Pain Management (Meds) Flashcards

1
Q

Define opioid

A

refers broadly to all compounds related to opium

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2
Q

______ is derived from greek word for stupor

A

Narcotic

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3
Q

What are the 4 classes of opioids?

A
  1. full agonists
  2. partial agonists
  3. mixed agonists - antagonists
  4. antagonists
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4
Q

What is a pro of using opioids?

A

have analgesic properties

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5
Q

What is a con of using opioids?

A

high potential for abuse/ addiction

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6
Q

Mechanism of action of opioids:

Alters the _____ & _____ aspects of pain
-opioids inhibit the transmission of ______ ______ from the ______ ______
-activates ______ pain inhibitory pathways
-alters _______ system activity

A

sensory & affective
-nociceptive info; spinal cord
-descending
-limbic system

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7
Q

Do opioids resolve all pain a patient feels?

A

patients typically report pain still being present, but feeling more comfortable

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8
Q

Where are the opioid receptors located?

A

dorsal horn
thalamus
cortex

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9
Q

What is the primary opioid pain receptor?

A

Mu (μ)

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10
Q

Mu (μ) pain receptors mediate:

A

analgesia
respiratory depression
euphoria
decreased GI activity
sedation
physical dependence

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11
Q

What are the other two opioid pain receptors?

A

kappa (k)
delta

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12
Q

Kappa (k) pain receptors mediate

A

some analgesia, sedation, decreased GI motility
dysphoria

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13
Q

What opioid pain receptors are not fully understood?

A

delta

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14
Q

Fill in the blanks with these 2 terms: (pharmacological & pharmacokinetic)

Opioids have very similar ______ effects, but significantly different ______ properties

A

pharmacological
pharmacokinetic

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15
Q

Peak times for short-acting opioids:
- oral
- IV

A

Oral - peak within 1 hr
IV - peak within 15 min

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16
Q

Pharmacokinetics of opioids:

Most opioids are readily absorbed from the ______ ______ & many other sites

A

GI tract

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17
Q

Pharmacokinetics of opioids:

Opioids are subject to _____ _____

A

First pass

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18
Q

Pharmacokinetics of opioids:

Some opioids have _____ ______

A

active metabolites
if these build up in the body they can actually make Sx/ pain worse

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19
Q

Pharmacotherapeutics of opioids:

What administration route is the MOST reliable way to achieve the therapeutic level?

A

Intravenously

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20
Q

Pharmacotherapeutics for opioids:

A

can have injectable but depends on muscle mass, fat, etc
hepatic metabolism
urine/ bile excretion
half life depends on the med
cross placenta/ breast milk

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21
Q

Full opioid agonists _____ to opioid receptors resulting in ______

A

bind; resulting in activation

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22
Q

activation of mu receptors leads to…

A

analgesia, respiratory depression, euphoria, & sedation

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23
Q

activation of the kappa receptors leads to…

A

analgesia, sedation & decreased GI motility

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24
Q

List some full opioid agonist meds

A

morphine
fentanyl
codeine
oxycodone
hydromorphone
meperidine
methadone

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25
Q

List some common side effects of full opioid agonists

A

respiratory depression
constipation
orthostatic hypotension
urinary retention

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26
Q

Full opioid agonists are ____ risk of dependence and _____ substances

A

high risk; controlled

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27
Q

What full opioid agonists is considered the GOLD standard?

A

Morphine

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28
Q

Morphine affects _____ & ______ receptors

A

central & peripheral receptors
it is a mu opioid agonist

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29
Q

What are the major side effects of morphine?

A

analgesia
drowsiness
mental clouding

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30
Q

What are other side effects caused by morphine?

A

respiratory depression
constipation
urinary retention
N/V
hypotension
pruritis

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31
Q

Morphine has active metabolites, such as _____, which can accumulate

A

M6-G

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32
Q

Morphine has multiple …

A

routes of administration & formulations

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33
Q

What full opioid agonists has essentially identical pharmacologic effects to morphine?

