Pain and Substance exam 1 Flashcards
1
Q
Acute pain
A
surgery, injury, illness, trauma
distress present
hours to days
predictable
primary analgesics
goal to cure
2
Q
Chronic nonmalignant pain
A
change in nerve function or transmission
months to year
depression, anxiety, etc problems
drug tolerance or dependence
multimodal drugs and behavior therapy
common insomnia
goal for function
3
Q
Chronic malignant pain
A
caused by cancer
unpredictable amount of time
increase pain w/ fear of dying
fear of loss control
drug tolerance or dependence
multimodal drugs
goal to cure, function, or palliative
4
Q
Monitor what for pain
A
pain level
type or quality
time of day that pain is worse or better
factors that worsen or lessen the pain
5
Q
Pain Scales
A
TJC standards require pain assessed in inpatient setting
0=no pain, 10=bad
6
Q
Minor pain, moderate pain, and severe pain on scale
A
minor: 1-3
moderate: 4-6
severe: 7-10
7
Q
Non pharm management for pain
A
exercise, education, CBT, PT, acupuncture, massage, mildfulness, topical therapy, biofeedback
8
Q
What is biofeedback
A
pt HR and other processes measured and info feed back to pt
9
Q
Electroanalgesia
A
stimulation to areas
non invasive: TENS
minimally invasive: PENS
high invasive: SCS
10
Q
Pregabalin and gabapentin additional info
A
renal dose adjustment
can decrease opioid requirements but associated with increased risk of opioid overdose or ADE
11
Q
What class of drugs lower the doses needed for analgesia than antidepressant effects
A
TCA
12
Q
What drug to consider for concomitant depression or mood disorders
A
duloxetine
13
Q
What drugs do you have to use with caution with other CNS depressants due to additive risk
A
antispasmodics with analgesic effects (baclofen, flexeril, tizanidine, caridoprodol, methocarbamol, diazepam)
14
Q
All muscle relaxants cause what ADE
A
excessive sedation, dizziness, confusion, asthenia
-do not use in elderly
15
Q
Tizanidine MOA
A
centrally acting alpha 2 agonist
-cause hypotension, dry mouth, increase LFT
16
Q
Why is carisoprodol a C-IV
A
rapid metabolizer will convert to active barbiturate metabolite faster
17
Q
What receptors are opioids and what do they produce
A
mu receptor agonists that provide pain relief, cause euphoria, and respiratory depression
18
Q
What is needed for all opioid medications
A
REMS
19
Q
What is physical dependence
A
physical withdrawal sx when opioid is stopped or dose missed
20
Q
What is addiction
A
drug seeking behavior
21
Q
What is opioid use disorder (OUD)
A
pattern of use that causes impairment or distress
22
Q
What is opioid hyperalgesia
A
dose is increased to treat pain but pain becomes worse rather than better, may need to switch opioid
23
Q
What is break-through-pain (BTP)
A
sharp spikes of severe pain despite use of ER opioid, when on scheduled opioids need to have BTP meds
24
Q
What is opioid induced respiratory depression (OIRD)
A
usual cause of fatality in opioid overdose
25
What is centrally acting opioid antagonists
block opioids from binding to mu receptor
-naloxone used to reverse respiratory depression
26
What is opioid tolerance
receipt of at least 60 mg MME per day for 1 wk
27
Opioid dependence
abstinence, withdrawal syndrome following:
abrupt dose reduction or disc
N/V/D, chills, hot flashed, ab cramps, insomnia
28
Tx of opioid induced hyperplasia
wean/taper med
switch to difference class
-methadone
non-opioid/adjunctive
-APAP, NSAID, anticonvulsant, antidepressant
29
Opioid boxed warning
addiction, abuse, misuse lead to death
respiratory depression
alcohol may cause death
in children can be fatal
crushing long acting may be fatal
withdrawal fastly or prolonged in pregnancy can be fatal
30
OIRD risk factors
h/o overdose
substance use disorder
large doses (≥50 mg morphine)
