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Pharm III Final > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Oxycodone is available w/ and w/o …

A

Acetaminophen

W/ = Percocet

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2
Q

Ultram = ______

A

Tramadol

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3
Q

Nucynta = ______

A

Tapendatol

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4
Q

Tramadol and Tapendatol are unique amongst the opioids for being…

A

Partial µ-agonists so not as strong as other opioids (and not Schedule 2)

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5
Q

Vicodin, Norco, and Lortab are all…

A

Hydrocodone with acetaminophen

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6
Q

Opana is …

A

Oxymorphone immediate release

No longer available as ER

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7
Q

Dilaudid is ….

A

Hydromorphone

Also available ER

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8
Q

ER indicates…

A

Extended release (long acting)

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9
Q

Possible side effects of opioids

A 
N/V
Constipation***
Pruritis
Dry mouth
Altered mental status***
Respiratory depression***
Tolerance
Dependence
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10
Q

The take away from Ms. Sears’ weird examples of patients presenting with pain and asking for opioids when they really are sick

A

Take your own complete history (don’t rely upon nurses/others to relate info)

Watch for personal bias

Acute on chronic pain meds, ask about increased use of pain meds at home

Look at vitals, they often reflect pain

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11
Q

What are some vital signs that indicate pain?

A

Tachycardia
Tachypnea
Elevated BP

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12
Q

Undertreated pain resulting in red flag behaviors

A

Pseudo-addiction

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13
Q

Withdrawal symptoms with abrupt d/c or decrease in opioids (usually chronic pain)

A

Physical dependence

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14
Q

Need for increased dose for pain relief or reduced effect of constant dose over time

A

Tolerance

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15
Q

Impaired control over drug use/craving and compulsive/continued use despite harm

A

Addiction characteristics

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16
Q

What are the three types of pain

A

Nociceptive
Neuropathic
Psychogenic

Etiology of the pain dictates treatment

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17
Q

Nociceptive pain is caused by…

A

Injury to tissues —> activation of peripheral pain receptors, either somatic or visceral

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18
Q

Examples of nociceptive pain

A 
Laceration or other skin injury
Fractures, strains, sprains
Surgery 
Tumors/cancer
Internal organ injury
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19
Q

How do you manage nociceptive pain?

A

Short term NSAIDs (ibuprofen, toradol)

Tylenol (can give up to 1g IV in-patient)

Corticosteroids

Oral/topical opioid pain management

Parenteral pain meds/PCA

PT

TENs unit

+/- muscle relaxants vs trigger point injections for spasm

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20
Q

Neuropathic pain results from…

A

Damage to or dysfunction of nerves, the spinal cord, or the brain

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21
Q

Examples of neuropathic pain

A

Post-hermetic neuralgia

Cervical/thoracic/lumbar radiculopathy

Trigeminal neuralgia

Diabetic neuropathy

Phantom limb pain

Central pain syndrome (CVA, traumatic cord injury)

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22
Q

What are the first line pain management options for neuropathic pain?

A

NOT OPIOIDS

Neurontin (Gabapentin)
Lyrics (Pregabalin)
Elavil (Amitriptyline)
Cymbalta (duloxetine)

Other options:
Tramadol and Nucynta (partial µ antagonists)
Lidoderm patch 
Spinal cord stimulations
Epidural steroid injections
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23
Q

How should lidoderm patch’s or creams be used?

A

Can wear for up to 12 hours then must take them off for 12 hours

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24
Q

What are some non-pharmacological intervention pain management techniques for neuropathic pain?

A 
Epidural steroid injections
Joint injections
Intrathecal pump implants
Spinal cord stimulator implants
Peripheral nerve blocks
Sympathetic nerve blocks and neurolysis
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25
Q

Which sympathetic nerve blocks are used more for palliative management of terminal cancer patients?

A

Superior hypogastric

Ganglion of Impar

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26
Q

Patient with persistent pain typically w/ evidence of psychologic disturbance but no evidence of disorder that could account for the pain or its severity

A

Psychogenic pain

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27
Q

Goals for treating psychogenic pain?

A

Improving comfort and psychologic function

Techniques:
• Biofeedback/distraction
• Encourage exercise
• Psychologic/psychiatric eval and therapy

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28
Q

What are your management options for nociceptive low back pain?