A

hydromorphone (dilaudid)

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34
Q

Is hydromorphone more or less potent than morphine?

A

more potent

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35
Q

Does hydromorphone (dilaudid) have active metabolites?

A

NO

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36
Q

Both morphine and hydromorphone have _____ acting forms

A

Short acting forms

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37
Q

hydromorphone has no ________ form available

A

Extended release

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38
Q

_______ extended release is available in 4 dose sizes

A

Oxymorphone

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39
Q

What can affect the absorption of extended release formulation?

A

Food & drinks

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40
Q

indications for fentanyl

A

surgical pre-medications (invasive procedures)
adjunct to anesthesia
breakthrough cancer pain
chronic pain

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41
Q

Fentanyl binds to opioid receptor sites in

A

CNS

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42
Q

What are the different routes available for fentanyl?

A

IV
IM
submucosal
sublingual
buccal
nasal spray
transdermal

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43
Q

What are some side effects of fentanyl?

A

confusion
H/A
sedation
bradycardia
hypotension
blurred vision
laryngospasm
constipation
respiratory depression

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44
Q

What full opioid agonists have numerous drug-drug interactions?

A

Fentanyl

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45
Q

Fentanyl patches should not be used for ____ pain

A

Acute pain

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46
Q

Fentanyl patches are used in patients with _______ _______ conditions

A

Chronic pain

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47
Q

How long are fentanyl patches applied for?

A

48-72 hrs

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48
Q

What should the nurse make sure of when applying a fentanyl patch?

A

that it is applied firmly, with no punctures or breaks in the patch

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49
Q

What side of a fentanyl patch is important NOT to touch

A

the sticky side (never touch actual medication)

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50
Q

Why do we need to ensure the patient is not in pain when using fentanyl patches?

A

they take several hours (6-12) to take effect

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51
Q

Where should a fentanyl patch not be placed & why?

A

On the chest b/c it could be placed over rib (bone) which will not absorb the medication

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52
Q

Why should fentanyl patches NOT be used in a patient who has a fever?

A

Fevers result in vasodilation of BV; increases peripheral BF and the drug is going to be absorbed faster

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53
Q

What skin condition can fentanyl patches cause?

A

Contact dermatitis

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54
Q

How is a fentanyl buccal “lollipop” used?

A

Have the pt put it in their cheek to dissolve

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55
Q

What full opioid agonist’s effectiveness is basically the same as ASA & acetaminophen?

A

Codeine

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56
Q

What is the major side effect of codeine?

A

constipation
more than any other mu agonist

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57
Q

About 10% of codeine is metabolized to ______ by __________ pathway

A

morphine; CYP 2D6

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58
Q

Oxycodone is available in ______ & ______ formulations

A

short-acting & long-acting (they are NOT the same)

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59
Q

Can oxycodone & oxycontin be used interchangeably?

A

No b/c oxycontin is LA & oxycodone is SA

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60
Q

What two drugs have limited usefulness?

A

codeine & oxycodone

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61
Q

Three types of hydrocodone?

A

vicodin
lortab
nocro

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62
Q

Does hydrocodone have a better or worse side effect than codeine

A

better

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63
Q

Hydrocodone is often combined with _____ or ______

A

acetaminophen or ibuprofen

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64
Q

Hydrocodone has different routes of admin & can also be used as a ______ ______

A

cough suppressant

65
Q

What kind of onset & duration does meperidine (demerol) have?

A

rapid onset with short duration of action

66
Q

Meperidine has ______ ______

A

active metabolites

67
Q

Meperidine:

No evidence that efficacy enhanced by _____ or ______
Does not have a lesser effect on the _______ of ______

A

vistaril; phenergan
sphincter of oddi

68
Q

How many mg of meperidine PO is equal to 10 mg of IV morphine?

A

300 mg PO = 10 mg IV morphine

69
Q

What is meperidine’s limited use for?

