Pain Mgmt 1 Flashcards
Non-opiod Analgesics
- What are the 2 Salicylates?
- Acetylsalicylic Acid (ASA) (give low dose for CVD)
- Choline & Mg Trisalicylate (doesn’t alter platelet function)
Non-opiod Analgesic - Acetaminophen
- Elderly - no more than __ g / day
- General population - no more than __ g / day
- 2
- 3
name the drug
- Adult FDA approved nonopioid analgesic
- Phenylacetic acids
- Patch form?
- Gel and Solution form?
- Diclofenac epolamine (Flector patch)
- Diclofenac sodium (solution / gel)
name the drug
- Propionic Acids
- Max daily dose of _____
Ibuprofen
- 3200 mg
Which Propionic Acid
- used for osteoarthritis?
- used for acute pain?
- Osteo = Naproxen
- Acute = Naproxen sodium
name the drug
- Pyrrolacetic Acids
Keorolac (parenteral)
name the drug
- Cox-2 Selective
Celecoxib
name the drug
- in cardiac pts where low dose ASA is indicated, give ASA first!!
- Protects stomach lining, but not the kidneys
Cox-2 Selective
(Celecoxib)
Which drug?
- ADE: Upper GI bleeding, Acute renal failure
- Monitor: CBC, stool guaiac, serum creatinine
- One of the leading causes of hospitalizations due to drug related ADE in the U.S.
NSAIDS
Which drug?
- ADE: hepatotoxicity
-
Monitor:
- Serum transaminases (ALT/AST)
- Liver synthesis tests (PT/INR, albumin)
- Serum concentration of this drug
Acetaminophen
Which 3 drugs?
- Used in mild - mod pain
- Care must be exercised to avoid overdose when combination products containing these agents are used
- NSAIDs
- Acetaminophen
- Aspirin
NSAIDs / Acetaminophen / Aspirin
- May use in conjunction w/ ___ agents to decrease doses of each
- Regular alcohol use w/ _____ use may result in liver toxicity
- W/ _____, underlying renal impairment, hypovolemia, and CHF may predispose to ________.
- opioid
- acetaminophen
- NSAIDs / nephrotoxicity
What is a good reference tool for prescribing Opioids?
Arizona Department of Health Services website
(AZdhs.gov)
Which Opioid Analgesic?
- Phenanthrenes
- Naturally occuring
- Lots of histamine release
- Morphine
- Codeine
Which Opioid Analgesic?
- Phenanthrenes
- Semi-synthetic
- Hydromorphone (Dilaudid)
- Oxymorhpone (Opana)
- Levorphanol
- Hydrocodone
- Oxycodone (Oxycontin, Oxecta, Roxicodone)
Which drug?
- Drug of choice in severe pain
- May use immediate-release product with controlled release product to control breakthrough pain in cancer pain
Morphine
Which drug?
- Use in severe pain
- More potent than morphine; otherwise, no advantages
Hydromorphone (Dilaudid)
Which drug?
- Use in severe pain
- May use immediate-release product with controlled release product to control breakthrough pain in cancer pain
- Extended-release reformulated to deter misuse
Oxymorphone (Opana)
Which drug?
- Use in severe pain
- Extended half-life useful in cancer patients
- In chronic pain, wait 3 days between dosage adjustments
Levorphanol
(Phenanthrenes)
Which drug?
•Use in mild to moderate pain and cough suppression
•Depends on CYP 450 2D6 for metabolism to morphine
•Weak analgesic; use with NSAIDs, aspirin, or acetaminophen, analgesic prodrug
•Should not be used in children
Codeine (Methylmorphine)
(Phenanthrenes)
Which drug?
- Use in moderate/severe pain
- Most effective when used with NSAIDs, aspirin, or acetaminophen
- Only available as combination product with other ingredients for pain
Hydrocodone
(Phenanthrenes)
Which drug?
- Use in moderate/severe pain
- Most effective when used with NSAIDs, aspirin, or acetaminophen
- May use immediate-release product with controlled release product to control breakthrough pain in cancer pain
- CR reformulated to deter misuse
Oxycodone (OxyContin)
(Phenanthrenes)
Name the drug
- Phenylpiperidines
- Synthetic
- Which one has large histamine release?
- Which one has transdermal, buccal, transmucosal, sublingual, nasal inhaled routes?
- Meperidine (Demerol) - Lots of histamine
- Fentanyl (Sublimaze, Duragesic, Actiq) - routes
Which drug?
- Use in severe pain
- Oral not recommended
•Do not use in renal failure**
•May precipitate tremors, myoclonus, and seizures (active metabolite normeperidine)**
•Produces mydriasis not miosis**
•When used with monoamine oxidase inhibitors can induce hyperpyrexia and/or seizures or opioid overdose symptoms
Meperidine
Which drug?