A

NSAIDs, oral or topical
Probably not muscle relaxant if they have an active job
Trigger point injections
Medrol dose back
Ice/heat
Consider short course of short-acting opioid (at bed time only, but this is very risky)

29
Q

Patient considerations when considering whether to prescribe opioids for low back pain

A

Employment (will it cause them to need to miss work)

Hx of addictive behavior (EtOH, tobacco)

Caring for small children at home

Teenagers in the home

30
Q

If you decide on conservative treatment for your patient with low back pain, how/when should you follow up?

A

1-2 weeks

If no improvement:
• Consider PT
• Consider imaging
• May repeat trigger point injection if they were effective short term
• Transcutaneous electrical nerve stimulator (TENS) for ongoing myofascial pain

31
Q

Should you give opioids to a patient with RA for their pain management?

A

Probably not

If they’re already on them though, work with rheumatologist to optimize dose

Tolerance increases faster on high dose, short acting opioids, consider switching them to long-acting med

32
Q

Possible long acting meds you could consider for a patient with long history of RA who is compliant with their meds but still having pain

A

OxyContin (oxycodone ER) q12 hrs
MS Contin q12hrs

DURAGESIC PATCH (fentanyl) q72 hours** Safe and steady state opioid w/o risk of OD

33
Q

How do you switch from a short acting to a long acting opioid in chronic pain patients?

A

Typically start by reducing total daily dose by 50-75%, with a lower dose opioid for breakthrough pain while converting

Breakthrough med no more than 20-25% of daily long-acting dose

Recommend patient follow up in 1-2 weeks for further titration as needed

34
Q

Good adjuncts for pain management in RA patients

A

Topical compound cream (lidocaine, ibuprofen, diclofenac)

TENS unit for myofascial pain

Aqua therapy

35
Q

Good meds for diabetic neuropathic pain

A

Gabapentin - titrate slowly 100mg-300mg starting qd, then BID, then TID over weeks-months

Pregabalin - titrate slowly 25-50mg qd then BID, then TID over weeks-months

Cymbalta

Topical compounded cream

TENs unit

36
Q

What recommendations should you give for pain management in fibromyalgia patients?

A

Encourage physical activity** Esp aqua therapy

Support - consider referral for counseling

Pregabalin or Gabapentin

Cymbalta

AVOID OPIOIDS - not recommended (tramadol if you must but not together with Cymbalta)

37
Q

Cancer pain is both…

A

Nociceptive and neuropathic

38
Q

When are PCAs used?

A

For severe post-op pain and intractable cancer pain

Can be used short term for patients on chronic, high dose opioids outpatient that are suddenly NPO to avoid withdrawal

39
Q

Who will follow a patient who is on a PCA?

A

Managed by surgeon or anesthesiologist (they will round on them daily)

40
Q

What are the different settings for PCAs?

A

“On demand” dose, ie 0.4mg morphine every 15 min

On continuous dose, ie 1 mg of IV morphine over one hour (used more for cancer pain)

Both continuous and on demand (basal rate plus available on demand amount)

41
Q

Benefits of PCAs

A

Patient psychologically feels that they have some control over their pain and are not “waiting for the nurse”

Patients typically do not use while they are sleeping so typically less opioid use overall

Can help get severe, debilitating pain under control fairly quickly

42
Q

Risks of PCAs

A

Family members pushing button for demand dose for the patient (ie while they are asleep)

OD risk if patient is not properly monitored and titrated - educate the family!!!

43
Q

What orders do you need to include when putting a patient on PCA?

A

Continuous pulse oximetry

Orders for naloxone prn

Discuss with RN, make note that she/he is to monitor for mental status changes, resp distress

Patient should be seen again within 12 hours, and every 12-24hrs thereafter

44
Q

What is the ratio of PO to IV morphine when converted a patient to oral therapy (ie for discharge)?

A

3:1

If patient was on 20 mg IV morphine/24 hours, they should get 60 mg PO morphine/24 hours

Can then convert to long acting pain meds plus something for breakthrough pain

Helpful to convert while they are still inpatient

45
Q

Fast facts about the fentanyl patch

A

Not great for acute pain

Can take up to 12 hours to reach therapeutic levels

When converting IV opioids to fentanyl patch do a two-step taper
• Reduce IV opioids by 50%, add patch, then d/c opioids 12 hours later

Less effective in cachectic patients

Warn patients about exposure to heat - can increase absorption —> death

46
Q

Fast facts about methadone

A

Can decrease neuropathic pain (good and cheap)