A

short procedures or to treat rigors (intense shivering/ shaking w/ high fever)

70
Q

tramadol (ultram, ultracet) mechanisms of action (binary)

A

weak mu-opioid agonist
blocks reuptake of norepinephrine & serotonin

71
Q

Tramadol (ultram, ultracet)

A

controlled substance
analgesic ceiling higher doses do not provide additional pain relief
active metabolites
Oral route only

72
Q

List some side effects of tramadol

A

nausea
dizziness
confusion
seizures
dry mouth

73
Q

What labs should be monitored for a patient who is prescribed tramadol?

A

BUN/ creatinine
LFTs
think ab liver & renal function; not taking prescribed dose can cause adverse effects

74
Q

Who should not be prescribed tramadol?

A

someone with impaired liver or kidney function

75
Q

What kind of opioid receptor is methadone

A

mu, kappa, & delta

76
Q

What medication is used to help patients withdraw from opioid abuse

77
Q

Methadone decreases ______ & ______ effects of opioids

A

cravings & euphoric

78
Q

Methadone blocks _____ receptor – decrease ______ pain threshold

A

NMDA receptor; CNS pain threshold

79
Q

What does it mean when someone says methadone is lipophilic?

A

stays in the fat for a long time

80
Q

What opioid is highly protein bonding

81
Q

Explain the half life & duration of methadone

A

long half-life (15-30 hrs), its duration of action of analgesia is up to 12 hrs

82
Q

Methadone can cause prolongation of _____

A

Q-T wave on ECG

83
Q

adverse effects:

respiratory depression

A

apnea
cardiac arrest
poor ventilation

84
Q

adverse effects:

GI side effects

A

nausea/ vomiting
constipation
abdominal pain

85
Q

Adverse effects:

neurologic

A

psychomotor & cognitive impairment
delirium

86
Q

adverse effects:

histamine release

A

itching or flushing of the skin

87
Q

List two other adverse effects

A

orthostatic hypotension
urinary retention

88
Q

Why can opioids cause constipation?

A

opioids bind to receptors in the GI tract & in the CNS, which reduces bowel motility & decreases transit time

89
Q

Constipation:

the decreased transit time leads to…

A

increased absorption of water from the stool into the intestine; causes stool to become hard, stretching of colon, & pain

90
Q

What opioid side effect can you NEVER build a tolerance to?

A

Constipation

91
Q

Contributing factors to constipation from opioids

A

decreased appetite
age
immobility
diabetes
other meds

92
Q

What other meds contribute to constipation from opioids

A

antidepressants
certain chemotherapy agents

93
Q

When is a PCA pump most often used?

94
Q

commonly used medications in PCA pump

A

morphine
fentanyl
hydromorphone

95
Q

How is medication delivered through PCA pump

A

continuously (basal rate)
bolus (only when button is pushed)

96
Q

How should a patient be monitored when using PCA pump

97
Q

How do opioid agonists-antagonists bind?

A

bind to more than one opioid receptor site, but block other receptors
**Partially activate mu receptors; act as antagonists at other opioid receptors, such as kappa receptor **

98
Q

What receptors do opioid agonists-antagonists antagonize & agonize

A

antagonize mu receptors & agonists to kappa receptors

99
Q

List opioid agonists-antagonists medications

A

buprenorphine (buprenex; subutex)
pentazocine (talwin)
nalbuphine (nubain)

100
Q

List the side effects of opioid agonists-antagonists

A

sedation
respiratory distress
constipation
may have more psychotic reactions

101
Q

opioid agonists-antagonists can help relieve pain during ____ & ____

A

labor & delivery

102
Q

Be careful to use opioid agonists-antagonists in what types of patients?

A

COPD patients
Pts experiencing MI or severe CAD
hepatic & renal disease

103
Q

Why do we need to be careful giving opioid agonists-antagonists to patients on chronic opioid therapy for pain?

