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Pain management Flashcards

1
Q

Learning Objectives
• At the end of the session, you will be able to
• Understand the importance of pain management
• Define, Classify and Describe different types of pain
• Describe the key steps in pain assessment
• Describe the principles of pain management

Compare and Contrast the different types pain
medications, including basic dose conversion and titration
- key features of drugs, specific dosage forms
- what to note when starting doses
- some dose titrations are key
- management of side effects as a whole class (N/V/Constipation)

A

1

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2
Q

The total concept of pain involves 4 key factors which are __, __, __ and __.

A

Physical
Psychological
Social
Spiritual

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3
Q

A poor __ or __ of pain can cause patients to over-report pain.

A
  1. past experience

2. anticipation

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4
Q

Pain is a __ and __ response that varies daily between individuals. It can reflect the quality of __ and may be evidence of __.

A
  1. physiologic
  2. psychological
  3. care/life
  4. under-treatment
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5
Q

Chronic pain is defined as pain that persists even after __. This duration varies depending on the __ and may last anywhere from 4-6wks to 3months.

A
  1. sufficient time provided for an insult/injury to heal

2. type of injury

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6
Q

There are 4 types of pain classified according to pathophysiology, which are __, __, __ and __.

A

Nociceptive Pain, Neuropathic Pain, Referred Pain and Ischemic Pain

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7
Q

Nociceptive pain is due to actual nociceptive input (in terms of __. It can be subdivided into __ and __.

A
  1. tissue damage

2. somatic and visceral pain

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8
Q

Somatic pain occurs when nociceptors are triggered by noxious stimuli (__, ___ or __ types). These signals are carried by small myelinated A delta fibers (__ stimuli) and C fibers (__) to the dorsal horn of the spinal cord.

A
  1. mechanical, thermal or chemical
  2. mechanical and thermal
  3. all three stimulus types
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9
Q

Somatic pain can be subdivided into __ and __ somatic pain. Somatic pain is __ to the site of injury, is constant and sometimes feels like it is __.

A
  1. cutaneous
  2. deep
  3. tender and localized
  4. throbbing or aching
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10
Q

Visceral pain is mediated by __ receptors. It is poorly __ and often referred to a __ which may be tender. Patients may find it difficult to pinpoint the exact location.

A
  1. stretch
  2. localized
  3. distant cutaneous site
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11
Q

Patients may describe it as __, __ and __ (eg, appendicitis, cholecystitis). It is a good idea to relate to __ to find possible pressing forces on viscera.

A
  1. deep, dull, and cramping

2. patient history

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12
Q

Neuropathic pain is caused by __ in either the peripheral or central region. It may be due to __ or its __ (diabetes, infection, cancer, drugs, radiation).

A
  1. injury to the nerves
  2. disease
  3. treatment
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13
Q

Neuropathic pain is often described as prolonged, severe, __, __ , or squeezing , and is often
associated with __. If severe, neuropathic pain may be accompanied by weakness.

A
  1. burning
  2. lancinating
  3. focal neurologic deficits
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14
Q

In neuropathic pain, there may be no __, but areas of __ (allodynia). It is also characterized by its relative __, making it the most challenging type of pain to treat.

A
  1. area of tenderness
  2. exquisite sensitivity to normally innocuous stimuli
  3. resistance to opioids
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15
Q

__ neuropathic pain results from abnormal nerve generation while __ neuropathic pain results from reorganization of central somatosensory processing.

A
  1. Peripheral

2. central

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16
Q

Referred pain is pain __. It may occur because signals from different part of body travel along the __ going to the spinal cord and the brain.
• i.e. Obstructed bile duct produces pain near right side of scapula
• i.e. Hip injury pain referred to the knee

A
  1. located away from its point of origin

2. same pathways

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17
Q

Ischaemic pain is caused by __ to tissue (poor/no perfusion to area), leading to tissue hypoxia and damage. This causes a release of inflammatory mediators and chemicals that stimulate nociceptors
• i.e. Angina Pain

A

loss of blood flow

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18
Q

Pain that feels aching, stabbing, throbbing, or pressure is likely to be __ pain, originating from __.

