Week 2 Flashcards
Pain management -
Guiding Principles for Prescribers
- Appropriate management of acute, subacute and chronic pain +/- opioids
- Recommendations are voluntary and intended to support person-centered care.
- A multimodal, multidisciplinary approach to pain management is imperative.
- Do not misapply clinical guidelines
- Be aware of health inequities, provide cultural and linguistically appropriate pain management for all.
Examples of pure opioid agonists
- Morphine
- Codeine
- Meperidine
- Fentanyl
- Methadone
Activate M and K receptors
What is used to calculate a patient’s overdose risk?
- 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
How would you know when to refer someone to a pain specialist for pain management?
- 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
Prescription Drug Monitoring Program (PDMP)
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.
What are the benefits of a PDMP?
- 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
How do renal and hepatic function impact medication levels in the body?
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).
How to assess someone for possible drug diversion.
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
When should naloxone be prescribed for a patient?
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)
Behaviors that predict controlled substance addiction
o Sexual risk behavior
o Experience of violence
o Mental health
o suicide
Rules around prescribing Schedule 2 Drugs
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
Schedule 1 Controlled Substances
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.
Examples of Schedule 1 Controlled Substances
- Heroin,
- LSD,
- marijuana,
- peyote,
- methaqualone,
- ecstasy
Schedule 2 Controlled Substances
Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.
Examples of Schedule 2 Controlled Substances
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
Schedule 3 Controlled Substances
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
Examples of Schedule 3 Controlled Substances
- Products with 90mg or less of codeine per dosage unit
- Buprenorphine
- Ketamine
- anabolic steroids
- testosterone
Schedule 4 Controlled Substances
substances in this schedule have a low potential for abuse relative to substances in schedule 3
Examples of Schedule 4 Controlled Substances
- Tramadol
- Xanax,
- soma,
- clonazepam,
- diazepam (Valium)
- Lorazepam (Ativan)
- clorazepate
- midazolam (versed)
- temazepam
Schedule 5 Controlled Substances
have a low potential for abuse relative to substances listed in schedule 4 and consist primarily of preparations containing limited quantities of certain narcotics
Examples of Schedule 5 Controlled Substances
- Cough medicines with less than 200mg of codeine per 100mL or per 100g
- ezogabine
- antitussives
- Analgesics
- Antidiarrheal
Risk factors for Opioid Use Disorder
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
Methadone black box warning
QT prolongation
Severe respiratory depression
Should only be prescribed by pain management specialist with special training
Benefits of methadone use in treating opioid use disorder
Transfer from opioid use to methadone
Prevent reinforcing effects of opioid induced euphoria
Prevents opiate withdrawal symptoms, blocks euphoria, minimizes cravings
Benefits of Buprenorphine/naloxone combination
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
Pregabalin
- 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.
Side effects of pregabalin
o Sedation, dizziness, and ataxia. dry mouth, constipation, weight gain
CDC 12 Steps for Pain management
- Opioids are not first line of treatment
- Establish goals for pain and function
- Discuss risks and benefits
- Use immediate release when starting opioids
- Use the lowest effective dose
- Prescribe short durations for acute pain
- Evaluate benefits and harms frequently
- Use strategies to mitigate risk
- Review PDMP data
- Use urine drug testing
- Avoid opioid and benzo prescribing together
- Offer treatment for opioid use disorder
What are risk behaviors that predict controlled substance abuse?
- sexual risk behaviors
- experience of violence
- Mental health issues
- Suicide
Treatment of chronic pain
- start with non-opioid options
- NSAIDS, exercise, PT, massage
work your way up the CDC list for pain management.
- NSAIDS, exercise, PT, massage
Adverse effects of opioids
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
What are strong opioid analgesics usually reserved for?
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)
Concurrent use of opioids and what types of medication should be avoided and why
a. Benzodiazepines, alcohol, antihistamines (constipation, urinary retention, sedation), barbiturates, tricyclic antidepressants (constipation and urinary retention)
b. Risk for oversedation, compounding effect, increased respiratory depression
Opioid overdose produces a classic triad of signs, what are they?
a. Respiratory depression
b. Constricted pupils
c. Coma
What drugs should be avoided for patients taking tramadol?
a. Benzos, NSAIDS, SSRIs,
b. Can intensify anything in the CNS
c. Alcohol, MAOIs (hypertensive crisis), tricyclic depressants, serotonin, norepinephrine (serotonin syndrome)
Agonist – antagonist opioid
Buprenorphine
Pure opioid antagonist
naloxone
What are some effects of opioid use that don’t change with long term use and tolerance?
- Constipation
- Pupil constriction
- Meiosis
- Euphoria
- Nausea
- Respiratory depression
