Pain Management Flashcards
List some of the strategies to minimise opioid misuse (10)
1) Opioids should be used only when ______
2) Nonopioid therapies are ______ as opioids for many common types of acute pain.
3) Nonopioid therapies are _____ for subacute and chronic pain.
4) When initiating prescribe ______-release opioids:
* Prescribe the ____effective dose, avoid _____ above levels likely to yield diminishing returns in benefits relative to risk
5) Exercise care when changing opioid dosage
* Optimize _____ while continuing opioid tx
* If benefits do not outweigh risk, _____
6) Prescribe ____
7) Evaluate benefits and risks ______
8) Evaluate and discuss if needed ______
* Clinicians should work with patients to incorporate into the management plan ______, including offering _____.
* Ask patients about their _____ and use validated tools or consult with behavioral specialists to screen for and assess _____ and _____.
* Drug monitoring program (PDMP)?/ Consider the benefits and risks of toxicology testing
* Our NEHR is somewhat useful for this, but may need drug testing (e.g. urinary drug testing – UDT)
9) Use caution when combining opioids with ___ and other _____
10) Use evidence based medicine to treat ____, Detoxification on its own, without medications for ___, is ____ for ____ because of increased risks for ____.
1) Opioids should be used only when benefits for pain and function are expected to outweigh risks
2) Nonopioid therapies are at least as effective as opioids for many common types of acute pain.
3) Nonopioid therapies are preferred for subacute and chronic pain.
4) When initiating prescribe immediate-release opioids:
* Prescribe the lowest effective dosage, avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks
5) Exercise care when changing opioid dosage
* Optimize nonopioid therapies while continuing opioid therapy
* If benefits do not outweigh risk, gradually taper
6) Prescribe no greater quantity than needed
7) Evaluate benefits and risks early and regularly
8) Evaluate and discuss if needed opioid-related harms and mitigation steps
* Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
* Ask patients about their drug and alcohol use and use validated tools or consult with behavioral specialists to screen for and assess mental health and substance use disorders.
* Drug monitoring program (PDMP)?/ Consider the benefits and risks of toxicology testing
* Our NEHR is somewhat useful for this, but may need drug testing (e.g. urinary drug testing – UDT)
9) Use caution when combining opioids with benzodiazepines and other CNS depressants
10) Use evidence based medicine to treat opioid use disorder (OUD), Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.
State when a transdermal fentanyl patch may be indicated and when it is not recommended
o Pain should be relatively well-controlled on an opioid prior to initiating the fentanyl patch.
- Use fentanyl patch only in patients tolerant to opioid therapy
- Patches are NOT recommended for unstable pain requiring frequent dose changes or dose titration.
List some counselling points for a patient who is newly started on Transdermal Fentanyl Patch. (4)
o Avoid exposing patch to heat as things such as Fever, topical application of heat (or external heat sources), or strenuous exertion may accelerate transdermal fentanyl absorption
o Transdermal fentanyl patch should not be punctured or cut.
o Make sure there is someone who is around you who can remove the patch if you start nodding off
o Don’t paste patch on broken skin
State when Methadone might be indicated (~5)
o Methadone may be a viable option for pain relief in patients experiencing hyperalgesia or unrelieved pain with current opioid use.
o Consider using methadone when a long-acting opioid that can be crushed or given in a liquid solution is needed.
o Methadone may be an option when opioid rotation is indicated.
o Not tolerated on previous opioid therapy
o patients with a history of SUD, neuropathic pain related to malignancy, renal insufficiency
List any active metabolites for the following opioids (if any):
a) Codeine
b) Morphine
c) Oxycodone
d) Hydrocodone
e) Tramadol
a) Codeine: Morphine, Hydrocodone, hydromorphone
b) Morphine: Morphine 6-Glucuronide, hydromorphone
c) Oxycodone: Oxymorphone, hydrocodone
d) Hydrocodone: Hydromorphone
e) Tramadol: O-Desmethyl tramadol
List which CYP enzymes affect the following opioids (if any):
a) Codeine
b) Morphine
c) Oxycodone
d) Hydrocodone
e) Tramadol
f) Fentanyl
All except Codeine, Fentanyl and Morphine: CYP3A4, CYP2D6 (substrate)
Codeine: CYP2D6 (substrate)
Morphine: Nil
Fentanyl: CYP3A4
State the drug classes (drugs) that may be used together with an opioid for neuropathic pain
1) Gaba acting Anticonvulsants (Gabapentin, Pregabalin)
2) SNRI (Duloxetine, Venlafaxine)
Which receptor affects opioid tolerance? And what is the clinical significance
NMDA receptor (antagonism of the receptor will reverse opioid tolerance). If using Methadone, lower doses are needed when converting. Ketamine which is NMDA antagonist may reverse opioid tolerance.