A
  1. Somatic (Nociceptive)

2. skin, muscle, bone

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19
Q

Gnawing, cramping, aching, or sharp pain is likely to be __ pain, originating from __.

A
  1. Visceral

2. Organs or viscera

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20
Q

Burning, tingling, shooting, or electric /shocking pain is likely to be __ pain, originating from __.

A
  1. Neuropathic

2. nerve damage

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21
Q

Pain evaluation of patients can be subjective via __ (even if tissue damage cannot be observed) or objective via autonomic signs associated with acute pain, (increase __) especially in unconscious patients.

A
  1. signs of distress

2. RR, HR, BP, diaphoresis

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22
Q

When taking pain history, the usage of __ can help elicit more details. History should be __ and we have to look out for __ (consider total concept).

A
  1. open-ended questions
  2. taken separately for each pain
  3. signs of psychological distress
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23
Q

The SOCRATES framework can help get a good pain history:
• S__: Where is it?
• O__: When did it start? How did it start?
• C__: How does it feel? (look for neuropathic pain)
• R__: Does it run anywhere?
• A__: A ny other symptoms?
• T__: How long have you had it?
• E__: What makes it worse/better?
• S__: How bad is it? (using 1-10 subjective scores)

A
  1. site
  2. Onset
  3. Character
  4. Radiation
  5. Associations
  6. Time course
  7. Exacerbating/relieving factors
  8. Severity
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24
Q 
The goal of pain assessment is to:
• \_\_ the pain
• Identify pain syndrome (Acute/chronic/breakthrough, Cancer/Non cancer related)
• Infer \_\_ (Nociceptive/Neuropathic)
• Evaluate physical and psychosocial \_\_
• Assess degree and nature of \_\_
• Develop a therapeutic strategy
A
  1. Characterize and Quantify
  2. pathophysiology
  3. comorbidities
  4. disability
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25
Q

General tool for quantifying pain intensity is via the __. When assessing pain for children and elderly who do not verbalize well, the __ tool is preferable (ensure the score is patient-reported and not by healthcare professionals!!).

A
  1. Numerical rating scale

2. Wong-Baker Faces Rating Scale

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26
Q

For patients who cannot self-report pain (i.e. < 3 years old), the FLACC scale (f_, L_, A_, C_, C_) is recommended. Each factor is scored 0-2, and the sum is reported on a scale of 0-10.

A
  1. face, legs, activity, cry, consolability
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27
Q

The __ assessment tool is based on a 10cm line where patient can make a marking on the line to indicate where their pain is. It is mainly used in the research setting to attempt a more ‘objective’ measure of pain.

A

visual analog scale

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28
Q

The __ assessment tool allows patients to assess their pain using various adjectives i.e. annoying, dreadful, agonizing etc..

A

adjective rating scale

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29
Q

The __ pain questionnaire is often used to measure effectiveness of analgesics. It measures 3 dimensions of pain:

  1. Sensory (location, temporal pattern, quality)
  2. Affective (emotional response)
  3. Evaluative (perceived intensity)
A

McGill-Melzack

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30
Q

Pharmacotherapy options for pain management include:

  • __ (opioids and non-opioids)
  • __ blocks
  • Adjuvant analgesics (neurophatic, musculoskeletal)
A
  1. Analgesics

2. Nerve

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31
Q

Alternative methods for pain management include:

  1. Electric stimulation (TENS/PENS)
  2. a__
  3. __ therapy
  4. c__
  5. Surgery
A
  1. Acupuncture
  2. Physical
  3. Chiropractics
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32
Q

The 3 key principles of pain management:

