Pain Mgmt Flashcards
1
Q
What receptor gives you the most analgesia?
A
Mue opioid receptor
2
Q
What is buprenorphine?
A
Partial opioid agonist
3
Q
What is used for mild to moderate pain?
A
NSAIDS
Acetaminophen
Aspirin
4
Q
T/F It is the acetyl group in aspirin that prevents platelet activation?
A
True
5
Q
T/F Methadone is used for neuropathic pain because of its SNRI properties
A
True
6
Q
Name the three type of opioid receptors?
A
Delta, Kappa, Mu
7
Q
Which opioid receptors have slowed GI motility?
A
MU and Kappa
8
Q
Which receptor has psycho mimetic effects?
A
Kappa
9
Q
Which opioid receptor depresses respiration the most?
A
Mu
10
Q
Which endogenous opioid acts on the kappa receptor?
A
Dynorphin
11
Q
Which endogenous opioid acts on the delta receptor?
A
Enkephalins
12
Q
Which endogenous opioid acts on the mu receptor?
A
Endorphins>Enkephalins>Dynorphins
13
Q
What is noxious stimuli?
A
mechanical, thermal or chemical impulses
14
Q
Which fibers are involved in pain transmission?
A
Alpha delta and C fibers
15
Q
Alpha delta fibers
A
large diameter
sparsely myelinated
sharp localized pain
16
Q
C fibers
A
small diameter
unmyelinated
-dull achy pain that is poorly localized
17
Q
Where are opioid receptors found?
A
CNS
18
Q
Where are NMDA receptors found?
A
dorsal horn
19
Q
How is pain modulated?
A
- Endogenous opiates
- blocking of NMDA receptor
- descending system in brain can stop transmission of pain to dorsal horn (modulated by serotonin,NE, GABA, and endogenous opiates)
20
Q
What is pathophysiological pain?
A
abnormally functioning of nerves in CNS and PNS
-pain circuits rewire themselves anatomically and biochemically= chronic pain
21
Q
What is somatic nociceptive pain?
A
arises from skin, joints, muscles, or CT
-throbbing well localized pain
22
Q
What is visceral nociceptive pain?
A
arises from internal organs
-referred pain
23
Q
T/F The brain can only accommodate 1 or 2 pain stimuli
A
True
24
Q
What is adaptive inflammation?
A
- inflammation that results as a response to promote healing but subsequently reduces the pain threshold causing an area to be more sensitive to pain
- central sensitization: increased excitability of neuron in CNS
- major cause of hypersensitivity to pain after injury
25
Neuropathic pain?
nerve damage
| Ex. diabetic neuropathy
26
Functional pain?
-abnormal operation of CNS
| Ex. fibromyalgia, IBS
27
T/F Cancer pain has multiple etiologies and can be chronic or acute
TRUE
28
What is acute pain?
- sharp, dull, shooting, radiating, shock that occurs with obvious pain stimulus in timely relationship
- not usually dependent on pain meds
- organic cause present
- small environmental issues
- insomnia unusual
- depression unusual
- goal: pain reduction
29
What is chronic pain?
- can appear to have no noticeable suffering
- anxiety depression can lower pain threshold
- dependent on pain meds
- significant environmental issues
- insomnia present
- depression present
- goal: functionality
30
What are non pharmacological treatments to pain?
1. exercise
2. TENS (trans electrical nerve stimulation)
3. Psychological interventions
31
Which salicylate lacks acetyl group and does not alter platelet function? (2)
- Choline and Mg trisulfate
| - Diflunisal
32
What is the limit of acetaminophen for the elderly? for general population?
- 2mg
| - 3-4 mg
33
What is pharmacokinetics of dicolfenac epolamine
transdermal patch applied BID for local pain
34
Which NSAID is used for osteoarthritis?
diclofenac sodium gel
35
How can Ibuprofen be delivered?What is max daily dose?
PO or IV , IV infused over 30 min
- 3200mg for inflammation
- 1200 for fever, dysmenorrhea,
36
What is the use Naproxen? Naproxen sodium?
- osteoarthritis
| - acute pain
37
What is maximum days you can use ketorolac? route/mode of delivery?
5 days
| -route: parenteral, oral, nasal spray
38
What are selective COX-1 Inhibitors?
Ketorolac, low dose aspirin, Indomethicin
39
What are selective COX-2 inhibitors?
Diclofenac, celecoxib, Etodolac
40
What are non selective cox inhibitors?
Naproxen, Ibuprofen and Diflunisal
41
T/F In patients with CVD aspirin is given first before celecoxib
TRUE
42
What are ADE of NSAIDS? What should you monitor?
- GI bleeds, monitor CBC, stool guaiac
| - Acute renal failure, monitor serum creatinine, GFR
43
What is ADE of acetaminophen? monitor?
liver toxicity
| -ALT/AST, PT/INR, albumin, acetaminophen serum concentration
44
What do you give for severe pain?
levorphenol, fentanyl, morphine, hydromorphone, oxymorphone, meperidine, methadone
45
Which opioids are used over morphine?
Fentanyl and Hydromorphone
46
Which opioids are for moderate efficacy? Which one has low efficacy?
- Hydrocodone and Oxycodone
| - codeine
47
PK of opioids?
- oral form has high first pass effect
- sub Q form
- distributed to brain, lungs, kidneys, liver, spleen
- skeletal muscle serves as reservoir
- metabolized by CYP3A4
- excreted by kidneys in urine
48
T/F Heroin is metabolized by plasma esterase
TRUE
49
Which two naturally occurring opioids release histamine?