A

can cause withdrawal

104
Q

What specific opioid agonist-antagonist medication should not be given to cardiac patients?

A

pentazocine (talwin)

105
Q

What kind of receptor med is buprenorphine (buprenex or subutex)

A

partial mu agonists, but in high doses acts as an antagonist

106
Q

List the different formulations of buprenorphine

A

injectable, IV, sublingual, nasal spray

107
Q

Why is buprenorphine used in place of methadone to treat opioid addiction? List examples.

A

it has a long duration of effect (2-3 days)
Ex:
Subutex - only buprenorphine given sublingually
Suboxone - buprenorphine w/ naloxone (schedule III)

108
Q

Is buprenorphine a high or low risk for abuse

109
Q

Nalbuphine (nubain) is a mixed agonists- antagonists by

A

kappa receptor agonist
mu receptor antagonist

110
Q

Nalbuphine is used in women experiencing labor when…

A

epidural anesthesia is not an option

111
Q

what else is nalbuphine used for

A

used in anesthesia

112
Q

Nalbuphine is ____ acting and lower risk of ______ _____ in both mother & baby

A

short acting
respiratory distress

113
Q

opioid antagonists bind to

A

bind tightly to opioid receptors but do not activate them

114
Q

What are opioid antagonists used for

A

to reverse opioids when levels are too high

115
Q

What are two medications considered opioid antagonists?

A

naloxone (Narcan, Evzio)
Naltrexone (revia)

116
Q

Opioid antagonists reverse what effects of opioids?

A

respiratory distress
hemodynamic instability
over sedation

117
Q

Someone who has an opioid addiction will experience _____ when taking opioid antagonists

A

Withdrawal

118
Q

List opioid antagonists formulations

A

IV
IM
Subcutaneous
nasal spray

119
Q

How does naloxone (nasal spray) counteract the effects of an OD of heroin or other opioids?

A

naloxone has a stronger attraction to the brain’s receptors & displaces the opioids long enough to allow breathing to resume

120
Q

Who should have naloxone at home?

A

anyone:
-taking opioids daily
-on opioids & benzodiazepines together
-chronic ETOH use
-Hx of opioid OD
-Hx of opioid addiction
-Hx of sleep apnea
-liver or kidney disease
-on methadone therapy

121
Q

List the adjuvant medications (10)

A

NSAIDS
corticosteroids
anti-depressants
anti-convulsant
local anesthetics
muscle relaxants
alpha 2 adrenergic agonists
NMDA receptor antagonists
cannabis
hypnotics & anxiolytics

122
Q

Give an example of hypnotics & anxiolytics

A

benzodiazepines

123
Q

Cannabis is considered what schedule of controlled substance?

A

schedule I
but varies by state

124
Q

list cannabis medications

A

dronabinol (marinol, syndros)
nabilone (cesamet)
cannabidiol (epidiolex)

125
Q

Further research needs to be done on the correlation of cannabis use and…

A

increasing use in Tx of chronic pain

126
Q

Cannabis has _____ & _____ properties

A

analgesia & anti-inflammatory properties

127
Q

Does cannabis have multiple indications & routes of administration?

128
Q

List side effects of cannabis

A

typically mild such as cough, anxiety & are well-tolerated

129
Q

Why are benzodiazepines often prescribed

A

for Tx of pain
(evidence shows they don’t work)

130
Q

Use of benzodiazepines with opioids increases risk of ______ & _______

A

sedation & respiratory depression

131
Q

How addictive are benzodiazepines?