  1. Treat the __ where possible
  2. Ask what is the __ behind the pain
  3. Pharmacological Treatments via __
A
  1. underlying cause
  2. Pain Mechanism(s)
  3. WHO LADDER
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33
Q

WHO treatment guide for cancer recommends:

  1. __ ROA recommended
  2. Regular __ of analgesia
  3. __ regimen
  4. Treat according to __
  5. Constant __ (attention to detail)
A
  1. PO
  2. intervals
  3. Individualize
  4. patient’s perception
  5. monitoring
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34
Q

We should match analgesic choice to severity of pain and titrate to response.
• __ titration for severe pain.
• __ titration for moderate pain.
• __ titration for mild pain.

A
  1. Rapid
  2. Slower
  3. Even slower
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35
Q

20% of cancer pain requires multi dimensional approach:

- __ of pain syndrome, use of 2nd line agents and/or __ interventions.

A
  1. reassessment

2. non-pharmacological

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36
Q

Based on WHO pain ladder, a pain score of 1-3 (mild pain) should be treated using:

  1. __ if patient is not on analgesics (aspirin generally avoided due to __ effect)
  2. __ and __ if patient is already on analgesics (i.e. max dose)
A
  1. Paracetamol/NSAIDs
  2. irreversible anti-platelet
  3. Short-acting opioid and bowel regimen
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37
Q

Paracetamol is dosed 500-1000mg doses every 6 to 8 hourly; Max dose: __. It is the most commonly used non-opioid but we have to be cautious of overdose from using different __.

A
  1. 4g/day

2. combination products

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38
Q

Paracetamol has a low incidence of (1), high oral/rectal (2), multi-preparations available and is __(3)_____ with opioids. However, it lacks ___(4)______ and can cause __(5)____ with large doses (avoid > 3 grams/day for elderly).

A
  1. ADR
  2. bioavailability
  3. synergistic
  4. anti-inflammatory action
  5. hepatotoxicity
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39
Q

Paracetamol is metabolized in the __ and eliminated in the __. We should watch out for patients with compromised __ function.

A
  1. liver
  2. kidney
  3. liver and kidney
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40
Q

When choosing NSAIDs, there is no preference and any cost-effective NSAID __ by patient can be used. Alternatively, we may consider the PO equivalent of max tolerated __ dose.

A
  1. tolerated

2. ibuprofen

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41
Q

If two NSAIDs are tried in succession without efficacy, we should __.

A

use another approach to analgesia

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42
Q

COX‐2 selective NSAIDs are associated with lower incidence of __ side effects and do not inhibit __. However, they are more __ than traditional NSAIDs.

A
  1. GI
  2. platelet aggregation
  3. expensive
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43
Q

NSAIDs are extensively protein bound and excreted mainly in __. They can appear in __ and cross the __.

A
  1. urine
  2. milk
  3. placenta
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44
Q

NSAIDs can cause __ side effects and reversible platelet inhibition. They should be avoided if patients are on chemotherapy (may develop __). Coxibs would be preferable in this case.

A
  1. GI

2. thrombocytopenia

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45
Q

NSAIDs can cause:
• __ effects: edema, HTN, renal failure
• CNS: headache, dizziness, nervousness and visual disturbance
• Cardiovascular effects: edema, cerebrovascular accident, hypertension, MI
• __ (esp classical NSAIDs i.e. indomethacin & mefanamic acid, diclofenac)
• __ : hemolytic anemia, pancytopenia, thrombocytopenia

Other SE:
________ platelet inhibition, ____

A
  1. Renal
  2. Hypersensitivity reaction
  3. Hematological
  4. reversible
  5. GI SE
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46
Q 
NSAIDs should be avoided in:
• Elderly (>65 years)
• \_\_ disorder
• \_\_, bronchospasm
• \_\_ disease (ulcers, bleeding)
• Cardiovascular disease
• \_\_ or Hepatic dysfunction
• Receiving \_\_
A
  1. Bleeding
  2. Asthma
  3. GI
  4. Renal
  5. anticoagulants
47
Q

