ROGERS Flashcards
what percent of americans have chronic pain
30%
subjective questions to ask a pt about pain
PQRSTU
precipitating factors
quality of pain
region
severity
time related
impact on U
also what have you tried
objective factors of pain
behavior changes
dilated pupils
paleness
sweating
tachycardia
tachypnea
which pain scale is helpful in kids?
Wong-Baker
(faces)
what is nociceptive pain
tissue
what is neuropathic pain
nerve
non-pharm options for pain
correct cause
exercise
acupuncture
massage
heat/ice
chiropractor
treatment ladder step 1
non opioid
+/- adjuvant analgesic
treatment ladder step 2
opioid for mild/mod pain
+ non opioid
+/- adjuvant analgesic
treatment ladder step 3
opioid for mod/severe pain
+ non opioid
+/- adjuvant analgesic
Tylenol dosage forms
tablet
capsule
chewable
liquid/gel
IV
suppository
Tylenol dosing adults
325-1000 mg q4-6h
max: 3-4 g /day
Tylenol dosing kids
10-15 mg/kg q4h
max: 75 mg/kg/day or 3-4 g
Tylenol hepatotoxicity likely with what dose
> 10 g dose
NSAID side effects
GI bleed
nephrotoxicity
fluid retention
increase in CV events
when to avoid NSAIDs
liver disease
CKD
Beers
CV history
counseling tip for NSAIDs
take with food
aspirin
tablet
capsule
chewable
ec tablet
er capsule
suppository
ASA dosing adult
325-1000 mg q4-6h
max: 4 g /day
ASA in children
AVOID
when to avoid ASA
children
pts on blood thinners
what is Reyes syndrome
swelling in brain and liver
(when kids have a viral infection)
ibuprofen dosage forms
tablet
capsule
chewable tablet
IV
suspension
ibuprofen dosing adult
200-800 mg q6-8 h
max: 3200 mg /day
ibuprofen dosing kids
> 6 months
5-10 mg/kg q 4-6h
max: 40 mg/kg/day or 2400 mg
diclofenac dosage forms
tablet
capsule
IV
suppository
topical gel
topical solution
ophthalmic
patch
diclofenac dosing
50 mg PO q8h or 2-4g QID topically
naproxen dosage forms
tablet
capsule
DR/ER tablet
suspension
naproxen dosing
220-500 mg PO q6-12 h
max: 1000 mg/day
ketorolac dosage forms
tablet
IV/IM solution
nasal spray
ophthalmic
ketorolac dosing adults
15-30 mg IV q6h
10 mg PO q6h
ketorolac dosing kids
0.5 mg/kg/dose IM/IV q6h
maximum duration of ketorolac
5 days
when is oral dosing used with ketorolac
continuation of IV or SUBQ
celecoxib dosage forms
capsule
oral solution
celecoxib dosing
200 mg PO BID
gabapentin / pregabalin uses
fibromyalgia
neuropathies
post op pain
gabapentin doing and max dose
100-300 mg TID
3600 mg / day
pregabalin dose and max
75 mg BID
max: 600 mg
pregabalin is what schedule
IV
gabapentin is what schedule
not scheduled
pregabalin and gabapentin side effects
sedation
dizzy
gabapentin and pregabalin are ____ dosed
renally
venlafaxine max dose
225 mg /day
duloxetine max dose
60 mg/day
duloxetine renal considerations
avoid in CrCl < 30
side effects of nortriptyline and amitriptyline
anticholinergic
sedation
when to use amitryptiline and nortriptyline in fibromyalgia/neuropathy
last line
max of nortriptyline and amitriptyline dose
150 mg /day
when to use muscle relaxants
musculo skeletal pain / pulled muscle
muscle relaxant drugs
cyclobenzaprine
baclofen
methocarbamol
carisoprodol
tizanidine
muscle relaxants duration of use
< 3 weeks
which muscle relaxant has abuse potential
carisoprodol
schedule IV
cyclobenzaprine max
30 mg
baclofen max
80 mg
carisoprodol max
1050 max
methocarbamol max
8 g
tizanidine max
24 mg
carbemazepine max
1200
carbemazepine risk
hypersensitivity with HLA B 1502 allele
autoinduction of hepatic enzymes
topical agent for pain
lidocaine
lidocaine dosage forms
patch
injection
topical
what can happen with continuous use of lidocaine patch
tolerance
12 hour break between patch
Beers oral NSAID recommendation
avoid chronic and acute use unless needed to but with a PPI or misoprostol
Beers recommendation ketorolac and indomethacin
avoid
Beers recommendation carisoprodol, cyclobenzaprine, methocarbamol
avoid
Beers tizanadine and baclofen
don’t avoid but substantial side effects
Beers reccomendation SNRI, TCA, carbamazepine
use with caution
Beers recommendations opioids and benzos together
avoid
Beers recommendations opioids and gaba/prega