•Used in severe pain
•Do not use transdermal in acute pain**
- With transmucosal, intranasal, sublingual dosing
- start with lowest dose despite daily opioid intake
- product-specific titration and maximum dose recommendations exist
- breakthrough cancer pain in patients already receiving or tolerant to opioids
- Transmucosal, intranasal, sublingual _____dosage forms are only available through a REMS program
Fentanyl
Name the drug
- Diphenylheptanes
- Synthetic
Methadone
Which drug?
- Effective in severe chronic pain
- Sedation can be major problem
•QT prolongation-major reason for lower use**
•Some chronic pain patients can be dosed every 12 hours
•Avoid dose titrations more frequently than every 2 weeks**
Methadone
Which drug?
Methadone
Agonist-Antagonist or Partial Agonist
- Name the 2 drugs
- Synthetic
- no histamine release
- Pentazocine (Talwin)
- Buprenorphine (Butrans, Subutex) - Transdermal, Sublingual
Which drug?
- Third-line agent for moderate-to-severe pain
- May precipitate withdrawal in opiate-dependent patients
- Parenteral doses not recommended
Pentazocine
Which drug?
- Second-line agent for moderate-to-severe pain
- May precipitate withdrawal in opiate-dependent patients
Butorphanol
Which drug?
- Second-line agent for moderate-to-severe pain
- May precipitate withdrawal in opiate-dependent patients
Nalbuphine
Which drug?** (KNOW)
•Second-line agent for moderate-to-severe pain
•May precipitate withdrawal in opiate-dependent patients
•Detailed manufacturer dosing conversion recommendations exist
•Naloxone may not be effective in reversing respiratory depression
•Must complete training to prescribe
Buprenorphine
Name the drug
- Opioid
- Central Analgesic
- Synthetic
- No histamine release
- Tramadol
- Tapentadol
Which drug?
•Maximum dose for nonextended-release, 400 mg/24 h,
•Decrease dose in patient with renal impairment and in the elderly
–> If more than 75 years old 300 mg/24 h
–> If creatinine clearance less than 30 mL/min 200 mg/24 h; maximum for extended-release, 300 mg/24 h
Tramadol
(central alagesic)
Which drug?
- First day of therapy may administer second dose after the first as soon as 1 hour after the first dose
- Maximum dose first day 700 mg, maximum dose thereafter 600 mg (maximum dose for CR 500 mg)
- REMS required
Tapentadol
(central analgesic)
2 main ADEs of Opioids
-
Respiratory depression
- monitor: RR or end tidal capnography
- Pts at high risk: obstructive sleep apnea, COPD
-
Constipation
- monitor: BM frequency & consistency
- Constipation may be assessed using Bristol Scale
What 2 ADE’s of Opioids will decrease over time?
- Sedation
- N / V
Which ADE of opioids?
- Monitor for: urticaria, pruritus, bronchospasm
Histamine release
Which ADE of opioids?
- Monitor for: biliary spasm, urinary retention
Increase in sphincter tone
Which ADE of opioids?
- Monitor: fatigue, depression, sexual dysfunction, amenorrhea
- Problem w/ chronic use
Hypogonadism
What are the 4 opioids to avoid/exercise caution?
- Codeine (naturally occuring, Phenanthrene)
- Meperidine (synethetic, Phenylpiperidine)
- Agonist / Antagonist agents (Pentazocine, Buprenorphine)
- Tramadol (synthetic, central analgesic)
Which opioid to avoid/caution?
- Do not use (esp. in children and breastfeeding)
- Pro-drug: Must be converted to CYP 2D6 to morphine to produce analgesia
- High degree of polymorphism of 2D6
- Ultra-rapid metabolism = toxicity, poor metabolism = no analgesia
Codeine
Which opioid to avoid/caution?
- DO NOT USE
Short duration, req freq dosing - Produces non-analgesic
- toxic metabolite
- accumulation results in seizures
- risk of accumulation increased in renal insufficiency
Meperidine
Which opioid to avoid/caution?
- Caution
- Can produce opioid withdrawal w/ chronic use
- Higher rate of psychomimetic rxns compared to other opioids
Agonist / Antagonist agents
Which opioid to avoid/caution?
- Caution: esp. in elderly or renal dysfunction
- Pro-drug: must be converted to CYP 2D6 to desmethyl (M1) to produce analgesia
- High degree of polymorphism of 2D6
- Ultra-rapid metabolism = toxicity, poor metabolism = no analgesia
- Risk of seizures, serotonin syndrome, hypoglycemia
Tramadol
