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445- Pain and Mental Health > Pain in Palliative Care: Treatment > Flashcards

Pain in Palliative Care: Treatment Flashcards

1
Q

how is pain classified? what is the tool?

A

ESAS-r on a scale of 1-10

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2
Q

what is indicated for an ESAS-r 1-3

A

nonopioid + adjuvant

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3
Q

what is indicated for an ESAS-r 4-6

A

opioid like codeine or tramadol + nonopioid + adjuvant

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4
Q

what is indicated for an ESAS-r 7-10

A

opioid like morphine or hydromorphone + nonopioid + adjuvant

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5
Q

the WHO analgesic ladder was originally developed for

A

cancer pain

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6
Q

____ should be rx along with opioids

A

laxatives

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7
Q

which step is often questioned in the WHO analgesic ladder

A

step 2- insuff evidence that weak opioids better than NSAIDs

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8
Q

which WHO step may be skipped if pain is rapidly prorgessing

A

step 2

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9
Q

BTP is usually dosed by

A

10% of TDD q1h PRN

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10
Q

what meds are used for step 1 of ladder

A

acetaminophen + NSAIDs

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11
Q

max ST acetamiophen dose

A

4g/d

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12
Q

max LT (>7d) acetaminophen dose

A

3g/d

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13
Q

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

A

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

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14
Q

T or F: NSAIDs are v robust for bone pain

A

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

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15
Q

NSAID AEs limit use in

A

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

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16
Q

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

A

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

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17
Q

T or F: opioids are v sedating

A

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

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18
Q

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

A

using naloxone may cause pain crisis

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19
Q

codeine is ___ as potent as morphine

A

10%

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20
Q

codeine is metabolized by

A

CYP2D6

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21
Q

codeine starting dose

A

8-15yrs

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22
Q

max codeine dose

A

300-400mg

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23
Q

tramadol MOA

A

Weak opioid + inhibitor of NE and 5HT uptake

24
Q

tramadol starting dose

A

50-100mg q6hr

25
Q

maz tramadol dose

A

400-600mg daily

26
Q

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

A

TCAs
SSRIs

27
Q

morphine starting dose

A

5-10mg PO q4h PO

28
Q

hydromorphone starting dose

A

1-2mg PO q4h

29
Q

oxycodone starting dose

A

2.5-5mg PO q4h

30
Q

fentanyl starting dose

A

25mcg/h

31
Q

fentanyl is ____x stronger than morphine

A

100

32
Q

fentanyl is not active _______ (route)

A

orally

33
Q

fentanyl routes of administration

A

injection
sublingual
patch

34
Q

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

A

1, 4

35
Q

methadone has _____ elimination

A

biphasic

36
Q

methadone renal elimination is dependent on urinary ___

A

pH

37
Q

methadone is a
____ agonist
____ antagonist __________ reuptake inhibitor

A

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

38
Q

methadone is metabolized by

A

CYP3A4, 1A2, 2D6

39
Q

main methadone AE

A

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

40
Q

what other agents result in cumulative QTc prolongation with methadone

A

levofloxacin, fluconazole, arsenic

41
Q

advantages of methadone

A

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

42
Q

disadvantages of methadone

A

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

43
Q

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

A

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

44
Q

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

A

T

45
Q

what are some classes used as adjuvants in cancer pain

A

NSAIDs/ acetaminophen
gabapentinoids
antidepressants
corticosteroids

46
Q

gabapentin and pregabalin for cancer pain mostly targets ______ pain

A

neuropathic

47
Q

gabapentin dosing for neuropathic pain

A

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

48
Q

pregabalin dosing for neuropathic pain

A

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

49
Q

which antidepressants can be used as an adjuvant for cancer pain

A

TCAs
duloxetine

50
Q

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

A

bone, neuropathic, and visceral pain

51
Q

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

A

short
1-3wks

52
Q

what is the CS fo choice for cancer pain

A

dexamethasone

53
Q

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

A

4- only if taken with NSAIDs

54
Q

why might BPs be used in cancer pain

A

to prevent skeletal fractures

55
Q

caution with BP use in ___

A

renal impairment

56
Q

T or F: clodronate is usually tolerated fine

A

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

57
Q

AEs of BPs

A

flu like sx
osteonecrosis of mandible with pamidronate and zoledronic acid

445- Pain and Mental Health (21 decks)

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