Pain Flashcards by Sara Bojarski

pain resulting from injury to internal organs (visceral) or from injury to the skin, muscles, bones, joints, or ligaments (musculoskeletal or somatic) – tissue damage

nociceptive pain

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pain caused by damage to or malfunction of the nervous system – ex are fibromyalgia, diabetic neuropathic

neuropathic pathic

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pain that begins suddenly and feels sharp

acute pain

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pain that persists for 3 months or longer

chronic pain

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pain is ___ and measured by the patient’s own description

subjective

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used to assess pain severity

pain scales

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pain control method using multiple MOAs

multimodal pain control

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added to primary pain treatment, should be considered for any pain type, especially neuropathic

adjuvant

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used to treat mild pain

non-opioid +/- adjuvant

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used to treat moderate pain

opioid for mild/mod pain +/- non-opioid +/- adjuvant

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used to treat severe pain

opioid for mod/sev pain +/- non-opioid +/- adjuvant

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antipyretic (reduces pain and fever) but does not provider anti-inflammatory effect; possible inhibits PG synthesis

APAP

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brand names of APAP

tylenol
FeverAll (suppository)

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MDD of APAP

<=4000 mg/day

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max APAP in RX combinations

325 mg per dosing unit

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dosing of APAP in pediatrics

10-15 mg/kg Q4-6H

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concentration of all peds APAP

160mg/5mL

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BBW for APAP

hepatotoxicity with doses >4g/day or using multiple APAP products

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when writing out acetaminophen, avoid doing what

abbreviating with APAP

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brand name APAP + caffeine

Excedrin Tension Headache

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brand name APAP/ASA/caffeine

Excedrin Extra Strength, Excedrin Migraine

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brand name APAP/caffeine/pyrilamine

MIdol COmplete

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antidote for APAP overdose? given how?

NAC - glutathione precursor

IV or PO - use Rumack-Matthew Nomogram (serum APAP and time since to assess risk and need for NAC)

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block COX2 and decrease pain, fever, and inflammation

NSAIDs

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which NSAIDs have LOWER GI risk but HIGHER CV risk

selective COX2 inhibitors

irreversible inhibitor of COX1 and 2 and an antiplatelet

aspirin

all RX non-aspirin NSAIDs must be dispensed with

MedGuide

NSAIDs RX need to be dispensed with a MedGuide due to what risks

GI- bleeding, ulceration CV - MI, stroke CABG - CI, antiplatelet recommended

what can be used for GI protection with NSAIDs? risk?

PPI dec bone density and inc infection

side effects of all NSAIDs

use w/ caution or avoid in renal failure inc BP- avoid in uncontrolled HTN nausea, dyspepsia, abd pain- take w/ food or switch to EC photosensitivity premature closure of ductus arteriosus - avoid in third trimester

used within 14 days after birth to close PDA if did not close on its own

IV NSAIDs indomethacin, ibuprofen

4 main COX1 and COX2 nonselective NSAIDs

ibuprofen indomethacin naproxen ketorolac

brand names of ibuprofen

advil motrin

brand name of indomethacin

Indocin

brand name of naproxen

aleve

brand name of naproxen + esomeprazole

Vimovo

OTC adult dose of ibuprofen

200-400mg Q4-6H

max RX dose per day of ibuprofen

3.2 g/day

dose of ibuprofen in peds

5-10 mg/kg/dose Q6-8H

limit self treatment with ibuprofen OTC to

<10 days

indomethacin has a high risk for which side effects

CNS

naproxen OTC dose

200mg Q8-12H

why may naproxen be preferable

BID dosing

BBW for ketorolac

max combined duration is 5 days

warnings for ketorolac

inc bleeding renal and liver failure

counseling for ketorolac nasal spray

<65 do each nostril, >65 do one nostril prime 5 times before use

3 NSAIDs with increased COX2 selectivity

celecoxib diclofenac meloxicam

brand name of celecoxib

Celebrex

which NSAID has MOST COX2 selectivity

celecoxib

contraindication to celecoxib

sulfonamide allergy

brand name of diclofenac + misoprostol

Arthrotec

brand name of topical diclofenac

voltaren

MDD of topical diclofenac

32 g/day

BBW for diclofenac + misoprostol

avoid in females of childbearing potential miso used to replace gut protective PGs

brand name of meloxicam

MObic

3 brand names of aspirin / acetylsalicylic acid

ascriptin bufferin ecotrin

cardioprotective dose of aspirin

81-162 mg/day

brand name of magnesium salicylate (non-acetylated salicylate NSAID)

Doan's Extra Strength

warning- avoid aspirin in

children & teens with viral infection - risk of Reyes

AEs of aspirin

dyspepsia, bleeding

AE of aspirin overdose

tinnitus

methyl salicylate is present in which 3 OTC topical products

BenGay IcyHot Salonpas

if taking IBU for pain and ASA for CV benefit, how should they be taken?

