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PHA 551 > Pain Management > Flashcards

Pain Management Flashcards

1
Q

Which fibers evoke sharp, well localized pain?

A

myelinated A delta fibers

large diameter

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2
Q

Which fibers evoke dull, aching, poorly localized pain?

A

unmyelinated C fibers

small diameter

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3
Q

Which cognitive and behavioral functions decrease pain?

Which worsen pain?

A

relaxation
meditation
distraction
guided mental imagery

anxiety
depression

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4
Q

Nonpharmacologic therapies for pain management

A

physical manipulation
heat/cold
massage
exercise

transcutaneous electrical nerve stimulation (TENS)

cognitive, behavioral, social aspects

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5
Q

Naturally occurring opioids

A

morphine
codeine
heroin

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6
Q

Semisynthetic agents

A 
hydromorphone
oxymorphone
levorphanol
hydrocodone
oxycodone
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7
Q

Synthetic agents

A 
meperidine
fentanyl
methadone 
pentazocine
butorphanol
nalbuphine
buprenorphine
tramadol
tapentadol
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8
Q

What is the effect of the acetyl group in aspirin? (vs other salicylates)

A

antiplatelet

other salicylates do not alter platelet function

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9
Q

Maximal daily dose of acetaminophen: general population

A

no more than 3mg/d

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10
Q

Nonopioid Analgesics: agents

A

salicylates (aspirin, choline and Mg salicylate, diflunisal)

acetaminophen

anthranilic acid (mefenamic acid)

indoleacetic acid (etodolac)

phenylacetic acids (diclofenac potassium, diclofenac epolamine, diclofenac sodium)

proprionic acids (ibuprofen, ketoprofen, naproxen, naproxen sodium)

pyrrolacetic acid (ketorolac)

cox 2 selective (celecoxcib)

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11
Q

Ibuprofen: maximum daily dose: pediatrics

A

40mg/kg/d

over 6months of age

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12
Q

Ibuprofen: maximum daily dose: inflammatory

A

3200mg/d

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13
Q

Ibuprofen: maximum daily dose: analgesic/fever/dysmenorrhea

A

1200mg

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14
Q

What is the maximum dosing of ketorolac?

A

5 days

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15
Q

NSAIDs: ADE, monitoring parameters

A

upper GI bleed (CBC, stool guaiac)

acute renal failure (serum creatinine)

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16
Q

Maximal daily dose of acetaminophen: elderly population

A

no more than 2mg/d

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17
Q

Acetaminophen: ADE, monitoring parameters

A

hepatotoxicity (ALT/AST, PT/INR, albumin, serum concentration)

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18
Q

Agents with relative histamine release

A

morphine
codeine
meperidine

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19
Q

What is the drug of choice in severe pain?

A

morphine

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20
Q

Morphine vs. Hydromorphone

A

hydromorphone is more potent than morphine

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21
Q

Codeine: indications

A

mild-mod pain and cough suppression

**weak analgesic – use w/ NSAIDs, ASA or APAP

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22
Q

Codeine: analgesic prodrug: what does this mean

A

requires liver (CYP450 2D6) to be converted to morphine (rate limiting step)

23
Q

Meperidine: contraindications

A

do not use in renal failure

24
Q

Which opioid analgesic produces mydriasis?

A

meperidine

**most opioids cause miosis

25
Q

Meperidine: ADEs

A

tremors
myoclonus
seizures

26
Q

Which route of administration is contraindicated for fentanyl?

A

transdermal

do not use transdermal in acute pain

27
Q

Methadone: ADEs

A

sedation
QT prolongation

**avoid dose titrations more frequently than every 2wks

28
Q

Which drugs can precipitate withdrawal in opiate dependent patients?

A 
agonist/antagonist agents:
pentazocine
butorphanol
nalbuphine
buprenorphine
29
Q

Naloxone may not be effective in reversing respiratory depression for which drug?

A

buprenorphine

30
Q

Which populations need decreased doses of tramadol?

