Unit 11 Pain Flashcards
A 63- year-old man is undergoing radiation treatment as an outpatient for metastatic bone cancer. His pain has been managed with a fixed combination of oxycodone plus acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse.
1) The most appropriate oral medication for his increasing pain is
(A) Buprenorphine (B) Codeine plus aspirin (C) Levorphanol (D) Pentazocine (E) Propoxyphene
The answer is C:
In most situations , pain associated with metastatic carcinoma ultimately necessitates the use of an opioid analgesic that is equivalent in strength to morphine, so hydromorphone, oxymorphone, or levorphanol would be indicated. Pentazocine or the combination of codeine plus salicylate would not be as effective as the original drug combination. Propoxyphene is even less active than codeine alone. Buprenorphine, a mixed agonist-antagonist, is not usually recommended for cancer-associated pain because of its analgesic “ceiling” and because of possible dysphoric and psychotomimetic effects.
A 63- year-old man is undergoing radiation treatment as an outpatient for metastatic bone cancer. His pain has been managed with a fixed combination of oxycodone plus acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse.
2) It is possible that this patient will have to increase the dose of the analgesic as his condition progresses as a result of developing tolerance. However, tolerance will not develop to a significant extent with respect to
A) Biliary smooth muscle B) Constipation C) Nausea and vomiting D) Sedation E) Urinary retention
The answer is B.
Chronic use of strong opioid analgesics leads to the development of tolerance to their analgesic, euphoric, and sedative actions. Tolerance also develops to their emetic effects and to effects on some smooth muscle, including the biliary and the urethral sphincter muscles. However, tolerance does not develop significantly to the constipating effects or the miotic actions of the opioid analgesics. The answer is B.
You are on your way to take an examination and you suddenly get an attack of diarrhea. If you stop at a nearby drugstore for an over-the-counter opioid with antidiarrheal action, you will be asking for
(A) Codeine (B) Dextromethorphan (C) Diphenoxylate (D) Loperamide (E) Tramadol
The answer is D.
Codeine and possibly nalbuphine could decrease gastrointestinal peristalsis, but not without marked side effects (and a prescription ). Dextromethorphan is a cough suppressant . The other 2 drugs listed are opioids with antidiarrheal actions. Diphenoxylate is not available over the counter because it is a constituent of a proprietary combination that includes atropine sulfate (Lomotil). The answer is D.
An emergency department patient with severe pain thought to be of gastrointestinal origin received 80 mg of meperidine. He subsequently developed a severe reaction characterized by tachycardia , hypertension, hyperpyrexia, and seizures. Questioning revealed that the patient had been taking a drug for a psychiatric condition. Which drug is most likely to be responsible for this untoward interaction with meperidine?
A) Alprazolam B) Bupropion C) Isocarboxazid D) Lithium E) Mirtazapine
The answer is C.
Concomitant administration of meperidine and monoamine oxidase inhibitors such as isocarboxazid or phenelzine has resulted in life-threatening hyperpyrexic reactions that may culminate in seizures or coma. Such reactions have occurred even when the MAO inhibitor was administered more than a week after a patient had been treated with meperidine. Note that concomitant use of selective serotonin reuptake inhibitors and meperidine has resulted in the serotonin syndrome , another life-threatening drug interaction (see Chapter 30 ). The answer is C.
Genetic polymorphisms in certain hepatic enzymes involved in drug metabolism are established to be responsible for variations in analgesic response to
A) Codeine B) Fentanyl C) Meperidine D) Methadone E)Tramadol.
The answer is A.
Codeine, hydrocodone, and oxycodone are metabolized by the cytochrome P450 isoform CYP2D6, and variations in analgesic response to these drugs have been attributed to genotypic polymorphisms in this isozyme. In the case of codeine, this may be especially important since the drug is demethylated by CYP2D6 to form the active metabolite, morphine. The answer is A.
A young male patient is brought to the emergency department in an anxious and agitated state. He informs the attending physician that he uses “street drugs” and that he gave himself an intravenous “fix” approximately 12 h ago. He now has chills and muscle aches and has also been vomiting. His symptoms include hyperventilation and hyperthermia. The attending physician notes that his pupil size is larger than normal.
1) What is the most likely cause of these signs and symptoms?
(A) The patient had injected methamphetamine
(B) The patient has hepatitis B
(C) The patient has overdosed with an opioid
(D) The signs and symptoms are those of the opioid abstinence syndrome
(E) These are early signs of toxicity due to contaminants in “street heroin”
The answer is D.
The signs and symptoms are those of withdrawal in a patient physically dependent on an opioid agonist. They usually start within 6– 10 h after the last dose; their intensity depends on the degree of physical dependence, and peak effects usually occur at 36– 48 h. Mydriasis is a prominent feature of the abstinence syndrome; other symptoms include rhinorrhea, lacrimation, piloerection, muscle jerks, and yawning. The answer is D.
A young male patient is brought to the emergency department in an anxious and agitated state. He informs the attending physician that he uses “street drugs” and that he gave himself an intravenous “fix” approximately 12 h ago. He now has chills and muscle aches and has also been vomiting. His symptoms include hyperventilation and hyperthermia. The attending physician notes that his pupil size is larger than normal.