Briefly state how to manage end-of-life dyspnea (non-pharm, pharm) (2,1)
1) Nonpharmacologic therapies including fans, cooler temperatures, stress management, relaxation therapy, and physical comfort measures
2) Oxygen therapy may be helpful in some cases, remember to consider if had previous bleomycin chemotherapy
3) Morphine PRN is routinely seen prescribed at NUH, titrated to respiratory rate
o Purpose of morphine here is to slow the respiratory rate in those with dyspnea due to hyperventilation.
Briefly state how to manage end-of-life secretions (non-pharm, pharm)
1) Gentle oropharyngeal suctioning (avoid deep suctioning)
2) Anticholinergics (e.g Glycopyrrolate) used but carefully weigh toxicities and patient preferences
List some shortcomings of using the opioid conversion tables
Individual patients may not have the characteristics of those who were included in the relative potency studies.
1) Doses are based on single dose studies and based on post-surgical pain but all pain not the same -> post-surgical different from chronic pain. Ratios may not work as expected
2) Conversion is not bidirectional (e.g can convert from morphine to hydrocodone using table, but may not be able to convert from hydrocodone to morphine)
3) Cutoffs are just a guide for dosing (Methadone conversion guide 199mg vs 200mg)
State half life of Methadone
15–120 hours
List preferred opioid choice in renal impaired patients (3)
fentanyl, methadone, tramadol
Does parent drug codeine have any analgesic effect?
Codeine has no analgesic effect unless it is metabolized into morphine by hepatic enzyme CYP2D6 and then to its active metabolite morphine-6-glucuronide by phase II metabolic pathways
List the ADRs of Opioids and their management (8)
1) Constipation
o Prophylactic laxatives (except bulk forming)
- PO preferred
- Use enemas if PO fail
* Avoid in patients with neutropenia or thrombocytopenia.
* To rule out bowel obstruction and hypercalcemia first
o Use adjuvant analgesic to see if can lower opioid dose
o Opioid antagonist (if fail prophylactic laxatives)
- E.g methylnaltrexone, lubiprostone
o Non-Pharm
- Drink water
- Adequate dietary fibre
2) Nausea and vomiting
o For patients with a prior history of opioid-induced nausea, prophylactic treatment with antiemetic agents is highly recommended. (may use CINV agents)
o If nausea persists for longer than 1 week, the cause of nausea needs to be reassessed and opioid rotation must be considered
3) Pruritus
o Exclude allergy reaction
o May trial antihistamine
4) Delirium
o Assess for other contributing factors for delirium (eg, infection, hypercalcemia, CNS, metastases, other psychoactive medications, uncontrolled pain).
o If other possible causes of delirium are excluded, consider lowering the dose of the current opioid or consider changing the opioid.
o Consider non-opioid analgesic to allow reduction of the opioid dose.
o If delirious behavior necessitates medical intervention, consider low dose antipsychotic
5) Respiratory depression
o Prevention:
- Reduce opioid dose
- Increase interval of opioid administration
- Assess for transdermal preparations (eg, a forgotten fentanyl patch)
- Monitor closely
o Management:
- If respiratory depression or opioid-induced sedation occur, and patient is medically stable, consider providing non-invasive respiratory support and hold additional doses of opioid until respiratory status improves.
- If patient is unstable or response is inadequate, consider naloxone administration but use reversing agents cautiously.
6) Motor and cognitive impairment
7) Sedation
o Rule out other cause of sedation
o If sedation is due to opioids, consider a lower dose of opioid given more frequently to decrease peak concentrations
o Decrease the dose of opioid if pain control can be maintained at a lower dose
o Consider opioid rotation
o Consider non-opioid analgesic to allow reduction of the opioid dose
o Consider the addition of (stimulants) caffeine, 100–200 mg PO every 6 hours; or methylphenidate, 5–10 mg 1–3 times per day; or dextroamphetamine, 5–10 mg PO 1–3 times per day; or modafinil, 100–200 mg per day; or armodafinil 150–200 mg per day.
8) Hypogonadism