A

highly addictive

132
Q

list medications considered benzodiazepines

A

alprazolam (xanax)
diazepam (valium)
clonazepam
lorazepam (ativan)

133
Q

benzodiazepines act as an ______ of opioids

A

antagonist

134
Q

Benzodiazepines may help with _____ Sx

A

withdrawal Sx

135
Q

Topical agents:

Capsaicin cream

A

depleted substance P in primary afferent neurons
belief is that with repeated reapplication you are desensitizing the neuron

136
Q

Topical agents:

How many times a day is capsaicin cream applied

A

3-4 times per day

137
Q

Topical agents:

list side effects of capsaicin cream

A

burning & redness at application site

138
Q

Topical agents:

EMLA cream

A

local anesthetic agent; inhibits depolarization of nerve & blocks neuronal firing (Blocks nerve signals that send pain to the brain)

Short term & wears off after a couple of hours

139
Q

Topical agents:

How should EMLA cream be applied?

A

apply thick coating & cover with occlusive dressing for 1 hour

Can use when needing IV access → let cream sit for 45 min to 1 hr & it numbs area to help the pt not feel pain

140
Q

Topical agents:

Lidocaine patch

A

local anesthetic agent; take time for effect to kick in

Available OTC

important to place patch where the pain is located

141
Q

Topical agents:

How many lidocaine patches can be worn at once & for how long?

A

up to 3 patches at one time; may be worn up to 12 hours

142
Q

Special populations & pain:

Older adults risks

A

respiratory depression, polypharmacy, falls

143
Q

Special populations & pain:

Older adults have age-related changes in _____, _____, _____, & _____

A

absorption, distribution, metabolism, & elimination

144
Q

Special populations & pain:

Rule of thumb for older adults & pain management

A

Start at a low dose & go slow

145
Q

Special populations & pain:

older adults should follow routine _____ regimen

A

bowel regimen (i.e. drinking enough fluids; eating high fiber foods; fruits & veggies; whole grain bread, etc)

146
Q

Special populations & pain:

Judicious use of opioids in what population

A

children & adolescents because there is little research

147
Q

Special populations & pain:

What kinds of opioids should be given to children & adolescents only in life-limiting conditions?

A

extended-release & long-acting

148
Q

Special populations & pain:

Watch for _____ in children & adolescents

A

diversion; illegal distribution or abuse of prescription drugs or their use for unintended purposes

149
Q

Special populations & pain:

~ what % of women with childbearing potential are prescribed opioids?

150
Q

Special populations & pain:

Women with childbearing potential need to be careful taking opioids as they can increase risk of ____ ____

A

fetal harm
most women don’t know they are pregnant in first few weeks

151
Q

Special populations & pain:

As the HC team what should be done when prescribing opioids to a pregnant women?

A

weigh the benefits vs. risks

152
Q

Special populations & pain:

Opioid use in pregnant women poses risk of

A

neonatal opioid withdrawal syndrome; should avoid opioids while pregnant

153
Q

Special populations & pain:

What should be given to a pregnant woman already on opioids?

A

methadone or buprenorphine

154
Q

Neurobiology of addiction:

Dopamine

A

Non-opioid neurotransmitter

Affect: reward, stimulation, mood

Drug–mimic neurotransmitter: cocaine, heroin, alcohol, methamphetamine

155
Q

Neurobiology of addiction:

serotonin

A

Non-opioid neurotransmitter

Affect: mood, sleep, appetite

Drug–mimic neurotransmitter: THC, alcohol, methamphetamine

156
Q

Neurobiology of addiction:

GABA (gamma-aminobutyric acid)

A

Non-opioid neurotransmitter

Affect: sedation, anti-anxiety

Drug–mimic neurotransmitter: alcohol, barbiturates, benzodiazepines

157
Q

Neurobiology of addiction:

Norepinephrine

A

Non-opioid neurotransmitter

Affect: mood, sedation, constriction of BV

Drug–mimic neurotransmitter: methamphetamine

158
Q

Neurobiology of addiction:

endorphins

A

Opioid transmitters

Affect: natural pain killers

Drug–mimic neurotransmitter: heroin, opiates, alcohol

159
Q

Neurobiology of addiction:

What happens when a neurotransmitter binds to a receptor?

A

The site is activated with an excitatory or inhibitory effect