same as Rx drugs
A
V
17
Q
Schedule ___ Drugs:
Narcotics: oxycodone, meperidine, methadone
Stimulants: cocaine, methamphetamine, methylphenidate
Depressants: pentobarbital, secobarbital
A
II
18
Q
Schedule ___ Drugs:
Narcotics: Codeine in combination w/ non-narcotic ingredients not to exceed 90 mg/day, Hydrocodone not to exceed 15 mg/tab
Stimulants: benzphetamine, chlorpheniramine, diethylpropion
Depressants: butabarbital
Anabolic Steroids
Testosterone
A
III
19
Q
Schedule \_\_\_\_ Drugs: Pentazocine Phentermine Benzodiazepines Meprobamate
A
IV
20
Q
Schedule \_\_\_ Drugs: Loperamide Diphenoxylate Cough medications w/ <200 mg/100 mL Pregabalin
A
V
21
Q
type of opioid that binds to mu opioid receptors in the brain. This produces endorphins and gives pain relief. Remember mu stimulation produces:
Analgesia
Respiratory Depression
Euphoria
A
Full Agonists
22
Q
Examples of \_\_\_\_\_\_ Agonists: Morphine (Kadian) hydromorphone oxymorphone heroin meperidine (Demerol) methadone (Dolophine) fentanyl (Sublimaze) sufentanil (Sufenta)
A
Strong
23
Q
Examples of \_\_\_\_\_\_ Agonists: Codeine (Tylenol with Codeine) propoxyphene (Darvon) oxycodone hydrocodone
A
Moderate
24
Q
type of opioid that binds primarily to muopioidreceptors and cause them to produce endorphins, but to a much lesser extent than full agonists. Increasing the dose of these results in much smaller increase in endorphin release, if any. This is why it is harder to abuse these than full agonists: they have a greater affinity for the receptor sites than full agonists so giving to someone who is addicted and using full agonistcan trigger withdrawal.When used in the treatment of addiction do not begin these until withdrawal from the opioid has begun.
A
Partial Agonists
25
Examples of _______ Agonists:
Buprenorphine (Subutex)
Buprenorphine plus naloxone (Suboxone)
Partial Agonists
26
type of opioid that act weakly on the mu receptor but strongly at the kappa receptor. Therefore, the effect seen is analgesia with less respiratory depression than seen with the drugs that bind preferentially to Mu receptors. These drugs binds to mu opioid receptors and cause them to produce endorphins, but to a much lesser extent than full agonists and ALSO have antagonist effects. Because of the antagonist effects, they should be used with caution in opioid addicted patients as they could cause withdrawal symptoms.
Mixed Agonist-Antagonists
27
Examples of ________:
Butorphanol (Stadol)
nalbuphine (Nubain)
Mixed Agonist-Antagonists
28
drugs that bind to the mu opioid receptors but don’t stimulate the production of endorphins. They prevent other opioids from stimulating the mu receptors.
Opioid Antagonists
29
Examples of ________:
Naloxone (Narcan)
Naltrexone (Reviva)
Opioid Antagonists
30
World Health Organization's (WHO) step-wise treatment of pain:
Give ________ ______ first.
oral analgesics
31
World Health Organization's (WHO) step-wise treatment of pain:
Give analgesics at ________ intervals and adjust the ________ until the patient is comfortable.
regular; dosage
32
World Health Organization's (WHO) step-wise treatment of pain:
Prescribe analgesics according to pain __________ as evaluated by a _______ of intensity of pain.
intensity; scale
33
World Health Organization's (WHO) step-wise treatment of pain:
Dosing of pain medication should be adapted to the ________--the correct dose is one that will allow adequate pain relief.
individual
34
World Health Organization's (WHO) MODIFIED step-wise treatment of pain:
_______ is found in step 3 and is very useful in the treatment of cancer pain, chronic noncancer pain, and refractory neuropathic pain nonresponsive to traditional treatment.
Methadone
35
World Health Organization's (WHO) MODIFIED step-wise treatment of pain:
________ meds suggested include steroids, anxiolytics, antidepressants, hypnotics, anticonvulsants such as gabapentin & pregabalin, and NMDA receptor antagonists for neuropathic pain. Cannabinoids can also be included in this group.
Adjunctive
36
This includes a fourth step for treatment of crises in chronic pain
World Health Organization's (WHO) MODIFIED step-wise treatment of pain:
37
Changes in _______ as related to pain management:
Renal and liver mass decrease leading to decrease in blood flow
Decrease in saliva may affect swallowing
Decrease GI motility = constipation
Elderly
38
Max dose of Acetominophen per day= ____ grams
| Reduce to ____ grams for elderly, frail, pt w/ decreased liver fxn
4; 3
39
The liver produces ________ which is a Queen antioxidant that enhances detoxifying effects of the liver. It is limited and when it's gone, it's gone.