avoid unless tapering off or swtiching to gaba
Beers recomendation two anticholinergics (like TCA and muscle relaxant)
avoid
Beers recommendation of CNS agents
avoid three or more CNS active drugs
best pain medications for elderly
tylenol
topical
SNRI
gaba
side effects muscle relaxants
anticholinergic
side effects venlafaxine/duloxetine
nausea, headache, sedation
weak opioid agonists
tramadol
codeine
signs of overdose
bradycardia
decreased respiratory rate
hypotension
pale
sedation
pinpoint pupils
signs of withdrawal
tachycardia
increased respiratory rate
hypertension
sweating
insomnia
dilated pupils
pts who should get naloxone
hx overdose
hx substance disorder
benzo use
higher opioid dosages
narcan dosing frequency
2-3 mins
who is codeine not recommended for
breastfeeding mothers
children <12
tramadol is ____ dosed
renal
tramadol risk
serotonin syndrome with other serotonin meds
codeine dosage forms
tablet
syrup`
tramadol dosage forms
tablet
capsule
solution
morphine dosage forms
tablet
capsule
solution
IV
suppository
hydromorphone dosage forms
tablet
oral solution
injection solution
suppository
hydrocodone dosage forms
tablet
oral solution
hydrocodone use with a 3A4 inhibitor will do what
increase concentration
oxyodone dosage forms
tablet
capsule
oral solution
which oxycodone formation is abuse deterrent
ER
fentanyl dosage forms
buccal
sublingual
lozenge
injectable sol
patch
fentanyl renal considerations
can use in impairment
who can use the noninjectible forms of fentanyl
opioid tolerant: 60 mg morphine daily for a week
swithcing between doses for fentanyl
not one to one between dosage forms
fentanyl patch duration
every 72 hours
methadone dosage forms
tablet
oral solution
injectible solution
which pain drug QTC prolong
methadone
which drug do we need to avoid with hx of seizures
tramadol
dilaudid
hydromorphone
duragesic
fentanyl
demerol
meperidine
which meds available in ER
tramadol
morphine
hydropmorphone
hydrocodone
oxycodone
naural opiates
codeine
morphine
synthetic opioids
fentanyl
methadone
miperidine
tramadol
if pt has allergy to natural or semi synthetic what can we give them?
synthetic
how much to reduce dose by when switching
25-50%
what type of opioid should be selected first?
IR, lowest effective dose
when should clinicains follow up with starting opioid therapu
1-4 weeks
what strength if not working should we taper opioids
> 50 MME
how to taper if pt has taken opiods > 1 year
reduce by 10% per month
how to taper if pt has taken opioids for weeks to months
reduce by 10% per week
what to do once lowest dose has been obtained and we’re tapering?
interval can be extended
frequency at which we can stop opioids?
once daily
who does 2014 chronic pain law apply to
> 60 pills / month for 3+ months
15 MME for 3+ months
transdermal patch 3+ months
ER med
7 day prescribing law
initial opioid rx for a patient cant be more than 7 day supply
unless: cancer, palliative care, substance abuse disorder, professional judgement
Inspect requirement
before prescribing opioid or benzo prescribers must check
no exceptions
on pain contract - check every 90
what does a pain contract do
if pt gets opioid from other prescriber than original will no longer write
what is OPEN and reccomendations
michican opioid prescribing engagement network
scheduled dosing of acetaminophen and ibuprofen
alternate tylenol 650 with ibuprofen 600 alternate every 3 hours for 3 days or until not needed
uses for patient controlled analgesia (PCA)
post-operative
pancreatitis
sickle cell crisis
first line low back pain
acetaminophen
NSAIDs
second line low back pain
SNRIs
TCAs
osteoarthritis first line
acetaminophen
oral/topical NSAIDs
osteoarthritis second line
intra articular hyaluronic acid
capsaicin
fibromyalgia FDA approved meds
pregabalin
duloxetine
fibromyalgia options not FDA approved
TCAs
gabapentin
venlafaxine
neuropathic pain first line
SNRIs
gaba/preg
neuropathic second line
TCAs
topical lidocaine
hospice meds
morphine IV under the tongue (pain)
lorazepam IV or SL (anxiety)
ondansetron ODT (nausea/vomit)
atropine drops/ scopalomine patch (secretions)
