Pain

Question 1

Somatic Pain

Answer 1

• Skin, bone, joint, soft tissue
• Well localized
• Sharp, aching or throbbing
• Constant
• Increases with movement
• Can point to the site of pain

Question 2

Visceral Pain

Answer 2

• Afferent nerves damage of the soft tissue or viscera (heart, lung, GI tract, GU tract)
• Stretching, cramping, distention
• Poorly localized
• “hard to describe”
• “Deep, aching”
• “colicky” or coming in waves

Question 3

Neuropathic Pain

Answer 3

Burning, shooting, pricking, paresthesias, dysesthesias

Question 4

Acute Pain

Answer 4

• < 1-3 month
• Pain, bruising, swelling
• Temporary loss of function
• May require scheduled therapy then prn therapy or just prn therapy for a short term

Question 5

Chronic Pain

Answer 5

• > 1-3 month to life-long
• Functional impairment
• Neuropathic pain
• Progression of sxs
  -Requires scheduled AND prn therapy

Question 6

PQRSTU

Answer 6

-Palliation
-Quality
-Region
-Severity
-Temporal
-How does it affect U

Question 7

Opioid Adverse Effects: Common

Answer 7

-Constipation: use Senna/bisacodyl (miralax if hard stools)

-Nausea: use dop. anta. (prochlor/meto/prometh)

-Sedation

Question 8

Opioid Adverse Effects: Uncommon

Answer 8

-Pruritus: change opioid, non-sed antihistamine

-Resp. Dep.: <8 breaths/min, ox <90
*start at low doses, titrate, monitor
*TX: Naloxone

Question 9

IF true morphine allergy, rare:

Answer 9

Methadone, fentanyl, tramadol

Question 10

Renal impairment/hemodialysis

Answer 10

• Contraindicated: codeine, meperidine
• Caution: morphine
• Better choices are oxycodone, hydromorphone, fentanyl (IVonly)
  -Chronic pain: best are methadone, fentanyl patch

Question 11

Hepatic dysfunction

Answer 11

• Contraindicated: codeine, meperidine
• Caution: Morphine, methadone (used by hepatology)
• Better choices are oxycodone, hydromorphone, fentanyl (IVonly)
  -Chronic pain: best is fentanyl patch

Question 12

Short-acting pain medication dose should be ___of the total daily dose of the long-acting medication.

Answer 12

10%

EX
* Long acting regimen is morphine 60 mg SR PO q12h
* Shorting acting dose should be morphine 15 mg IR q2h prn pain

Question 13

Css is good to know WHEN to titrate up to the next dose

Answer 13

• Mean half-life of extended-release hydromorphone tablets (Exalgo) is 11 hours
• Steady state is 5 half-lives (3.3 half-lives)
• 11x 5= 55 hours ~2.5 days

Question 14

Opioid tolerant

Answer 14

on at least 60 mg/day of morphine (or equivalent opioid) for at least 7 days

Question 15

Tramadol, ultram VS Tapentadol, nucynta

Answer 15

Both for nocicpetive/neuro pain

Tramadol: C4, seizures/serotonin syn, hypoglycemia, renal/hepa dose adj

Tapentadol: only in opioid tolerant pts, C2, renal/hepa dose adj

Question 16

Fentanyl Transdermal

Answer 16

-DOC in renal/hepatic dysf
-good for NPO

-Only for opioid tolerant pts
-long half life

Question 17

Methadone

Answer 17

-GOOD for ESRF

-BAD for ESLF, cardiac arr

Question 18

PCA Dosing

Answer 18

Opioid naive:
*Start with bolus doses
-Morphine 2, HM 0.2, Fen 20 mcg
-Lockout 10 min

Constant pain:
-If >20 bolus in 24hr OR >2 attempts times doses given = start basal
-Basal dose can be 2/3 of total opioid use in 24 hr (total opioid divided by 24 hr times 0.66)