take ASA 1 hour before or 8 hours after IBU

DDI- NSAIDs can INCREASE the levels of

lithium

mu receptor agonists which causes pain relief (but can also cause euphoria and respiratory depression)

opioids

partial mu-receptor agonist (becomes antagonist at higher doses) lower doses used to treat pain

buprenoprhine

safety concerns associated with opioids

BBWs REMs program proper disposal - drug takeback

BBWs associated with opioids

addiction/misuse respiratory depression opioid + benzo or other depressant (alcohol) can inc risk resp depression or death morphine, nucynta, oxymorphone, and hydrocodone ER- DO NOT consume alcohol, can inc drug levels accidental ingestion in children can be fatal crush/chew/dissolve long acting products can delivery fatal overdose life-threatening opioid withdrawal in neonates from use in pregnancy

physiologically adapted, experience physical withdrawal symptoms when an opioid is stopped or a dose is missed

physical dependence

drug-seeking behavior

addiction

pattern of opioid use causing impairment or distress

opioid use disorder

higher opioid dose is needed to produce same level of analgesia

tolerance

opioid dose is increased but the pain becomes worse

opioid hyperalgesia

sharp spikes of severe pain that occur despite use of ER opioid

breakthrough pain (BTP) med should be prescribed

blocks opioids from binding to opioid receptors

centrally acting opioid antagonists

AEs for all opioids

constipation, NV (esp acute, high dose), somnolence, dizziness/lightheadedness, seizures

pruritis may be common with opioids, especially morphine use/opioid naive manage with

diphenhydramine

control class for MOST opioids

CII

class for codeine + APAP

CIII

class for codeine cough syrups

BBW for codeine

resp depression and death in children who were URM DUE TO CYP2D6 POLYMORPHISM after tonsillectomy or adenoidectomy

contraindication to codeine

children <12 or <18 after tonsillectomy or adenoidectomy

codeine is a prodrug and is metabolized to ___. caution in___

morphine nursing infants

brand name of fentanyl

Sublimaze

how often/how to apply fentanyl patch

Q72H (mcg/hr) hairless skin, do not cover with heating pad fold sticky sides and flush- keep away from pets and kids

similar IV drug to fentanyl

remifentanil

BBW for fentanyl

CYP3A4 inhibitors can inc effects

AEs of fentanyl

application site redness/erythema

who CAN and CANNOT use a fentanyl patch or lozenge

NO - opioid naive OK- morphine 60mg/day for at least 7 days

class of buprenorphine

CIII

brand name of buprenorphine BUCCAL FILM

Belbuca

brand name of buprenorphine PATCH

butrans

how to use buprenorphine buccal film

between gum and cheek tissue

how often is buprenorphine patch applied? AE?

weekly application site reaction flush down toilet

Butrans can only be covered with

Bioclusive, Tegaderm

BBW for hydrocodone products

starting CYP3A4 inhibitors may cause overdose

brand name of hydromorphone

Dilaudid

ORAL starting dose of hydomorphone

2-4mg Q4-6H PRN

IV starting dose of hydromorphone

0.2-1mg Q2-4H PRN

BBW for hydromorphone

risk for med errors with high potency injection use in opioid tolerant patients only

key point of hydromorphone potency

potent - high risk for OD

BBW for methadone

QT prolongation

methadone DDI

major CYP3A4 substrate

methadone can contribute to sexual dysfunction due to

dec testosterone

methadone is hard to dose safely due to

variable half life

brand name of meperidine

Demerol

warnings of meperidine

normeperidine (metabolite) is renally cleared - accumulation can cause seizures serotonergic

duration of action of meperidine

short

when is meperidine recommended for analgesia

no longer recommended

brand name of morphine ER

MS Contin

2 brand names of morphine injections

Duramorph Infumorph

AE of morphine and how to manage

pruritis diphenhydramine for histamine-induced

brand name of oxycodone IR

Roxicodone

brand name of oxycodone CR

OxyContin

brand names of oxycodone + APAP

Endocet, Percocet

BBW of oxycodone

initiation of CYP3A4 inhibitors can cause OD

AEs of oxycodone

pruritis

how to take oxymorphone

empty stomach

methadone DDI - caution with drugs that increase risk of

QT prolongation serotonergic

which 4 opioids are CYP3A4 substrates

hydrocodone fentanyl methadone oxycodone

when converting opioids, round the dose

down to reduce risk of OD

morphine IV/IM to oral

IV/IM 10 mg PO 30mg

hydromorphone IV/IM to oral

IV/IM 1.5mg PO 7.5mg

morphine to hydromorphone IV/IM conversion

morphine 10mg hydromorphone 1.5mg

morphine : hydromorphone : oxycodone PO conversions

morphine 30mg hydromorphone 7.5mg oxycodone 20mg

when converting, can reduce dose by 25% but if not specified on exam

calculate equivalent, do not reduce

how to dose convert to fentanyl patch

dosing table provided mcg/hr

when converting to methadone, since it has variable half life, must

use separate conversion chart for pain specialists

opioids are not 1st line for chronic pain, if used, follow safe recommendations

reach low vs no pain start w/ IR evaluate risk factors check PDMP use adjunctive meds avoid benzos

if someone has a true opioid allergy, use

difference chemical class

common opioids that cross react have what in their name

cod or morph (norph) codeine, hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, buprenorphine, heroin

