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NR565 - Advanced Pharmacology > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Pain management -
Guiding Principles for Prescribers

A
  1. Appropriate management of acute, subacute and chronic pain +/- opioids
  2. Recommendations are voluntary and intended to support person-centered care.
  3. A multimodal, multidisciplinary approach to pain management is imperative.
  4. Do not misapply clinical guidelines
  5. Be aware of health inequities, provide cultural and linguistically appropriate pain management for all.
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2
Q

Examples of pure opioid agonists

A
  • Morphine
  • Codeine
  • Meperidine
  • Fentanyl
  • Methadone

Activate M and K receptors

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3
Q

What is used to calculate a patient’s overdose risk?

A
  • The total morphine milligram equivalent (MME) per day
  • Increase risk of overdose by 2x if dose is greater or equal to 50MME per day compared to 20MME per day
  • Use extra precautions over 50MME per day
  • Avoid or carefully justify increasing dose to over 90MME/day
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4
Q

How would you know when to refer someone to a pain specialist for pain management?

A
  • Complex pain syndrome management
  • High level of narcotic use
  • Methadone treatment
  • 120MME threshold
  • Unknown pain cause, current treatment not working
  • Confirm a diagnosis or need extensive workup due to multiple chronic conditions that cause pain
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5
Q

Prescription Drug Monitoring Program (PDMP)

A

Prescription drug monitoring program is an electronic database that tracks controlled substance prescriptions in a state. Provides information about prescribing and patient behaviors so providers can make a targeted response to problems.

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6
Q

What are the benefits of a PDMP?

A
  • Stops doctor shopping
  • Allows clinician to see if other providers are prescribing narcotics
  • Allows clinicians to avoid prescribing medications that interfere with things the patient is already taking (benzos and opioids)
  • Support clinical decision making
  • Drug history
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7
Q

How do renal and hepatic function impact medication levels in the body?

A

Renal or hepatic insufficiency can cause patients to experience a greater peak effect of medication and longer duration of action thereby reducing the dose at which respiratory depression and overdose may occur (especially in people over 55).

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8
Q

How to assess someone for possible drug diversion.

A

o Full evaluation to assess and verify the need for pain medication
o Look at medication history from PDMP
o Screen for substance abuse (urine drug test)
o Use pain assessment tools to monitor effectiveness of controlled substances

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9
Q

When should naloxone be prescribed for a patient?

A

o When MME is greater or equal to 50
o When comorbidities may interfere with meds (OSA, COPD)
o When patient is also getting benzodiazepines
o Have a history for overdose
o Are receiving medication for opioid use disorder
o Are using illegal drugs
o Are over 65 and have a mental health disorder, excessive alcohol use, nonopioid substance abused disorder
o History of opioid use and recently released from controlled setting (prison, hospital)

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10
Q

Behaviors that predict controlled substance addiction

A

o Sexual risk behavior
o Experience of violence
o Mental health
o suicide

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11
Q

Rules around prescribing Schedule 2 Drugs

A

 Prescriptions may not be refilled – need a new prescription each time
 Must be a written prescription signed by the provider
 Can be phoned in in an emergency, written prescription must be given to the pharmacy within 7 days
 Can write multiple scripts for up to a 90 day supply
* Each one on a new form
* Must be for a legitimate medical purpose
* Must write earliest fill date by pharmacy

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12
Q

Schedule 1 Controlled Substances

A

Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.

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13
Q

Examples of Schedule 1 Controlled Substances

A
  • Heroin,
  • LSD,
  • marijuana,
  • peyote,
  • methaqualone,
  • ecstasy
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14
Q

Schedule 2 Controlled Substances

A

Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

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15
Q

Examples of Schedule 2 Controlled Substances

A

a. combo products with less than 15mg of hydrocodone per dosage (Vicodin)
b. cocaine
c. methamphetamine
d. methadone
e. hydromorphone
f. meperidine (Demerol)
g. oxycodone (oxycontin)(
h. fentanyl
i. Dexedrine
j. Adderall
k. Ritalin

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16
Q

Schedule 3 Controlled Substances

A

Substances have a potential for abuse less than schedule 1 or 2 and abuse may lead to moderate or low physical dependence or high psychological dependence

17
Q

Examples of Schedule 3 Controlled Substances

A
  • Products with 90mg or less of codeine per dosage unit
  • Buprenorphine
  • Ketamine
  • anabolic steroids
  • testosterone
18
Q

Schedule 4 Controlled Substances

A

substances in this schedule have a low potential for abuse relative to substances in schedule 3