Question 19

Bolus dose can be one of 3 options based on clinical picture

Answer 19

1. Half the basal dose (pain score of 1-3)
2. The same as the basal dose (pain score of 4-6)
3. OR double the basal dose (pain score of >7)

Question 20

Neuro Pain: 1st Line

Answer 20

1. Tricyclic Antidepressants (TCAs)
   *amitriptyline, desipramine
2. Gabapentin/Pregabalin
3. Serotonin norepinephrine reuptake inhibitors (SNRIs)
   *duloxetine, venlafaxine
4. Lidocaine patch (Lidoderm)

Question 21

TCAs
* Amitriptyline,imipramine
* Doxepin,clomipramine
* Nortriptyline,desipramine

Answer 21

AE: sedation, dry mouth, blurry vision, weight gain, urinary retention

DI: MAOI, SSRI, AC agents, antiarrhythmics, prolong QTc

Start at 10-25 mg, max is 150

Question 22

Gabapentin, pregabalin

Answer 22

AE: dizzy, ataxia, sedation, diplopia, weight gain, edema (WE SADD)

DI: potential sedation if with opioids/alc/benzo

Lower dose in elderly, RENAL DOSE ADJ

-Gaba: start 100-300, max 3600 (not sched, cheaper), give in AM, titrate up 300 every 2-3 days, have to titrate down (seizure/withdrawal)

-Prega: start 150, incr to 300 within 1 wk, max 450-600

Question 23

4% or 5% Lidocaine Patch (Lidoderm)

Answer 23

Well localized pain
-12 hour on, 12 hour off
-Up to 3 patches for simultaneous use
-Cut/shaped
-No burned/broken/inflamed skin
-Caution in hepatic disease

Question 24

Fentanyl strengths

Answer 24

25, 50, 74, 100 mcg/hr

Question 25

Hydromorphone strengths

Answer 25

2, 4, 8 mg ORAL IR

Question 26

Methadone strengths

Answer 26

5, 10 mg

Question 27

Morphine strengths

Answer 27

Oral: 15, 30, 60 Solution: 10mg/5ml, 20mg/5m IR: 15, 30

Question 28

Hydrocodone strengths

Answer 28

5/325, 7.5/325, 10/325

Question 29

Oxycodone strengths

Answer 29

IR: 5, 10, 15 Solution: 20mg/ml, 5mg/5ml Oral ER: 10, 15, 20, 30

Question 30

Tramadol strengths

Answer 30

50 mg

Question 31

STEPS FOR OPIOID CONV FOR LA AND SA

Answer 31

1. Calc total amount of op in 24 hr 2. LA dose per day: -Pain 7-10: 90-100% if calc total -Pain 4-6: 75% if calc total -Pain 1-3: 50% of calc total *LA dose is TWICE a day (divide into 2, q12h) 3. SA dose per day: 10% of LA dose -PRN only, q2-4 hr -If rounding up, use 4. Rounding down, use 2.

Question 32

STEPS FOR PCA CONV/DOSING

Answer 32

1. Basal -After 24 hr (SS), if > 20 boluses or attempts >2 times doses given: add basal -Basal dose is 2/3 (66%) of total opioid use in 24 hr = (total op / 24 hr * 0.66) 2. Bolus -Pain 7-10: double basal -Pain 4-6: same as basal -Pain 1-3: half basal

Question 33

STEPS FOR FENTANYL CONV

Answer 33

1. Check if pt is opioid tolerant first -60 mg morphine (equiv) 3. Evaluate pain score -Same as LA/SA conversions -High (100%), Mod (75%), Mild (50%) 2. Once converted... -Morphine to fentanyl ratio is TWO TO ONE -Morphine 50 ~ Fentanyl 25

Question 34

SNRI, duloxetine, venlafaxine

Answer 34

Sexual dysfunction BBW for suicidal thoughts Good for pts who don't want sedation/sleepy side effect Take in AM - keeps you up