BZD, gabapentin, pregabalin
comorbid illness like respiratory or psychiatric disease
-need naloxone on hand
31
ADE of opioids
mood change, solnolence, n/v, respiratory depression, urinary retention, histamine release, dependence
-constipation and miosis will not go away
32
ppx for opioid induced constipation
stimulant (senna, bisacodyl) OR
osmotic (peg), laxative
w/ or w/out stool softener
33
Opioids are not first-line for chronic pain tx but may have some benefit for what
low pain rather than no pain
IM and go slow
evaluate risk factors for harm
check PDMP database
use adjunctive
avoid BZD
34
What opioids can cross react
Cod, morph, and norph
-make sure there is an actual allergy not just nausea or itching
35
What are the naturally occurring opioids
morphine (MS contin)
codeine
36
Dosing for morphine
q4-6 hr: IR
q8-12 hr: ER
37
Morphine metabolism
haptic conjugation with M6G-active analgesic and M3G-inactive analgesic
-avoid if CrCl <30
-not for ESRD or dialysis
38
Codeine metabolism
prodrug
CYPD6, M3G
39
BBW and CI for codeine
BBW: respiratory depression in ultra rapid metabolizers (CYP2D6 polymorphism)
CI: children <12, children <18 following tonsillectomy, adenoidectomy)
40
What are the semisynthetic opioids
Hydrocodone, hydromorphone, oxycodone
41
Hydromorphone risk
med error with high potency (use in opioid-tolerant pt only)
high risk for overdose
oral: 2-4 mg q4-6 hr prn
iv: 0.2-1 mg q2-3 hr prn
42
oxycodone risk
used first line if morphine not able to be utilized due to renal
CYP3A4 inhibitors cause fatal overdose
43
What are the synthetic opioids
meperidine, fentanyl
44
Meperidine considerations
limited use in practice
short duration
normeperidine metabolite (renally cleared, cause seizures)
serotonergic
45
What kind of pain is fentanyl used in the outpatient setting
chronic pain
not for opioid-naive pt
46
Boxed warning and side effect for fentanyl
CYP3A4 inhibitors
application site redness/erthema
47
Fentanyl Patch
1 patch q72h
hairless skin
flush patch down toilet
do not use in cachectic patients
apply to chest, back or upper arm
48
Opioid drug interactions
Additive CNS effects: alcohol, BZD
Methadone: QT prolongation, serotonergic
Hypoxemia: COPD, sleep apnea
CYP3A4 inhibitors
49
Centrally acting analgesics MOA
mu receptor agonist and inhibitors of NE reuptake
tramadol also inhibits reuptake of serotonin
50
Risk of tramadol and tapentadol
seizure and serotonin syndrome
51
Centrally acting analgesics drug interactions
seizures: lower threshold
serotonin syndrome: avoid use in MAO-I
CYP2D6 inhibitors
52
Opioid considerations
cont IV for opioid tolerant pt
PCA alt to cont infusion
-cont infusion
-prn
beneficial in post op (24-48 hours)
53
Meds for free from cancer pain patients
opioid for moderate to severe pain
+/- nonopioid
+/- adjuvant
54
Meds for pain persisting or increasing patients
opioid for mild to moderate pain
+/- nonopioid
+/- adjuvant
55
Meds for pain persisting or increasing patients
nonopioid
+/- adjuvant
56
What is the WHO pain latter
developed for cancer pain
ultilized for acute, chronic non-cancer, neuropathic pain
57
Patients should be opioid tolerant if initiated on ___ preparation
ER
58
Adjuvants for analgesic regimen
for all severities of pain especially for neuropathic pain
59
Meds for acute and subacute low back pain
1st: superficial heat, massage, acupuncture, spinal manipulation
2nd: NSAID or skeletal muscle relaxants
60
Mild-moderate pain meds
non-opioid and/or adjuvant first line in combo w/ non-pharm therapy
low dose opioid or centrally acting opioids second line
61
Moderate-severe pain meds
non-opioid and/or adjuvant first line
opioids added based on acuity of situation
with non pharm therapy
62
Multimodal definition
use of different therapies to achieve analgesia