2) Which drug will be most effective in alleviating the symptoms experienced by this patient?
(A) Acetaminophen (B) Codeine (C) Diazepam (D) Methadone (E) Naltrexone
The answer is D.
Prevention of signs and symptoms of withdrawal after chronic use of a strong opiate like heroin requires replacement with another strong opioid analgesic drug. Methadone is most commonly used, but other strong μ-receptor agonists would also be effective. Acetaminophen and codeine will not be effective. Beneficial effects of diazepam are restricted to relief of anxiety and agitation. The antagonist drug naltrexone may exacerbate withdrawal symptoms. The answer is D.
Which statement about butorphanol is accurate?
(A) Activates μ receptors
(B) Does not cause respiratory depression
(C) Is a nonsedating opioid
(D) Pain-relieving action is not superior to that of codeine
(E) Response to naloxone in overdose may be unreliable
The answer is E.
Butorphanol and nalbuphine are κ agonists, with weak μ-receptor antagonist activity. They have analgesic efficacy superior to that of codeine, but it is not equivalent to that of strong opioid receptor agonists. Although these mixed agonist-antagonist drugs are less likely to cause respiratory depression than strong μ activators, if depression does occur, reversal with opioid antagonists such as naloxone is unpredictable. Sedation is common. The answer is E.
Which drug does not activate opioid receptors, has been proposed as a maintenance drug in treatment programs for opioid addicts, and with a single oral dose, will block the effects of injected heroin for up to 48 h?
A) Amphetamine B) Buprenorphine C) Naloxone D) Naltrexone E) Propoxyphene
The answer is D
The opioid antagonist naltrexone has a much longer half-life than naloxone, and its effects may last 2 d. A high degree of client compliance would be required for naltrexone to be of value in opioid dependence treatment programs. The same reservation is applicable to the use of naltrexone in alcoholism. The answer is D.
Which statement about dextromethorphan is accurate?
A) Activates κ receptors B) Analgesia equivalent to pentazocine C) Highly effective antiemetic D) Less constipation than codeine E) No abuse potential
The answer is D
Dextromethorphan, the active component in many over-the-counter cough suppressants, has no appreciable analgesic activity. Compared with codeine, also an effective antitussive, dextromethorphan causes less constipation. When formulated properly and used in small amounts, dextromethoprhan can be safely used as a cough suppressant. However, overdose toxicity in toddlers has raised concern, and abuse of the drug in powdered form has caused disorientation, hallucinations, seizures, and death. The answer is D.
Among NSAIDs, aspirin is unique because it
A) Irreversibly inhibits its target enzyme
B) Prevents episodes of gouty arthritis with long-term use
C) Reduces fever
D) Reduces the risk of colon cancer
E) Selectively inhibits the COX-2 enzyme
The answer is A Irreversibly inhibits its target enzyme
Which of the following is an analgesic and antipyretic drug that lacks an anti-inflammatory action?
(A) Acetaminophen (B) Celecoxib (C) Colchicine (D) Indomethacin (E) Probenecid
The answer is A Acetaminophen
Acetaminophen is the only drug that fits this description. Indomethacin is a nonselective COX inhibitor and celecoxib is a COX-2 inhibitor; both have analgesic, antipyretic, and anti-inflammatory effects. Colchicine is a drug used for gout that also has an anti-inflammatory action. Probenecid is a uricosuric drug that promotes the excretion of uric acid. The answer is A.
A 16-year-old girl comes to the emergency department suffering from the effects of an aspirin overdose. Which of the following syndromes is this patient most likely to exhibit as a result of this drug overdose?
(A) Bone marrow suppression and possibly aplastic anemia
(B) Fever, hepatic dysfunction, and encephalopathy
(C) Hyperthermia, metabolic acidosis, and coma
(D) Rapid, fulminant hepatic failure
(E) Rash, interstitial nephritis, and acute renal failure
The answer is C Hyperthermia, metabolic acidosis, and coma
Salicylate intoxication is associated with metabolic acidosis, dehydration , and hyperthermia. If these problems are not corrected, coma and death ensue. The answer is C.
Which of the following drugs is most likely to increase serum concentrations of conventional doses of methotrexate, a weak acid that is primarily cleared in the urine?
(A) Acetaminophen (B) Allopurinol (C) Colchicine (D) Hydroxychloroquine (E) Probenecid
The answer is (E) Probenecid
Like other weak acids, methotrexate depends on active tubular excretion in the proximal tubule for efficient elimination. Probenecid competes with methotrexate for binding to the proximal tubule transporter and thereby decreases the rate of clearance of methotrexate. The answer is E.
The main advantage of ketorolac over aspirin is that ketorolac
(A) Can be combined more safely with an opioid such as codeine
(B) Can be obtained as an over-the-counter agent
(C) Does not prolong the bleeding time
(D) Is available in a parenteral formulation that can be injected intramuscularly or intravenously
(E) Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment
The answer is (D) Is available in a parenteral formulation that can be injected intramuscularly or intravenously
Ketorolac exerts typical NSAID effects. It prolongs the bleeding time and can impair renal function, especially in a patient with preexisting renal disease. Its primary use is as a parenteral agent for pain management, especially for treatment of postoperative patients. The answer is D.