A 
renal impairment (CrCl < 30)
elderly (75+yo)

**risk of seizure, serotonin syndrome, hypoglycemia

31
Q

Opioids: ADEs

A 
respiratory depression (high risk: OSA, COPD)
constipation
sedation (dec over time)
N/V (dec over time)
tolerance
dependence
addiction/abuse/pseudo-addiction 
histamine release (urticaria, pruritus, bronchospasm)
inc sphincter tone
hypogonadism (long term use)
32
Q

Codeine: do not use in…

A

children

breastfeeding women

33
Q

Meperidine: do not use bc…

A

toxic metabolite (normeperidine) – accumulation can lead to seizures and renal insufficiency

34
Q

Naloxone: special instructions

A

repeat dose bc duration of opioid may outlast naloxone

call 911!

35
Q

Neuropathic Pain: adjunctive therapy agents

A 
anticonvulsants (gabapentin, pregabalin)
TCA
SNRI (duloxetine)
opioids
topical analgesics (lidocaine, NSAIDs, salonpas, tiger balm)
36
Q

Gabapentin, Pregabalin: MOA

A

dec excitatory NT through Ca channels (alpha 2)

**pregabalin is more selective than gabapentin

37
Q

Gabapentin: ADEs

A 
dizziness, fatigue
peripheral edema
tremoer, headache, ABNORMALITY IN THINKING, amnesia
ATAXIA, ABNORMAL GAIT
weight gain
38
Q

Pregabalin: ADEs

A

PERIPHERAL EDEMA
weight gain
tremor
dizziness, ataxia

39
Q

Duloxetine: MOA

A

potent inhibitor of neuronal serotonin and NE reuptake

40
Q

Duloxetine: ADEs

A

headache, drowsiness, fatigue
nausea, xerostomia
insomnia, agitation

41
Q

Regional Analgesia: ADEs

A

CNS excitation and depression

CV effects

42
Q

Ziconotide: MOA

A

selectively binds N type voltage sensitive Ca channels

blocks excitatory NT release and reduces sensitivity to painful stimuli

43
Q

Ziconotide: ADEs

A

confusion, dizziness, hallucinations
urinary retention

sedation, somnolence, nausea, headache

44
Q

Guidelines for Management of Low Back Pain

A

initially: nonpharmacologic therapy

inadequate response:

  • acute: NSAIDs, skeletal muscle relaxants
  • chronic: NSAIDs (2nd: duloxetine, tramadol)

opioids if other agents failing, benefits>risks

45
Q

Neuropathic Pain: pharmacologic management

A

first line: AEDs, SNRIs, TCAs, lidocaine patch
second line: opioids, central analgesics (tramadol)
third line: capsaicins

**NSAIDs and acetaminophen rarely effective

46
Q

True Opioid Allergy: MOA, presentation

A

IgE or T cell mediated

BRONCHOSPASM, angioedema

hives, inc HR, low BP

47
Q

Opioid Pseudoallergy: MOA, presentation

A

caused by histamine release from mast cells (nonimmunologic effect)

itching
flushing
sweating

hives, inc HR, low BP

48
Q

Choosing an analgesic: options for a patient with a pseudoallergy

A

nonopioid analgesic (acetaminophen, NSAID)

more potent opioid less likely to release histamine

avoid codeine, morphine, meperidine

consider concurrent administration of an antihistamine

dose reduction (if tolerated)

49
Q

Choosing an analgesic: options for a patient with a true allergy

A

nonopioid analgesic (acetaminophen, NSAID)

opioid of a different class

50
Q

Opioid potency: lowest to highest

A

meperidine < codeine < morphine < hydrocodone < oxycodone < hydromorphone < levorphanol < fentanyl

51
Q

Phenylpiperidines: agents

A

meperidine
fentanyl
sufentanil
remifentanil

52
Q

Diphenylheptanes: agents

A

methadone

propoxyphene

53
Q

Morphine group: agents

A 
morphine
codeine 
hydrocodone 
oxycodone 
oxymorphone 
hydromorphone 
nalbuphine 
butorphanol 
levorphanol 
pentazocine

PHA 551 (9 decks)

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