Morphine and codeine
50
What are two semi synthetic opioids?
Oxymorphone and Hydromorphone
51
Why is hydromorphone used over morphine?
more potent
52
T/F controlled release form helps with breakthrough pain in cancer and helps control misuse
TRUE
53
Which semi synthetics opioids are given PO only
levorphenol
hydrocodone
oxycodone
54
Which opioid suppresses cough? What is special about codeine?
codeine
| -metabolized into morphine
55
what is clinical use of levorphenol?
- extended half life
| - used in cancer patients
56
Which synthetic opioid releases histamine?
meperidine
57
What are routes of delivery for Fentanyl?
IM, transdermal, sublingual, nasal inhaled
58
Why is meperidine avoided?
- anti-cholinergic effects
- precipitates seizures(from active metabolite normeperidine)
- mydriasis
- oral form not recomended
59
Which opioid blocks shivering?
-Meperidine
60
T/F Dont use transdermal Fentanyl patch in acute pain
TRUE- due to delayed onset of effect
61
What are ADE of methadone?
QT prolongation
| avoid dose titration more frequently than every 2 weeks
62
T/F Naloxone may not reverse the resp depression with Buprenorphine
TRUE
63
What is medication of choice for MAT?
Buprenorphine
64
What are the three drugs used in MAT?
Methadone,
Buprenorphine
Naltrexone
65
Which opioid in MAT has weak affinity for the mu receptor?
Methadone
66
What is route of Tramadol? Tapendol? what is half life of each?
- PO
- 7 hrs for Tramadol
- 4 hrs for Tapendol
67
High degree of tolerance to some effects of opioids? (8)
- Analgesia
- Euphoria
- Mental clouding
- sedation
- respiratory depression
- anti-diuresis
- N/V
- cough suppression
68
Medium degree of tolerance to some effects of opioids?
bradycardia
69
Minimal degree of tolerance to some effects of opioids?
Miosis
Constipation
Convulsions
70
**What are ADE of opioids with acute use? (10)
```
respiratory depression
N/V
itchiness
constipation
urticaria
urinary retention
delirium
sedation
myoclonus
seizures
```
71
*What are ADE of opioids with chronic use? (7)
- hypogonadism
- immunosuppression
- increased Growth Hormone secretion
- withdrawal effects
- dependence/addiction
- hyperalgeisa
- impaired driving
72
T/F Benzos with narcotics = DEATH
TRUE
73
MAO-I and opioids can cause a hypyrexic coma?
TRUE
74
What are drug drug interaction with opioids? (3)
sedative hypnotics: increases respiratory depression
anti-psychotic agents: increased sedation
MOA-I: hypyrexic coma
75
What are ADE of opioids?
```
Respiratory depression
constipation
sedation
tolerance
dependence
N/V
```
76
What should you monitor when taking opioids?
- capnography-high risk of respiratory depression in sleep apnea
- stool/bowel movements
- tolerance
- dependence
77
T/F Opioids increase sphincter tone?
TRUE
78
T/F You can use codeine in children and pregnant women
False
| High degree of polymorphism
79
T/F Codeine is a pro drug that is converted into morphine by CYP2D6
TRUE
80
T/F Meperidine is a short acting drug that requires many dosing times and produces toxic side effects like convulsions
TRUE
81
Who should not use tramadol?
elderly
| people with renal insufficient
82
T/F Tramadol is a prodrug that has high polymorphism and is metabolized by CYP2D6
TRUE
83
T/F Some opioids may out last the effect of Naloxone so a dose may need to be repeated
TRUE
84
T/F If no response to the Narcan you can repeat a dose with in 5 min?
TRUE
85
What are are alternative tx for chronic pain?
TCA, SSRI, SNRI
| -they block the reuptake of serotonin and NE increasing pain inhibition
86
Name 2 ibuprofen patches?
Flector
| Voltarin
87
What are some ingredients in Tiger balm?
Capsacin
Menthol
Camphor
88
How does doluxetine/cymbalta decrease pain?
- potent serotonin reuptake inhibitor -decreases pain
- weak dopamine re uptake inhibitor
- can treat neuropathic pain
89
What are ADE of cymbalta?
agitation, insomnia
90
What is classification of a true opioid allergy?
- IgE
- T cell mediated
- angio edema
- bronchospasms
- RARE
91
What is classification of a pseudo opioid allergy?
- more common
- histamine release from cutaneous mast cells
- itching, flushing, sweating
92
What symptoms can be seen in both?
HIVES
- increased HR
- angioedema
- low BP
93
What is tx of a pseudo opioid allergy?
use NSAIDS if possible
DON'T USE codeine, morphine or meperidine
USE: hydrocodone, oxycodone, hydromorphone, levorphenol, fentanyl
94
T/F The stronger the opioid the less likely it is to release histamine
TRUE
95
What is tx for a true opioid allergy?
use NSAIDS if possible
| choose an opioid in difference chemical class
96
Give some examples of opioids and class?
diphenylheptane: methdone
phenylpiperidines: fentanyl
Morphine: codeine, morphine, hydrocodone,oxycodone, hydromorphone,oxymorphone, levorphenol
97
How can you deter opioid abuse?
- dont use tablets that crush or grind
- controlled release formulation
- gelling agents
- depot shot