Glutathione
40
Tylenol w/ _______ decreases the detoxifying action of the liver
alcohol
41
Unilateral, throbbing, pulsatile headache that lasts 4-72 hours, includes nausea and vomiting, light sensitivity, may have auras, more common in women, and genetically linked. There are variants that include focal neurologic findings.
migraines
42
most common headache that responds well to NSAIDs
tension HA
43
“Ice pick headache”, unilateral, severe pain behind one eye, nasal congestion with rhinorrhea, occur in groupings over weeks to months, often at night, more common in men and blacks.
cluster HA
44
combination of cluster and migraine HA
mixed HA
45
HA that occur due to overuse of medications to treat headache pain. The medication causes worsening of the pain. Treatment entails discontinuing all pain medications.
Rebound HA
46
Ergots and Triptans are vaso_________.
constrictors
47
MOA of ________:
| constrict intracranial blood vessels and suppress inflammatory neuropeptides
Ergots and Triptans
48
Ergots are contraindicated in _________!!!!
pregnancy
49
Triptans Contraindicated in _________
(IHD) ischemic heart disease
50
data indicates that Sumatriptan (Imitrex) for headaches does not increase the rate of __________ above baseline
birth defects
51
Pregnant patient presenting with HA should cause the provider to consider the MOA of _________ of HA medications, and the provider needs to evaluate and consider __________ and ___________.
vasoconstriction
| coronary artery disease and HTN
52
Level ____ Evidence for Migraine Treatment:
>Antiepileptic Drugs: Divalproex Sodium, Sodium, valproate, Topiramate
>Beta Blockers: Metoprolol + Propranolol
>Triptan: Frovatriptan
A
53
Level ____ Evidence for Migraine Treatment:
>Antidepressants: Amitriptyline (TCA), Venlafaxine (SNRI)
>Beta Blockers: Atenolol, Nadolol
>Triptans: Naratriptan, Zolmitriptan
B
54
FDA-approved drug for preventive treatment of chronic migraines that is injected in 31 sites across head and neck muscles repeated q12 weeks
Botox
55
Botox is Pregnancy Category ___
C
56
Contraindication of ________:
| Intradetrusor (bladder wall) injection with UTI or Urinary Retention
Botox
57
Adverse Effect of ________:
| Mostly related to spread of the toxin to unwanted areas
Botox
58
Drug Interactions of ________:
Anticholinergics- may potentiate effects
Muscle relaxants- may lead to exaggerated weakness if given before/after injection
Botox
59
Indications for __________ Treatment for Migraines:
Attacks last >24 hrs
Duration >2 months
Major disruption of ADLs >3 days
Abortive therapy fails or is overused
Symptomatic meds are contraindicated or ineffective
Use of abortive meds > twice/week
Migraine variants produce profound neurological effects
Prophylactic
60
_________ Treatments for Migraines:
Triptans (Selective Serotonin Receptor Agonists (5-HTI)
Egort alkaloids (ergotamine + dihydroergotamine (DHE)
Analgesics
NDAIDs
Antiemetics
Combination products
Abortive
61
3 FDA-approved drugs for fibromyalgia:
milnacipran (Savella), duloxetine (Cymbalta), pregabalin
62
_____________, Amitriptyline for fibromyalgia is Evidence Level A
Tricyclic Antidepressant
63
_____ for fibromyalgia are Evidence Level A:
Duloxetine (Cymbalta)-also indicated for concmitant depression
Milnacipran (Savella)- been shown to decrease pain, fatigue, and improve fxn
Pregabalin
SNRIs
64
______ for fibromyalgia are Evidence Level:
Citalopram= Grade D NOT effective
Fluoxetine= Grade B found to decrease pain
Paroxetine= Grade B found to improve fibromyalgia impact scores
SSRIs
65
_________ for fibromyalgia are Evidence Level:
Gabapentin= GradeB found to decrease pain and improve fibromyalgia pain scores
Pregabalin= Grade A improves pain/sleep/overall wellbeing, reduces fatigue
Anticonvulsants
66
________ for fibromyalgia are Evidence Level B:
| Cyclobenzaprine- similar to TCAs which might explain its ability to improve sleep, stiffness and fatigue
Muscle Relaxants
67
________ for fibromyalgia is Evidence Level C:
conflicting reports
use in caution w/ pt taking SNRI or SSRI
lowers seizure threshold so caution in epileptics
Tramadol
68
Opioids, benzodiazepines, NSAIDs, magnesium, guaifenesin, DHEA, melatonin and calcitonin have not demonstrated effectiveness in treating __________ = Grade: C
fibromyalgia
69
not knowing what is in a supplement; some are contaminated with things like mercury or other harmful substances
supplement contamination
70
This new law expanded the authority of APRNs to treat opioid addictions with buprenorphine in office-based settings. This is an expansion of APRN ability to be on the front line in drug treatment
Comprehensive Addiction and Recovery Act (CARA) of 2016
71
System used nationwide to record when a scheduled drug is prescribed; what is prescribed & quantity that helps prescribers to identify drug seeking behavior
Downside: all systems nationwide are not linked so you may not be able to see all use by patients if they are using in multiple unlinked systems
Prescription Drug Monitoring Program (PDMP)
72
Women who use opioids in the peri-conceptual period have a _____-fold increase in fetal risk of neural tube defects
2.2
73
Weaning pregnant women with __________ has become more popular due to its accessibility and association with better neonatal outcomes.