NSAIDs DRUG INTERACTIONs

  1. Increased risk of bleeding (Anticoagulants and Antiplatelet drugs)
  2. Increased risk of __ (ACE inhibitors, ciclosporin, tacrolimus, or diuretics)
  3. Increased risk of GI ulceration (__)
  4. Reduced __ effects (ACE inhibitors, beta blockers, and diuretics)
A
  1. nephrotoxicity
  2. corticosteroids
  3. antihypertensive
48
Q

Adjuvants for neuropathic pain includes: __, __, antidepressants, antiepileptics and topical lidocaine.

A
  1. Gabapentin

2. pregabalin

49
Q

__ can be used as an adjuvant for: Bone pain, neuropathic pain, raised intracranial pressure, liver capsule stretch pain

A

Corticosteroids

50
Q

NSAIDs and bisphosphonates are adjuvants for __ pain.

51
Q

Muscle relaxants e.g. __ and __ are useful adjuvants for Cramps or muscle spasm

A
  1. baclofen

2. benzodiazepines

52
Q

Hyoscine butylbromide are useful adjuvants for __.

A

Intestinal colic

53
Q

Based on the WHO ladder, a patient with a pain score of 4-6 (moderate pain) should be started on a __ agonist. A patient with a pain score of 7-10 (severe pain) should be started on a __ agonist.

A
  1. weak opioid

2. strong opioid

54
Q

Opioids can have effects other than analgesia as a__, a__, s__ and for severe __ (in patients as an allergic alternative).

A
  1. antitussives
  2. antidiarrheals
  3. sedatives
  4. Headache
55
Q

Codeine Phosphate has good onset of __, but a short duration of 4-6h. It can cross the placenta and enter the breast milk. Codeine is metabolized in the __ to morphine and excreted in the __.

A
  1. 0.5-1h (PO)
  2. liver
  3. urine
56
Q

The Equianalgesic dose of codeine is: 200mg (oral) codeine = __ mg(IM/SC) Morphine = __mg (IV) codeine

57
Q

Codeine phosphate and Tramadol are major substrates of __ and may have reduced effects from __ such as chlorpromazine, fluoxetine, miconazole, paroxetine, quinidine and quinine.

A
  1. CYP2D6

2. CYP2D6 inhibitors

58
Q

Codeine causes __ but patients are expected to develop tolerance after 2 weeks. It can also cause __ (no tolerance will develop).

A
  1. drowsiness

2. constipation

59
Q

Tramadol is an opioid agonist that also inhibits reuptake of __ and __, allowing it to have good __ and __ analgesic effect.

A
  1. noradrenaline
  2. serotonin
  3. somatic and neuropathic
60
Q

Tramadol is favorable clinically due to its lesser __ and __ side effects compared to other opiates along with a __ potential for abuse.

A
  1. cardiovascular
  2. respiratory
  3. “Low”
61
Q

Tramadol has a onset of action of __ with a duration of 9hrs (allowing for longer intervals). It is metabolized exclusively hepatically via __ to a active metabolite and excreted __.

A
  1. within 1hr
  2. CYP2D6
  3. in the urine
62
Q

Dosing adjustment for codeine and tramadol are necessary in patients with __ or __ impairment.

A
  1. liver

2. renal

63
Q

Tramadol comes in __ and __ ROAs but regardless of ROA, has a max dose of __ (unlike other opioids who do not have ceiling doses).

A
  1. injection
  2. tablet
  3. 400mg/day
64
Q

At high doses of Tramadol, it can __ which explains why it should be avoided in patients __ i.e. patients with brain tumors or patients on drugs with __ (Neuroleptic agents, SSRIs and TCAs).