Can cause QT prolongation —> TdP
• Always do baseline EKG/check renal/hepatic function and EKG yearly

1/2 life up to 55 hours so very slow titration every 3-5 days

Many drug interactions, so need thorough history

47
Q

Fast facts about tramadol

A

Consider for neuropathic pain

Can consider in patients with fibromyalgia if absolutely necessary (but not recommended)

Caution with patients on antidepressants, possible serotonin syndrome

48
Q

Fast facts about the Buprenorphine patch

A

Can cause QT prolongation

Is NOT for use with opioids

49
Q

Drug of choice for pain in ESRD

A

Fentanyl (either patch or parenteral)

Methadone

50
Q

What pain meds should be avoided in patients with ESRD?

A

Avoid morphine, Demerol, hydrocodone, codeine

Extreme caution with hydromorphone, oxycodone

If concomitant hepatic disease, avoid opioids all together

51
Q

Can you give opioids to a patient with increased intracranial pressure?

A

NOPE

52
Q

Considering opioids?

Only give them if you can answer yes to all of these questions?

A

Does the patient have a definitive diagnosis?

Has there been a documented workup with abnormal findings?

Is the patient experiencing impairment of function?

Have you evaluated for contraindications to opioid management?

Has teh patient tried adjunct treatments and failed?

53
Q

Prescriptions for controlled substances must include…

A

Date of issue

Patient’s name and address

Practitioner’s name, address, telephone, and DEA number

Drug name, strength, form and quantity

Don’t use short hand, write out # of pills per day, quantity, and refills in long hand

Directions for use

Manual signature

54
Q

Possible sources of pediatric pain

A

Developmental impairment

Procedural and post op somatic pain

Sickle cell disease

Trauma

Chronic pain

Cancer

55
Q

Self-reporting of pain by peds patients relies on…

A

Child’s cognitive ability

May need to use pain rating scales and location tools

56
Q

What is the name of the pain rating scale we use for peds patients?

A

Wong-Baker FACES

57
Q

How do we evaluate pain in infants and children who are not able to self-report?

A

Revised FLACC pain score

58
Q

What are the categories that make up the FLACC score?

A 
Face
Legs 
Activity
Cry
Consolability
59
Q

When using the FLACC score, what is the difference between evaluating sleeping or awake patients?

A

If awake, observe for at least 1-2 min with legs and body uncovered

If asleep, observe for at least 2 min or longer with body and legs uncovered

60
Q

What should be your initial choice for pain management in a febrile 4 year old with a URI?

A

Tylenol 10-15 mg/kg q4-6 hours prn

Ibuprofen 4-10mg/kg q6-8hours prn

Opioids - HELL NO

61
Q

What do you need to give the poor kid with testicular torsion for pain control prior to his detorsion surgery?

A

IV analgesics

IV antiemetic

62
Q

Are opioid analgesics indicated pre-operatively for appendicitis?

A

YES - give that kid some morphine

Also give them an antiemetic
• Promethazine if >2 years
• Metoclopramide

63
Q

Should you give opioid pain meds to a kid with burns over 19% of body?

A

YES - IV morphine to start, and with wound treatment

64
Q

Which pain meds should be avoided in patient <12 years

A

Codeine and tramadol - variability in metabolism can alter the level of active drug in system —> fatal overdose in extreme cases

65
Q

What’s the most important thing to take into account when treating geriatric pain?

A

Polypharmacy - 87% of patients aged 62-85 are on at least one prescription med

Don’t forget about herbal/dietary supplements

66
Q

Herbal supplements that can have disasterous adverse effects

A

Ginkgo biloba extract with warfarin —> increased risk of bleeding

St. John’s Wort with a SSRI —> increased risk of serotonin syndrome

67
Q

Stepwise approach to prescribing in the elderly

A 
Review current meds
D/c unnecessary meds
Consider adverse drug events for any new symptoms
Consider non-pharmacological options
Care in the use of commonly prescribed drugs
Reduce dosing when able
Simplify the dosing schedule 
Prescribe beneficial therapy
68
Q

How is the Beers Criteria used?

A

To help avoid concurrent use of opioids with benzos or gabapentinoids —> OD and severe ADE including respiratory depression and death

To avoid use of SNRIs in patients with a history of falls or fractures

69
Q

What is the STOPP criteria?

A

Screening Tool of Older Person’s Prescriptions

Considers drug-drug interactions and duplications of drugs within a class

Pharm III Final (8 decks)

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