Term
Which of the following is NOT a non-pharmacological treatment for pain as discussed in class?
a)interventional
b)surgical
c)psychological
d)physical therapy
e)acupuncture
f)massage therapies |
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Definition
all are non-pharm treatments except for the Massage therapies
Physical therapy: ice, heat, ‘TENS’ transcutaneous elec stimulus that they do to the nerve |
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Term
| true or false: Can always consider non-pharm and adjuvant options. But if mild then prob don’t want to use opioid. |
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Definition
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Term
what factors are part of the Multimodal Approach? What type of pain is this used for?
a)Determine mechanism of pain (Nociceptice? Neuropathic?)
b)Education
c)Non-pharmacologic |
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Definition
Multimodal Approach is for chronic pain.
these are all a part of it.
Incorp non-pharm and explain to pt about setting goals together and talk abt how they feel abt taking them, are they scared of taking opioids, etc. need to determine mechanism of pain, somatic or visceral? Neuropathic? Etc.. Will help determine what meds to use. |
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Term
which of the following are FIRST line for neuropathic pain?!
a)Nortriptyline
b)Amitriptyline
c)Pregabalin
d)Gabapentin
e)Duloxetine
f)Bupropion
g)Baclofen
h)Tramadol
i)Opioids
j)Venlafaxine |
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Definition
1st line: Amitriptyline, nortriptyline, pregabalin, gabapentin, duloxetine venlafaxine
remember that Ami, Nora, and Gabby got Pregnant by Dull Ven
2nd line: Tramadol, Opioids
3rd line: Baclofen, tizanidine
Neuropathic pain is easier bc not as general. First line meds, some have FDA indications. How to decide which to pick? Depends on SE, comorbidities, other dz states, etc. 2nd line have less data but some compelling data still. 3rd and 4th line is throwing kitchen sink |
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Term
Which of the following are true about Post-Operative pain??
a)Can be nociceptive and/or neuropathic
b)Should use a Multimodal approach PLUS Acute pain algorithm
c)May use Preemptive analgesia: administration prior to onset of noxious stimuli.
-Local (anesthetics)
-Systemic (NSAIDs, AEDs, COX-2)
d)May use Neuraxial (regional) analgesia
-Epidurals and intrathecals |
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Definition
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Term
When it comes to Cancer Pain, which type (acute or chronic) is associated with:
a)directly assoc with cancer, antineoplastics, radiation
b)tumor, HA, antineoplastics, postop, post-radiation
______ Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering |
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Definition
Acute-directly assoc with cancer, antineoplastics, radiation
Chronic- tumor, HA, antineoplastics, postop, post-radiation
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering |
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Term
| True or false: there is no ceiling/limit for pure opioid analgesias |
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Definition
true. No ceiling effect for analgesia
Exception: non-opioid combination products and mixed agonists have maximum doses
There is NO MAX DOSE of morphine! Some cancer pts on so much. But combination products, like Percocet (oxy with APAP) has ceiling bc of the APAP.
Only PURE opioids have no ceiling |
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Term
| True or false: Always try to use oral opioids for chronic pain. In general, addiction has to do with peaks such as with IV meds which has more euphoria with peaks and so you want pt to have ORALS so more slowly available and hopefully less addiction potential |
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Definition
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Term
Out of these opioids, which is associated with: acute use only? chronic use only?
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
Acute use only: meperidine
Chronic use only: methadone, fentanyl patches
all others can be used in acute or chronic |
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Term
Out of these opioids, which is associated with: Hypotension (increased with concurrent benzodiazepine)
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with:Metabolite is 4x more potent and renally excreted-caution in renal impairment
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with:
1)caution in renal impairment
2)can be used in renal dysfunction?
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
1)caution in renal impairment: morphine, oxycodone (but has nice SE profile)
2)can be used in renal dysfunction: hydromorphone, maybe fentanyl (since accumulation is rare) |
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Term
Out of these opioids, which is associated with: Preferred for hemodynamic instability, on vasopressors; Quick onset when used as IV
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with: Weak analgesic, Prodrug, Pharmacogenetic issue (10% lacks enzyme to convert)
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with: dosed in mcg
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with: Neurotoxic metabolite; No more than 1-2 days; ONLY USE LAST, LAST LINE for analgesia
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
meperidine.
No more than 1-2 days
ONLY USE LAST, LAST LINE for analgesia |
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Term
Out of these opioids, which is associated with: Reserved for severe chronic pain or addiction. Complex conversion to other opioids. May cause QT prolongation
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
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Term
Out of these opioids, which is associated with: Have a ceiling dose effect for analgesia. Caution in tolerance--> may cause withdrawals. Limited place in therapy
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone |
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Definition
| Partial agonist or mixed agonist antagonists |
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Term
If using break through more than __-__ times a day, what should you change in patient's regimen?
a)Consider ATC if not being used already
b)Increase ATC (With amount used in 24 hr increase by __% mild, __-__% moderate, __-__% for severe
c)Increase the breakthrough dose as well. Approx __% of total 24 hour ATC given PRN (in mult doses, depends on agent half life when deciding how many times a day) |
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Definition
all are true
If using break through more than 3-4 times a day, what should you change in patient's regimen?
a)Consider ATC if not being used already
b)Increase ATC (With amount used in 24 hr increase by 25% mild, 25-50% moderate, 50-100% for severe
c)Increase the breakthrough dose as well. Approx 15% of total 24 hour ATC given PRN (in mult doses, depends on agent half life when deciding how many times a day) |
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Term
Which of the following are problems with conversion charts?
a)Most done with Single dose equivalency
b)Unidirectional
c)Pharmacogenomics |
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Definition
Problem with conversion charts:
a)Most done with Single dose equivalency (so what If pt gets multidoses)
b)Unidirectional: So A=B, but does B=A?