A
  1. lower the seizure threshold
  2. pre-disposed to epileptic activity
  3. CNS activity
65
Q

Tramadol can cause CNS side effects: __, headache, somnolence and GI side effects: __, ___

A
  1. Dizziness

2. Constipation, nausea

66
Q

__ may increase risk of seizures if used together with Tramadol while concomitant use of warfarin and tramadol may lead to __.

Carbamazepine can ______ half-life of tramadol by 33 to 50%

A
  1. Naloxone, neuroleptic agents, SSRIs, TCAs
  2. elevated prothrombin times
  3. decrease
67
Q

Morphine has a good onset of action: __ (PO) and __ (IV). It is metabolized in the __ to active metabolites and excreted mainly in the __.

active metabolite: _____

A
  1. 30min (PO)
  2. 5-10min (IV)
  3. liver
  4. urine
  5. morphine-6-glucuronide
68
Q

The oral : parenteral ratio of morphine is __.

69
Q

Morphine is available in a variety of ROAs: : Injection, mixture, tablet and capsule. Dose adjustments are required for __. Excessive sedation may occur in patients with __.

A
  1. renal impairment

2. cirrhosis

70
Q

Morphine can cause GI side effects of __ (tolerance usually develops), __ (with chronic use) and __ (reason for bowel regimen).

A
  1. Nausea
  2. vomiting
  3. Constipation
71
Q

Morphine can cause __ (may be increased with antipsychotics), drowsiness, __ (secondary to histamine release) and __ (esp in epidural or intrathecal use).

A
  1. hypotension
  2. pruritis
  3. urinary retention
72
Q

Patients on morphine should avoid the following as they may increase its effects/toxicity:

  1. CNS depressants
  2. __
  3. __ (some manufacturers recommend 14 day wash out)
  4. Herbs/nutraceuticals (Avoid valerian, St John’s wort, kava kava, gotu kola)
  5. _____ increase hypotensive effect of morphine
A
  1. Alcohol
  2. MAOI
  3. antipsychotic
73
Q

Fentanyl has an almost immediate onset: __ (IM), __ (IV). It is mainly metabolized hepatically via __ and excreted in __.

A
  1. 7-15min
  2. almost immediate
  3. CYP3A4
  4. urine
74
Q

Fentanyl is about 100 times more potent than morphine. The equianalgesic dose is 100 mcg (IM) fentanyl = __ mg (IM) morphine

75
Q

__ is a great opioid in the sense that it has no dose adjustments for hepatic/renal impairment (only requires monitoring in hepatic impairment).

76
Q 
Transdermal fentanyl is used only if: 
• intolerable undesirable side effects from \_\_
• \_\_ failure
• inability to \_\_
• ‘tablet phobia’ or poor \_\_
A
  1. morphine
  2. renal
  3. swallow
  4. oral compliance
77
Q

Transdermal fentanyl patches achieve steady state concentrations after __ (delayed onset) and have a duration of action of __ (48h for fast metabolizers). The elimination half life post patch removal is __.

A
  1. 36-48h
  2. 72h
  3. 13-22h
78
Q

Patients may experience withdrawal symptoms when switching from PO morphine to TD fentanyl despite satisfactory pain relief due to __. These withdrawal symptoms include: e.g. colic, diarrhoea, nausea, sweating and restlessness.

A

Different impact on peripheral and central µ opioid receptors.

79
Q

The rate of absorption of TD fentanyl may be increased in __ patients or if the patch’s skin area gets __ due to external heat source i.e. electric blanket/heat pad. __ may be a sign of fentanyl overdose.

A
  1. febrile
  2. vasodilated
  3. A very sedated patient
80
Q

It is preferable to place patches on __ areas. __ the hair is preferred over shaving (may shave off epithelial layers and increase absorption rate). Used fentanyl patches should be __ before disposal as it still contains some drug.