Buprenorphine
74
Opiate antagonist that blocks or reverses opioids by competitively occupying the receptor site that the narcotic occupied.
Use/Indication: Reversal of opioid depression
Naloxone (Narcan)
75
Naloxone half-life is _____ minutes, shorter than opioid half-life so watch for respiratory depression after it wears off
30-81
76
__________ during breastfeeding results in difficulty w/ temp regulation, hydration, feeding, seizures, and SIDS
Chronic opioid use
77
____ receptors demonstrate the classic effects of:
Analgesia
Euphoria
Respiratory Depression
(EX: morphine, meperidine , fentanyl, sufentanil, hydromorphone)
Mu
78
______ receptor stimulation results in:
Analgesia
Sedation
(EX: Stadol, Nubain)
Kappa
79
Suboxone is made up of:
buprenorphine = __________ (class)
naloxone = __________ (class)
partial agonist
| antagonist
80
Tramadol is a ___drug so be careful w/ poor or ultra metabolizer
pro
81
BBW for Tramadol
lowers seizure threshold, respiratory depression
82
SE of Toradol
GI bleeds, kidney issues
83
Do not give NSAID to someone in renal failure because it:
decreases renal blood flow
84
opioid use preconceptually can cause ________
neural tube defects
85
codeine turns into morphine after metabolized so a __________ may harm breastfed infant
ultra-rate metabolizer
86
Do not use NSAIDs in pt w/ severe kidney problems because NSAIDs block ________ which vasodilate to keep blood flowing to kidneys- NSAIDs vasoconstricts kidneys and decreases GFR
prostaglandins
87
Do not use acetominophen in pt w/ liver damage because it gets rid of _________ (antioxidant)
gluthathialone
88
these sensitize pain receptors to bradykinin + other biochemical mediators causing vasodilation and increased vascular permeability
>they protect gastric mucosa by increasing mucous production + inhibiting gastric acid production
>***ensure renal blood flow via vasodilation***
prostaglandins
89
_________ irreversibly blocks the production of the prostaglandin thromboxane in platelets
ASA
90
how many days after stopping ASA would it take to see platelets that can clot?
7-10 days
91
increases risk of cardiovascular event with NSAID use
COX-2 selective
| higher dose/longer use
92
NSAIDs w/ higher CV risk
celebrex, vulcaran
93
NSAID w/ lower CV risk
naproxen
94
risk of GI bleed w/ NSAID use
higher dose/longer use
| longer-acting product
95
NSAID w/ higher GI bleed risk
felvene, ketoralac (Toradol)
96
NSAID w/ lower GI bleed risk
ibuprofen, celebrex
97
```
Use cytotec or PPI w/ _______ if:
long-term use
age>65,
daily ASA
previous uncomplicated ulcer
```
NSAIDs
98
#1 cause of liver failure in the US
acetominophen
99
____% of patients prescribed opioids in primary care setting are struggling w/ addiction
25
100
acute post-surgical pain should be treated w/ ___ days of opioids
3 (no more than 7)
101
topical NSAIDs can still cause ________
GI bleed
102
be aware of _________ with pain management in elderly
drug to drug
103
hypersensitivity that occurs as a result of ASA use that is rare but common in patients w/ asthma, rhinitis, and nasal polyps- more common in women, similar reactions may occur with NSAIDs, so avoid nonselective (1st generation)
Aspirin-exacerbated Respiratory Disease (AERD)
104
DO NOT give ASA to any patient under age ___ during __________ illness due to correlation between taking ASA with viral illness and Reye's Syndrome
19; fever-inducing
105
condition that occurs due to ASA use during fever-inducing viral illness characterized by continuous vomiting listlessness, somnolence, delirium, LOC, and death
Reye's Syndrome
106
The use of high doses of _____ greater than 150 mg per day in pregnancy is associated with prolonged gestation and labor, maternal and neonatal bleeding, fetal growth restriction, and increased mortality during the perinatal period.
