Pain in Palliative Care: Treatment

Question 1

how is pain classified? what is the tool?

Answer 1

ESAS-r on a scale of 1-10

Question 2

what is indicated for an ESAS-r 1-3

Answer 2

nonopioid + adjuvant

Question 3

what is indicated for an ESAS-r 4-6

Answer 3

opioid like codeine or tramadol + nonopioid + adjuvant

Question 4

what is indicated for an ESAS-r 7-10

Answer 4

opioid like morphine or hydromorphone + nonopioid + adjuvant

Question 5

the WHO analgesic ladder was originally developed for

Answer 5

cancer pain

Question 6

____ should be rx along with opioids

Answer 6

laxatives

Question 7

which step is often questioned in the WHO analgesic ladder

Answer 7

step 2- insuff evidence that weak opioids better than NSAIDs

Question 8

which WHO step may be skipped if pain is rapidly prorgessing

Answer 8

step 2

Question 9

BTP is usually dosed by

Answer 9

10% of TDD q1h PRN

Question 10

what meds are used for step 1 of ladder

Answer 10

acetaminophen + NSAIDs

Question 11

max ST acetamiophen dose

Answer 11

4g/d

Question 12

max LT (>7d) acetaminophen dose

Answer 12

3g/d

Question 13

acetaminophen dose of 2g/d or avoid should be done for pts with

Answer 13

heavy alcohol use
malnutrition
LBW
advanced age
febrile illness
advanced liver disease
intx meds

Question 14

T or F: NSAIDs are v robust for bone pain

Answer 14

F- not as good as previously thought but still benefit in soem cases

Question 15

NSAID AEs limit use in

Answer 15

frail elderly, those with increased bleed risk (GI, kidney)

Question 16

T or F: if opioids are started too early and pain worsens at EOL, there may be no alternative

Answer 16

F- pain doesn’t always increase at EOL- can always rotate opioids

Question 17

T or F: opioids are v sedating

Answer 17

F- can be at the beginning but most overcome this in a few days

Question 18

a pain pt has requested a naloxone kit as they use fentanyl. what should you tell them

Answer 18

using naloxone may cause pain crisis

Question 19

codeine is ___ as potent as morphine

Answer 19

10%

Question 20

codeine is metabolized by

Answer 20

CYP2D6

Question 21

codeine starting dose

Answer 21

8-15yrs

Question 22

max codeine dose

Answer 22

300-400mg

Question 23

tramadol MOA

Answer 23

Weak opioid + inhibitor of NE and 5HT uptake

Question 24

tramadol starting dose

Answer 24

50-100mg q6hr

Question 25

maz tramadol dose

Answer 25

400-600mg daily

Question 26

caution with ____ and ____ with tramadol due to lowered seizure threshold

Answer 26

TCAs SSRIs

Question 27

morphine starting dose

Answer 27

5-10mg PO q4h PO

Question 28

hydromorphone starting dose

Answer 28

1-2mg PO q4h

Question 29

oxycodone starting dose

Answer 29

2.5-5mg PO q4h

Question 30

fentanyl starting dose

Answer 30

25mcg/h

Question 31

fentanyl is ____x stronger than morphine

Answer 31

100

Question 32

fentanyl is not active _______ (route)

Answer 32

orally

Question 33

fentanyl routes of administration

Answer 33

injection sublingual patch

Question 34

methadone is 1. a synthetic opioid 2. a hydrophilic opioid 3. a semisynthetic opioid 4. a lipophilic opioid 5. combo- state the combo

Answer 34

1, 4

Question 35

methadone has _____ elimination

Answer 35

biphasic

Question 36

methadone renal elimination is dependent on urinary ___

Answer 36

pH

Question 37

methadone is a ____ agonist ____ antagonist __________ reuptake inhibitor

Answer 37

mu, k, delta agonist NMDA angatonist NE and 5HT reuptake inhibitor

Question 38

methadone is metabolized by

Answer 38

CYP3A4, 1A2, 2D6

Question 39

main methadone AE

Answer 39

prolongs QTc interval with doses of 300-600mg/d

Question 40

what other agents result in cumulative QTc prolongation with methadone

Answer 40

levofloxacin, fluconazole, arsenic

Question 41

advantages of methadone

Answer 41

Potent and effective Inexpensive Less neurotoxicities Long half life (few daily doses) Neuropathic pain (NMDA, NOR, 5HT) Can be administered to those highly tolerant to other agents Incomplete cross tolerance helps control intractable pain Tablets and syrup commercial available

Question 42

disadvantages of methadone

Answer 42

Kinetics unpredictable = prescribers must take a course Rectal and injectable forms not commercially available = must compound

Question 43

can methadone be used with other opioids? what might be some advantages/ issues?

Answer 43

yes- as a coanalgesic doesn't require the full 4 day rotation or expertise but pt doesn't get full benefit of methadone + more difficult to determine orgins of toxicity with more than one opioid o nboard

Question 44

T or F: an ambulance must still be called if naloxone was given

Answer 44

T

Question 45

what are some classes used as adjuvants in cancer pain

Answer 45

NSAIDs/ acetaminophen gabapentinoids antidepressants corticosteroids

Question 46

gabapentin and pregabalin for cancer pain mostly targets ______ pain

Answer 46

neuropathic

Question 47

gabapentin dosing for neuropathic pain

Answer 47

start at 100-300mg hs and increase to 900-3600mg/d in 2-3 div doses

Question 48

pregabalin dosing for neuropathic pain

Answer 48

25-75mg po bid and increase up to 300mg po bid

Question 49

which antidepressants can be used as an adjuvant for cancer pain

Answer 49

TCAs duloxetine

Question 50

corticosteroids are used in cancer pain for ___, ___, and _____ pain

Answer 50

bone, neuropathic, and visceral pain

Question 51

CS is cancer pain are usually used for ___ courses of ___wks to manage pain crisis

Answer 51

short 1-3wks

Question 52

what is the CS fo choice for cancer pain

Answer 52

dexamethasone

Question 53

which of the following if false about dex 1. Minimum mineralocorticosteroid effects 2. causes less fluid retention 3. first line corticosteroid for cancer pain 4. increases risk of GI ulceration

Answer 53

4- only if taken with NSAIDs

Question 54

why might BPs be used in cancer pain

Answer 54

to prevent skeletal fractures

Question 55

caution with BP use in ___

Answer 55

renal impairment

Question 56

T or F: clodronate is usually tolerated fine

Answer 56

F- 4 large capsules on empty stomach + no food 1hr after + cant lie down

Question 57

AEs of BPs

Answer 57

flu like sx osteonecrosis of mandible with pamidronate and zoledronic acid