A
  1. less hairy skin
  2. Cutting
  3. folded inward
81
Q

TD fentanyl have an onset of __ and can accumulate in the __, with effects lasting 12h after the patch is removed. As such, no __ is required when switching patches. However, when switching from TD fentanyl to another opioid, __ is required to provide time for fentanyl to be excreted.

A
  1. 6h
  2. subcutaneous fat
  3. break
  4. a break of 12h
82
Q

Methadone is a µ opioid receptor agonist, an __ receptor channel blocker and a presynaptic blocker of __ re-uptake. It is available as oral tablets and have an onset of __. Its duration of action increases from 4-5h to 6-12h with repeated doses.

A
  1. NMDA
  2. serotonin
  3. 30min
83
Q

Methadone is mainly metabolized in the liver via __, CYP2B6, and CYP2C19. Therefore, it makes sense that Methadone levels will be affected by __ inducers/inhibitors. It is excreted mainly in the urine.

84
Q

Avoid __ and herbs/nutraceuticals for patients on Methadone (i.e. St John’s wort, valerian, kava kava, gotu kola. As Methadone is metabolized by CYP3A4 (intestinal), avoid __.

A
  1. ethanol

2. grapefruit juice

85
Q

For methadone, dosage adjustment is required for __ impairment. Avoid in __.

A
  1. renal

2. severe liver disease

86
Q

Generally for opioids, tolerance for adverse effects may develop over time; however, constipation and __ (especially bad for methadone) may persist.
Other possible side effects of methadone include: h__, d__ and N/V.

A
  1. sweating
  2. Hypotension
  3. Drowsiness
87
Q

Oxycodone has a good onset of action: __min (PO) with a long duration of action: __ (IR) and __ (CR). It is metabolized hepatically to active metabolites and excreted in the urine.

A
  1. 20-30
  2. 4-6h
  3. 12h
88
Q

Dosage adjustment of oxycodone is required in __ impairment. Its adverse effects are similar to other opioids: d__, __ and constipation.

A
  1. renal/liver
  2. drowsiness
  3. N/V
89
Q

Oxycodone is an useful morphine alternative with about __ the potency and a longer duration of action (__ vs morphine 4h).

A
  1. double

2. 6h

90
Q

Since oxycodone is metabolized to active (more potent) metabolites by __ , __ inhibitors (i.e. chlorpromazine, fluoxetine, miconazole, paroxetine, quinidine, quinine) are expected to __ effects of oxycodone. Oxycodone is also a major substrate of CYP3A4.

A
  1. CYP2D6
  2. CYP2D6
  3. decrease
91
Q

Patients on oxycodone should avoid __ and __ i.e. valerian, St John’s wort, kava kava, gotu kola as they may increase CNS depression.

A
  1. ethanol

2. Herbs/Nutraceuticals

92
Q

Tapentadol requires no dose adjustment in __ renal impairment and __ hepatic impairment. Dosages exceeding __ mg daily on the first day of therapy or __ mg daily on subsequent days have not been evaluated and are not recommended.

A
  1. mild/moderate
  2. mild
  3. 700
  4. 600
93
Q

Pethidine requires dose adjustment in renal and hepatic impairment. The equianalgesic dose is __ mg (IV) pethidine = __ mg (IM/SC)morphine.

94
Q

Pethidine is not commonly used in palliative care as:
• Quick onset, short duration of action (2-3h). Not
good for regular analgesia, and increases risk of
__
• Toxic metabolite (norpethidine) which accumulates if given regularly, esp. in Renal failure
• Norpethidine decreases __
• More __ than morphine

A
  1. dependence
  2. seizure threshold
  3. emetogenic
95
Q

Pethidine has a quick onset __ (IV) and __ (SC). It is indicated for __ pain and has less prominent CVS/GIT side effects compared to morphine.