ASA
107
NSAIDs and ASA can cause premature closure of ______________ if taken at the end of pregnancy
the ductus arteriosus (DA)
108
Avoid _____ with breastfeeding although some guidelines allow use with caution.
ASA
109
All NSAIDs reduce PG synthesis with differences in the extent of inhibition of _______ and ______ (enzymes)
COX1 and COX2
110
Selective ______ Inhibitors are more likely to cause cardiovascular events
COX2
111
Less _________ COX1 + COX2 Inhibitor ________ are more likely to cause GI bleeds
selective; NSAIDs
112
Nonselective NSAIDs increase GI bleed risk x___
| COX2 Inhibitors increase GI bleed risk x____
4
| 3
113
Rx of NSAIDs w/ ____________ increases bleeding risk ____x
12
114
Rx of NSAIDs w/ Spironolactone increases bleeding risk ____x
11
115
Rx of NSAIDs w/ SSRI increases bleeding risk ____x
7
116
COX2 Inhibitors have higher _______ risks and lower _______ risks
higher cardiovascular risks
| lower GI risks
117
_________ is contraindicated in patients who drink > 3 drinks per day or take other liver-toxic drugs
Acetominophen
118
Advantages of _________:
| minimal GI irritation, non-interference with bleeding times, and no effect on uric acid levels or respiratory rates
Acetominophen
119
Avoid ________ in:
| hepatitis, dehydration, liver disease, cirrhosis, or those who are heavy drinkers
Acetominophen
120
acetylcysteine is the antidote for _________
Acetominophen
121
ASA should not be used as the primary treatment for _______ due to lack of net benefit
ASCVD
122
ASA is recommended to patient post-___ to prevent reoccurrence
MI
123
Do not use _____ in children under 19 w/ viral fever
ASA
124
Avoid using _____ long-term if also using ASA for prophylaxis as it interferes w/ ASA cardioprotective effects
NSAIDs
125
Caution using _______ with concurrent use of corticosteroids, anticoagulants, ASA, and alcohol as this furthers risk for UGI bleed
NSAIDs
126
Use of high-dose ______ for long periods in pregnancy also increases the risk of bleeding in the brain of premature infants.
ASA
127
Exposure to _______ after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus and oligohydramnios
NSAIDs
128
fetal adverse effects of ______ use in pregnancy include brain, kidney, lung, skeleton, gastrointestinal tract and cardiovascular system
NSAIDs
129
________ are no more effective in the treatment of low back pain than acetaminophen or NSAIDs and they carry the risk of drowsiness and dependence
Muscle relaxants
130
__________ muscle relaxants may cause CNS sedation and increase the risk of falls and injury, particularly in the elderly
Centrally Acting
131
With __________ use, consider additive effects of concomitant medications (anticholinergics and other CNS depressants) and alcoho
Muscle relaxants
132
Ergots are contraindicated in ________ and while there is not enough data on all of the triptans, data indicates that Sumatriptan (Imitrex) does not increase the rate of __________ above baseline.
pregnancy; birth defects
133
a long-acting opioid used as a substitution to gradually taper a client off other opioids or given in the long-term management of opioid addiction (tapered down)
methadone
134
use of __________ in the treatment of drug addiction is restricted to Substance Abuse Mental Health Service Administration (SAMHSA) and state-certified programs.
methadone
135
a partial-agonist opioid that can be used to facilitate detoxification or as maintenance therapy for addiction
Buprenorphine
136
a law that expanded the authority of APRNs to treat opioid addictions with buprenorphine in office-based settings which is an expansion of APRN ability to be on the front line in drug treatment.
Comprehensive Addiction and Recovery Act (CARA) of 2016.
137
__________ have a greater affinity for the receptor sites than full agonists, so giving it to someone who is addicted and using full agonists can trigger withdrawal
partial agonists
138
opioid antagonist that works in the brain to block opioid-induced pleasurable effects and is not initiated until complete withdrawal of opioids has occurred.