63
What is neuropathic pain
pain becomes independent of initial injury
no nociception, neurons generate pain on their own
can be present regardless of the presence of diabetes
peripheral neuropathy associated with mortality, regardless of diabetes
64
Wind up pain
nervous system in state of high reactivity
65
Sensitization
exaggerated response to stimuli that might not otherwise be painful
-allodynia
-hyperalgesia
66
Clinical presentation and assessment of pain
pain scale and PQRST
have hard time describing pain or sensations they feel
pain scores are subjective
lav test consider vit D, TSH, B12
imaging: x-ray, CT, MRI
67
If pain reduce to 3/10 and pt tolerating continue therapy, what to do if partial or no relief
partial: add another 1st line agent
no relief: change to another first line agent
if trials of previous fail, consider 2nd or 3rd line agents
68
First line recommendations for chronic pain
gabapentin
pregabalin
duloxetine or venlafaxine
TCA
69
2nd and 3rd line recommendations for chronic pain
2: capsaicin, lidocaine patch
3: tramadol, botulinum toxin A, strong opioids
70
Adequate trial before switching therapy for chronic pain
all around 4 weeks
71
Diabetic Peripheral Neuropathy Treatment
1: pregabalin, duloxetine, gabapentin
2: TCA, venlafaxine, carbamazepine, topical capsaicin
Tapentadol may be considered but avoid opioids
72
Treatment for Chronic low back pain
1: non pharm
2: NSAID, tramadol, duloxetine
3: opioids
73
Cancer pain treatment
bone pain: NSAID, corticosteroids, bisphosphonates
other pain management principles are the same with cancer pain, lower threshold to utilize opioids compared to non-cancer pain
74
For cancer pain, persistent use of short-acting opioids should receive ___ opioids with breakthrough short-acting meds
ER
75
CDC chronic pain guidance for opioids
IR over ER
benefit vs risk for ≥50 MME/day
avoid ≥90 MME/day unless justified
3 days for acute pain, 7 day MAX
naloxone for ≥50 MME/day or when on BZD
do not abrupt withdrawal
76
Risk for abuse and addiction
opioid risk tool (ORT): help discriminate btw high and low risk pt
diagnosis, intractability, risk, efficacy (DIRE): help determine if pt are suitable for long term opioid therapy
77
Patient expectations and counseling for chronic opioids
30% reduction in pain
provide naloxone
counsel on combos of BZD, CNS depressants
78
If med is effective but runs out to fast what should you do
increase frequency
79
When to switch to another pain med
dose increased and interval shortened but no pain relief
side effects are intolerable
drug unaffordable
IV to PO
80
Steps to convert opioids
calculate 24 hours doses
use ratio conversion to calculate dose of new drug
reduce dose by 50% of new drug
divide for appropriate interval
give BTP with 10-15% of new dose q2-4 prn, use IR
81
When switching to which opioids when do you not have to dose decrease by 50%
fentanyl patch and methadone
82
Decrease in prescribing of opioids can be a combination of what factors
increased regulatory oversight
enhanced awareness of opioid related risks
educational initiatives
new legislative efforts to improve prescribing and dispensing
83
What are the methods to combat opioid epidemic
PDMPS
CDC guideline for prescribing opioids for chronic pain
REMS
84
What are abuse deterrent opioids
product more difficult to crush and use as IV, snorting
-med will become gummy
-methods to work around abuse deterrent products
85
SUPPORT for pt and communities act
first responders carry naloxone
change in medicare/medicaid processes to limit overprescribing
raise awareness and educate
reduce transport across border
increase penalties
86
Types of opioids abused: methadone
multiple pharm properties other than mu-receptor
prolonged elimination half-lie longer than analgesic effect