19
Q

Examples of Schedule 4 Controlled Substances

A
  • Tramadol
  • Xanax,
  • soma,
  • clonazepam,
  • diazepam (Valium)
  • Lorazepam (Ativan)
  • clorazepate
  • midazolam (versed)
  • temazepam
20
Q

Schedule 5 Controlled Substances

A

have a low potential for abuse relative to substances listed in schedule 4 and consist primarily of preparations containing limited quantities of certain narcotics

21
Q

Examples of Schedule 5 Controlled Substances

A
  • Cough medicines with less than 200mg of codeine per 100mL or per 100g
  • ezogabine
  • antitussives
  • Analgesics
  • Antidiarrheal
22
Q

Risk factors for Opioid Use Disorder

A

o A combination of genetic, environmental, and developmental factors influences risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction.
 Physical/sexual abuse
 Exposure to drugs at an early age
 Parental guidance
 genetics

23
Q

Methadone black box warning

A

 QT prolongation
 Severe respiratory depression
 Should only be prescribed by pain management specialist with special training

24
Q

Benefits of methadone use in treating opioid use disorder

A

 Transfer from opioid use to methadone
 Prevent reinforcing effects of opioid induced euphoria
 Prevents opiate withdrawal symptoms, blocks euphoria, minimizes cravings

25
Q

Benefits of Buprenorphine/naloxone combination

A

 Reduces the potential for abuse as buprenorphine can induce typical opioid effects like euphoria, naloxone counters these effects
 Decreases the risk for diversion and misuse
 Renders it less useable via IV injection

26
Q

Pregabalin

A
  • schedule 5 drug
  • anitconvulsant
  • used for treatment of chronic pain
  • four approved indications
    o neuropathic pain associated with diabetic neuropathy
    o postherpetic neuralgia (burning nerve pain from shingles)
    o adjunctive therapy of partial seizures
    o fibromyalgia.
27
Q

Side effects of pregabalin

A

o Sedation, dizziness, and ataxia. dry mouth, constipation, weight gain

28
Q

CDC 12 Steps for Pain management

A
  1. Opioids are not first line of treatment
  2. Establish goals for pain and function
  3. Discuss risks and benefits
  4. Use immediate release when starting opioids
  5. Use the lowest effective dose
  6. Prescribe short durations for acute pain
  7. Evaluate benefits and harms frequently
  8. Use strategies to mitigate risk
  9. Review PDMP data
  10. Use urine drug testing
  11. Avoid opioid and benzo prescribing together
  12. Offer treatment for opioid use disorder
29
Q

What are risk behaviors that predict controlled substance abuse?

A
  1. sexual risk behaviors
  2. experience of violence
  3. Mental health issues
  4. Suicide
30
Q

Treatment of chronic pain

A
  1. start with non-opioid options
    • NSAIDS, exercise, PT, massage
      work your way up the CDC list for pain management.
31
Q

Adverse effects of opioids

A

a. Drowsiness/sedation
b. Constipation
c. Nausea and vomiting
d. Respiratory depression
e. Urinary retention
f. Lethargy
g. Confusion/delirium
h. Orthostatic hypotension
i. Neurotoxicity
j. Tolerance/physical dependence

32
Q

What are strong opioid analgesics usually reserved for?

A

a. Severe pain
b. Cancer patients having chronic pain
c. Hospice/palliative care
d. Post-op
e. Pain of labor and delivery
f. Acute/traumatic events (burns)

33
Q

Concurrent use of opioids and what types of medication should be avoided and why

A

a. Benzodiazepines, alcohol, antihistamines (constipation, urinary retention, sedation), barbiturates, tricyclic antidepressants (constipation and urinary retention)
b. Risk for oversedation, compounding effect, increased respiratory depression

34
Q

Opioid overdose produces a classic triad of signs, what are they?

A

a. Respiratory depression
b. Constricted pupils
c. Coma

35
Q

What drugs should be avoided for patients taking tramadol?

A

a. Benzos, NSAIDS, SSRIs,
b. Can intensify anything in the CNS
c. Alcohol, MAOIs (hypertensive crisis), tricyclic depressants, serotonin, norepinephrine (serotonin syndrome)

36
Q

Agonist – antagonist opioid

A

Buprenorphine

37
Q

Pure opioid antagonist

A

naloxone

38
Q

What are some effects of opioid use that don’t change with long term use and tolerance?

A
  • Constipation
  • Pupil constriction
  • Meiosis
  • Euphoria
  • Nausea
  • Respiratory depression

NR565 - Advanced Pharmacology (13 decks)

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