Naltrexone
139
drug indicated for the maintenance of abstinence from alcohol by reducing alcohol cravings (does not eliminate or diminish withdrawal symptoms)
Campral (acomprasate calcium)
140
___________ is not known to cause alcohol aversion and does not cause a disulfiram-like reaction...it just reduces cravings
Campral (acomprasate calcium)
141
Campral is contraindicated in patients w/ ___________ and use caution giving to __________ and __________
severe renal disease
| depressed and elderly
142
___________ is a potent alcohol dehydrogenase inhibitor that blocks the oxidation of alcohol, so if alcohol is ingested while this medication is in the body, the patient will experience unpleasant effects
Antabuse (disulfiram)
143
___________ does not eliminate or diminish withdrawal symptoms from alcohol....contraindicated for patients with psychosis, severe myocardial disease, or recently used metronidazole (Flagyl)
Antabuse (disulfiram)
144
COX that is s around all the time and is responsible for stimulating prostaglandin production in the stomach.
COX-1
145
COX that is produced by gene transcription in the presence of tissue injury then produces the vasodilating prostaglandins that cause swelling, erythema, and pain.
COX-2
146
Viox and Bextra (COX-2 Inhibitors) were removed from the market for causing _______ abnormalities
cardiac
147
There are also concerns about cardiac problems with the remaining COX-2 inhibitor _________ as well as with the nonselective NSAID __________
celecoxib (Celebrex)
| Naproxen (Aleve
148
Level A Evidence for Migraine _________ Therapies:
Antileptic Drugs (Divalproex, Sodium Valproate, Topiramate)
Beta Blockers (Metoprolol, Propanolol)
Triptan
Fovatriptan
Preventative
149
Level B Evidence for Migrain ___________ Therapy:
Antidepressants (TCA-Amitripyline, SNRI-Venlafaxin)
Beta Blockers (Atenolol, Nadolol)
Triptans
Zolmitriptan
Preventative
150
```
Drugs DO NOT have supportive evidence for treatment of ___________:
Opioids
benzodiazepines
NSAIDs
magnesium
guaifenesin
DHEA
melatonin
calcitonin
citalopram (SSRI)
Conflicting data--tramadol
```
Fibromyalgia
151
Pain meds to avoid in ___________:
Tramadol
Codeine
Children (Tramadol <18, Codeine <12)
152
Pain meds to avoid in ___________:
NO ASA
NO CODEINE
**Can cause withdrawal or SIDS; can cause long-term self-destructive behavior, suicide, amphetamine, or opioid addiction
Breastfeeding
153
People who abuse cocaine, opioids (e.g., morphine, heroin), and other drugs frequently abuse __________ as well. At high doses, it can cause subjective effects—euphoria, sedation, hallucinations—that some individuals find desirable. In addition, it can intensify the subjective effects of some abused drugs, including benzodiazepines, cocaine, and opioids. Because it costs less than these drugs, the combination allows abusers to get high for less money.
Clonidine
154
Prescribe less than _____ days (ideally less than ___ days) of medication when initiating opioids”
7; 3
155
drugs that bind primarily to mu opioid receptors and cause them to produce endorphins, but to a much lesser extent than full agonists. Increasing the dose of partial agonists results in much smaller increase in endorphins release if any.
partial agonists ("mixed")
156
drugs that bind to the mu opioid receptors in the brain. This produces endorphins & give pain relief. Remember mu stimulation produces:
● Respiratory Depression
● Analgesia
● Euphoria
full agonists
157
drugs that bind to the mu opioid receptors but don’t stimulate the production of endorphins. They prevent other opioids from stimulating the mu receptors.
antagonists
158
how much reaction we get from the drug
activation
159
IF RECEPTOR SITES are full of drug (heroin) & you give them a ___________, we can put them into withdrawal
partial agonist
160
Buprenorphine (Subutex only) is a partial agonist at the ____ sites and full antagonist at the ______ sites
mu; kappa
161
Buprenorphine + Narcan = _________
Suboxone
162
No suboxone in pregnancy because.....
the Narcan portion can send baby into withdrawal (death)
163
_______ use in the periconceptional period appeared to be associated with a modest increased risk of neural tube defects
What should the provider do?
opioid...make sure they're on folic acid/birth control
164
If mother is ultra-rate metabolizer, _________ can be turned into morphine, transmitted to baby and kill
codeine
165
COX-2 is ______selective
cardio
166
Risk Factor that increases cardiovascular risk w/ NSAIDs
Hx of MI
167
Which 2 NSAIDs have the highest CV risk?
celebrex & voltarin
168
Which NSAID has the lowest CV risk?
Naproxen (nonselective COX-2)
169
Which NSAID increases GI risk?
long acting (toradol, toradine)
170
When do we Rx cytotec or PPI to NSAID users?
long term use for GI mucosal protection (>65yrs old)
171
_______ NSAIDs are EXPENSIVE, only last 2wks, can still cause GI bleed! Higher concentrations.
Topical