We don’t know this for sure. If do dose reduction from morphine to oxycodone, do we do dose increase from oxy to morphine? Would make sense but we still do dose increase actually!
c)Pharmacogenomics: not every drug is metabolized the same. Cant just see this on a conversion chart. |
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Term
which drugs are commonly used in Patient Controlled Analgesia (PCA)?
a)morphine
b)fentanyl
c)hydromorphone
d)codeine
e)meperidine
f)methadone
g)partial agonist or mixed agonist antagonists
h)oxycodone
What are the two types of dosing for PCAs? |
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Definition
Morphine
Hydromorphone
Fentanyl
Dosing
1)Basal rate (ie, ATC): if needed, is around the clock.
2)Bolus dose with lockout: pt can push button for PRN dose. In case nurse is busy. But there is a lockout so they don’t OD themselves. |
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Term
| How long do you have to wait to increase dose after beginning a long acting opioid? |
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Definition
| 2-3 days, bc of long half life. takes time to get to steady state |
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Term
What are the indications for using PCAs?
a)Actual or expected inadequate analgesia from intermittent IV (when pt wont get enough pain control from intermittent IV)
b)Oral analgesia not possible
c)For pts that cant take long acting.
d)Also, good for pts who need frequent dosing, like morphine q 2hr or q 1hr. |
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Definition
| all of the above are good indications to use PCAs |
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Term
| If patient is already on methadone, comes into ER with acute pain, can you adjust their methadone dose to help their acute pain? |
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Definition
NO. If on methadone- do not change dose for pain.
Definitely try non-pharm and adjuvant in naive pts so they don’t get addicted. Some pts on methadone for pain, some on it for addiction. Even if on methadone for chronic pain and not have acute pain, don’t change their methadone pain bc is messy. |
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Term
Which of the following are factors to help you determine if patient is at HIGH risk for abuse potential?
Current heavy smoking
Young age
History of alcohol or drug misuse
Family history of alcohol or drug misuse
Poor support system
Chronic unemployment
Major psychiatric disorder |
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Definition
Regard as high risk if:
-History of alcohol or drug misuse
-Family history of alcohol or drug misuse
-Major psychiatric disorder
Other risk factors
(indicating possible drug abuse or hx)
-Current heavy smoking
-Young age
-Poor support system
-Chronic unemployment |
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Term
When stratifying risk of abuse potential or history, what are Factors that can mitigate risk?
a) Poor performance status (like end of life dz, will pass away in 3 months)
b) Restricted prognosis
c) Active recovery program |
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Definition
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Term
when trying to avoid potential for abuse, doctor can make patient sign a strategy to treatment (contract agreement). which are parts of this agreement?
a)Treatment agreement (for chronic mgmt)
b)Use of drug monitoring (ie, urine drug testing, need for early refills, etc)
c)Small quantities/amounts prescribed
d)No use of short/immediate-acting drugs
e)Pill counts at time of visit/use of one pharmacy |
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Definition
all are parts of strategy to treatment.
so is...
Document
Plan for monitoring and education of patient and family
Monitoring of drug-related behavior on a regular basis
probably won't need a contract is pt just has acute pain... |
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Term
How to taper opioids?
Acute pain: Decrease by __% daily
Chronic: Decrease by __% every __-__ days
true or false: Tolerant patients may experience withdrawals if abruptly discontinued
true or false: Long acting agents associated with more symptoms of tolerance after stopping |
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Definition
How to taper
Acute pain: Decrease by 20% daily
Chronic: Decrease by 10% every 3-5 days
This is hard to do when u just have 10, 20, 40, 60mg tablets. Have to figure out what formulations you have, what you feel comfortable doing, and if it works for pt.
Both are true |
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Term
Which of the following are side effects of opioids?
a)Sedation and respiratory depression
b)Constipation
c)Nausea and vomiting
d)Itching
e)Rash
f)Allergy
g)Opioid-induced hyperalgesia |
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Definition
| all except for rash are side effects |
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Term
which of the following are situations that you will commonly see sedation and respiratory depression with opioid use?
a)Opioid naïve
b)Elderly
c)High doses
d)Fast rate of administration
e)Concurrent sedating medications (ie, midazolam)
f)Pulmonary disease (ie, COPD)
g)Sleep apnea
h)Obesity
True or false: These sedation and resp depression sx usually abate within a few days of therapy.
Respiratory depression is when RR is below __-__ breaths/min or hypoxemia.
Which will fall/decrease first, sedation or respiratory depression??? |
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Definition
ALL are common in sedation and resp depression:
Opioid naïve, elderly, high doses, fast rate of administration, concurrent sedating medications (ie, midazolam), pulmonary disease (ie, COPD), sleep apnea (big one! scary bc happens at night), obesity (risk for breathing)
true:These sx usually abate within a few days of therapy
Resp depression: RR below 7-8 breaths/min or hypoxemia
Sedation falls before respiratory rate |
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Term
What are the rating #s on the Sedation Scale?
What drug may be used to reverse sedation and resp depression? |
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Definition
Ranks from 1 to 4, with:
1:Awake and Alert
2:Occasionally drowsy, easy to arouse
3:Frequently drowsy
4:Difficult to arouse, requires immediate medical attention (RED ZONE)
when SS 2-4: review medications and consider change (when 2 or beyond?)
Naloxone (opioid antagonist)
-Consider administering for SS 4, or RR < 7
-Caution: will reverse analgesia and may cause withdrawals in tolerant patients
-Also consider why pt was on opioid in first place. If have lots of broken bones, naloxone can put them back in pain even tho will take them out of resp depression, has long half life. Usually, pt can end up on breather mask or more advanced breathing regimen. |
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