A
  1. 5min
  2. 10-15min
  3. acute
96
Q

A minimal 24h morphine PO dose of __-__ mg is required before patients are candidates for conversion to __mcg/h fentanyl patch.
A minimal 24h morphine PO dose of 30mg is required before patients are candidates for conversion to 12.5mcg/h fentanyl patch. (refer to manufacturer’s table)

A
  1. 45-134

2. 25

97
Q

The equianalgesic dose ratio for tramadol and morphine is __ : __.

A

5 Tramadol : 1 Morphine

98
Q

Conversion of morphine to methadone is complicated and done __.

A

stepwise over 3 days

99
Q

When switching from 1 opioid to another, a __ is common (especially in __ patients or patients with __ dysfunction).
Converting to methadone requires larger reduction (75-90%); depends on the dose of prior opioid.

A
  1. 25-50% dose reduction
  2. elderly
  3. organ
100
Q

Dose reductions when switching opioids may not be necessary when:
Converting to __ (6h onset delay)
Patients have __ (likely to be under-treated)

A
  1. transdermal fentanyl

2. severe pain

101
Q

General principles of opioid use:

  1. Choice and dose based on __
  2. Dose on a __
  3. Switch to __ to improve compliance
  4. Consider alternatives if ineffective
A
  1. severity of pain
  2. regular basis
  3. SR preparation
102
Q

Breakthrough opioid doses are dosed at __. They may be dosed hourly as needed.

A

1/6 of the total daily dose

103
Q

The total daily dose should be re-titrated when __. It also depends on the __ of the regimen.

A
  1. breakthrough doses used daily exceeds 3 or 4.

2. patient’s tolerance

104
Q

For patients previously on a weak opioid switching to morphine, give __ or modified release __. For frail, elderly and opioid naïve patients switching to morphine, give half of the standard dose (i.e. __).

A
  1. 10mg q4h
  2. 20-30mg q12h
  3. 5mg q4h
105
Q

Naloxone is an opioid antagonist used for treating __. It has a rapid onset of __ (IV), is metabolized in the liver and excreted in the kidney. In children, it is dosed by __ while adults follow the hospital’s dosing protocol.

A
  1. over dosage of opioids
  2. within 2min
  3. body weight
106
Q

Common side effects of opioids include:
• N__ (tolerance expected within 1-2wks)
• C__ (unlikely to develop tolerance)
• S__, mental clouding (Advise against driving, tolerance possible)

A
  1. Nausea/Vomit
  2. Constipation
  3. Somnolence
107
Q

Psychostimulants i.e. c__, d__ and m__ are used in the management of sedation and cognitive dysfunction in opioids.

A
  1. caffeine
  2. dextroamphetamine
  3. methylphenidate
108
Q

Myoclonus caused by opioids can be managed using __ and __. Pruritis can be managed using antihistamines but we should avoid __ i.e. cetirizine.

A
  1. clonazepam
  2. anti-convulsants
  3. the sedating ones
109
Q

There are 3 strategies for treating adverse effects from opioids:
• Dose reduction (using __)
• Changing to a different __
• __ management

A
  1. adjuvants
  2. opioid or route of administration
  3. Symptomatic
110
Q 
Monitor the following for patients on opioid therapy:
• Pain relief
• Side effects
• \_\_ (physical and psychosocial)
• \_\_ behaviors
A
  1. Function

2. Drug related

111
Q

Psuedo-addiction and addiction both lead to aberrant drug-related behaviour. However, pseudo-addiction is caused by __ and is reduced __. As the 2 can co-exist, knowing the patient well and __ are critical factors in distinguishing them.

A
  1. uncontrolled pain
  2. using improved pain control
  3. having a good history
112
Q

Addiction is unlikely to be due to pain management and is more commonly due to patients __. For such patients, __ can be drawn up to help reduce opioid abuse.

A
  1. having a history of addiction and substance abuse

2. opioid contracts

113
Q

What are the two types of tolerance?

A
  1. tolerance to SE is desirable

2. tolerance to analgesia is seldom

114
Q

tolerance does not cause ________

Cancer managment (4 decks)

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