-full effect not for 3-5 days, accumulate in tissues, QTc prolonging agent
87
Types of opioids abused: fentanyl
due to IMF (illicitly manufactured fentanyl)
usually mixed with heroin and cocaine and sold as BZD or opioid
88
Types of opioids abused: OTC products
dextromethorphan: depressant or hallucinogenic
loperamide: mu opioid agonist for diarrhea, inhibit P-glycoprotein, will cross BBB
89
OUD DSM-5 criteria
problematic pattern of opioid use leading to significant impairment or distress, manifested by at least 2 of the following within 12 month time period
90
What two factors of the DSM-5 for opioids are not applicable if under appropriate medical supervision
Tolerance or Withdrawal
91
Mild OUD disorder
2-3 symptoms present
92
Moderate OUD disorder
4-5 symptoms present
93
Severe OUD disorder
≥6 symptoms
94
Early remission
criteria for OUD was previously met
none of criteria for OUD have been met for at least 3 months but for less than 12 months
95
Sustained Remission
criteria for OUD previously met
none of criteria for OUD have been met for at least 12 months
96
Opioid intoxication
recent use of opioid
sign problematic behavior or change with use
pupillary constriction and at least one: drowsiness, slurred speech, impairment in attention or memory
may have concomitant OUD
97
Symptoms of OUD
euphoria, apathy, sedation, attention impairment
98
Signs of OUD
pin-point pupils, decreased breathing, pulmonary edema, loss of consciousness
99
Diagnostic tests for OUD
arterial blood gas, pulse ox to assess respiratory status
100
Opioid withdrawal is the presence of either what
cessation of, reduction in, opioid use that is heavy prolonged
admin of opioid antagonist after a period of opioid use
101
Opioid withdrawal is at least 3 of the following that develop within several minutes to days after meeting the first criteria
dysphoric mood, N/V/D, muscle aches, lacrimation, pupillary dilation, yawning, fever, insomnia
102
Onset of opioid dependent
short acting: 8-24 hours after stopping therapy
long acting: 36-72 hours after stopping therapy
103
Duration of opioid dependent
short acting: 7-10 days
long acting: up to 14 days (or longer)
symptoms peak at 72 hours
104
Symptom of opioid withdrawal
piloerection, insomnia, muscle aches, restlessness, ad cramps, hot flashes, chills
severe: psychological distress, change in mood, suicide
psychological sx linger after 1 month
105
Severity of opioid withdrawal assessed with ________ tool
COWS (higher score = worse)
106
Signs and diagnostic tests for concomitant withdrawal from another drug other than opioid
sings: delirium, tremor, N/V/D, irritability, rhinorrhea
diagnostic: CMP, LFT
107
What is the nonpharm therapy for overdose
none (this is life-threatening)
108
Naloxone for overdose
mu-opioid receptor antagonist
repeat after 2-3 minutes
consider lower dose in opioid dependent patients to avoid acute/severe withdrawal
109
Naloxone consideration
NO adverse effects
can be give in mixed overdoses or intoxication
110
What is clonidine's use for acute withdrawal supportive care
reduce sx of anxiety, tachycardia, HTN, chills, piloerection
monitor: hypotension, dizziness, sedation
111
What is IV fluids use for acute withdrawal supportive care
replace fluid loss from perspiration, vomiting, diarrhea
112
What is GI effects from acute withdrawal
anti-emetics for N/V
intestinal opioid agonists for diarrhea (loperamide) or (lomotil)
113
Opioids for acute withdrawal
methadone or buprenorphine
treat withdrawal symptoms
also indicated for maintenance therapy
114
Non pharm tx for opioid use disorder maintenance therapy
CBT, should be offered to all pt
115
Maintenance therapy may be prolonged or ________ in OUD disorder patients
indefinite
116
Maintenance agents: full agonist, partial agonist, antagonist
full agonist: methadone (generates effect)
partial agonist: buprenorphine (generates limited effect)
antagonist: naltrexone (blocks effect)
117
Methadone mechanism, effect, and timing
full mu-opioid agonist (NMDA receptor antagonist, serotonin, and NE reuptake)
once daily (given at program to prevent potential abuse)
medically supervised every time given
118
Methadone clinical effects and restrictions
clinical: reduce sx, blocks opioid effects, reduce overdose risk, reduce HIV infection
restrictions: CII, limited to methadone clinics
119
Methadone Maintenance Treatment (MMT) liquid handcuffs
take home doses
daily or near daily attendance to clinic
ingest dose under supervision
14 day supply (max 28)
120
Indications for methadone
pt must meet federal opioid treatment program standards
cause QT prolongation (need EKG at baseline, avoid >500)
121
Buprenorphine MOA, route, and timing
partial mu-opioid agonist
combo with naloxone
medically supervised withdrawal, maintenance
122
Buprenorphine restrictions
X waiver not needed
prescriber needs to be REMS certified
implant indications: opioid tolerant, stable dose for at least 3 motnhs
admin q26days (SQ depot)
not for moderate to severe hepatic impairment
123
When should buprenorphine first be administered
initiated at time of opioid disc or significant reduction in use of other opioids and no withdrawal symptoms or cravings for opioids
124
Naltrexone MOA, route, timing
mu-opioid receptor antagonists (no analgesic)
oral therapy not recommended
maintenance prevents relapse after medically supervised withdrawal
125
ADR of naltrexone
tenderness (risk of induration)
injection site pain
126
Monitoring for naltrexone
urine tox screen
LFT, EKG (methadone), BAC, adherance
127
Cyclobenzaprine contraindications
not be used with MAOI or CNS depressants
128
Tizandine drug interactions
fluvoxamine, cipro, CYP1A2 inhibitors, oral contraceptives
129
Baclofen drug interactions
CNS depressants, anxiolytics, muscle relaxants, antihistamine
130
What kind of opioids are most likely to lead to dependence
fast acting injectable
131
Opioid overdose triad
depressed respiration, pinpoint pupils, coma
132
Acute toxicity
respiratory depression
nausea and vomiting
counteracted with naloxone
133
Chronic toxicity
injections, sharing needles spread blood-borne diseases
134
Detoxification phase
initial and immediate phase of treatment
withdrawal symptoms n/v/d, aches, pain
methadone: long acting agonist
buprenorphine: partial, long acting agonist
135
Maintenance phase
longer term strategy used to help a dependent individual avoid relapse
methadone most common (approved by SAMHSA)
buprenorphine not as common
136
Methadone MOA
mu-opioid receptor but also NMDA
high lipid solubility and slow metabolism
137
Buprenorphine MOA
partial agonist at opioid receptors
can be combined with naloxone
implanted device (probuphine)
138
Buprenorphine side effects
loss of appetite, skin rash, tooth decay
139
Naloxone moa
pure short acting opioid antagonist
no analgesic effect
for opioid overdose
140
Naltrexone moa
long acting opioid antagonist
for opioid dependence and alcohol disorders
may cause anxiety
141
Naloxone side effects
tremors, fast heart rate, pounding heartbeat, increased BP, goosebumps
142
Agonist or substitution therapy
induce cross-tolerance to the abused drug
(methadone for heroin depenedence)
143
Antagonist therapy
prevents the user from experiencing the reinforcing effects of the abused drug
(naltrexone)
144
Punishment therapy
produces aversive reaction following ingestion of abused drug
(disulfiram for alcohol dependence)
145
Suzetrigine MOA and drug interactions
block sodium channels
Child-pugh class C
non-opioid med for treating mod-to-severe acute pain