5 risk factors for opioid induced respiratory depression (OIRD)

hx of overdose SUD using large doses (>=50mg morph or equiv) use w/ benzo, gaba, pregab comorbid resp or psych disease

what should be given to all patients at elevated risk for OIRD

naloxone

which opioid AE does not lessen with time

constipation OIC - reduce GI tract peristalsis must be anticipated and treated

how to take all PO opioids (except oxymorphone)

w/ food to decrease nausea

1st and 2nd line options for OIC

1- stim or osmotic laxatives +/- stool softener 2- PAMORA 30 lubiprostone

3 peripherally acting Mu opioid receptor antagonists (PAMORAs) used to reduce OIC

methylnaltrexone naloxegol naldemedine

brand name methylnaltrexone

Relistor

brand name naloxegol

Movantik

warning for PAMORAs

GI perforation

AE of PAMORAs

abdominal pain

PAMORAs are only used in patients who have failed

OTC laxatoves

3rd line option for OIC

lubiprostone CL channel activator

brand name of lubiprostone

Amitiza

2 mu receptor agonists and inhibitors of NE reuptake? 1 has an additional MOA?

tramadol - also inhibits serotonin reuptake tapentadol

class of tramadol

CIV

BBW tramadol

resp depression and death following tonsillectomy or adenoidectomy in children that were URM of CYP450 2D6 POLYMORPHISM

warnings for tramadol

seizure, serotonin syndrome when used with inhibitors of 2D6 or 3A4, hypoglycemia

contraindications to tramadol

children <12 or <18 following tonsillecotmy or adenoidectomy MAOIs within 14 days

AEs of tramadol and tapentadol

dizziness, constipation, nausea, somnolence

tramadol is a prodrug that requires metabolism by

CYP2D6 - use with inhibitors has varied effects

warnings of tapentadol

seizure risk, serotonin syndrome

DDIs w/ central acting analgesics (tramadol, tapentadol)

drugs that lower seizure threshold serotonergic drugs avoid tramadol with 2D6 inhibitors

combination product with abuse-deterrent naloxone

Suboxone

3 examples of opioids with technology to deter crushing, dissolving, etc

OxyContin ROxybond Hysingla ER

s/sx of overdose

extreme sleepiness, slow/shallow breathing, fingers or lips turning blue, pinpoint pupils, slow heartbeat, and/or low BP

what to do in suspected OD

give naloxone even if questioning life support if not breathing monitor for resp depression and repeat doses

2 formulations of naloxone

nasal spray- 3-4mg OTC or RX in 1 nostril and repeat every 2-3 mins alternating injection- mult vials, separate syringes, repeat every 2-3 mins

2 opioid antagonists used to revere OIRD

naloxone nalmefene

brand names of naloxone

Narcan RiVive

AEs of opioid antagonists

acute withdrawal symptoms, pain

2 options to treat OUD

methadone buprenorphine (suppress withdrawal, + naloxone to prevent misuse)

opioid antagonist used in OUD

naltrexone

class of buprenorphine

CIII

brand name of buprenorphine/naloxone SL FILM

Suboxone

brand name of buprenorphine/naloxone SL TABLET

AE of buprenorphine

dizziness

adjuvants are commonly used for

neuropathy postherpetic neuralgia (PHN) fibromyalgia

injectable adjuvant given via epidural pump for cancer pain

clonidine

3 ASMs used as adjuvants

gabapentin pregabalin carbamazepine

brand name of gabapentin

Neurontin

2 indications for ER gabapentin

PHN and restless legs

brand name of pregabalin

lyrica

AEs of gabapentin and pregabalin

dizziness, somnolence, peripheral edema/weight gain (+ mild anxiolytic for pregabalin)

class or pregabalin

3 approved indications of pregabalin

fibromyalgia PHN neuropathic pain

brand name of carbamazepine

Tegretol

indication of carbamazepine for pain

trigeminal neuralgia

4 SNRI/TCAs used as adjuvants

milnacipran amitriptyline desipramine duloxetine

brand name duloxetine

cymbalta

3 antispasmodics with analgesic effect

baclofen cyclobenzaprine tizanidine

brand name baclofen

Lioresal

brand names cyclobenzaprine

Amrix Fexmid

brand name tizanidine

Zanaflex

AEs of all muscle relaxers

sedation, dizziness, confusion, asthenia (muscle weakness)

additional AE for cyclobenzaprine

dry mouth

DDI cyclobenzaprine

serotonergic - do not combine with other agents

additional AEs of tizanidine

dry mouth, hypotension

3 muscle relaxants that work through sedation

carisoprodol metaxolone methocarbamol

brand name and class of carisoprodol

Soma CIV

brand name methocarbamol

Robaxin

genomic key point for carisoprodol

poor CYP2C19 metabolizers will have increased concentrations

muscle relaxer used for malignant hyperthermia

dantrolene (Dantrium)

4 topical adjuvant options

lidocaine patch, gel capsaicin methyl salicylate trolamine

brand name lido 5% patch

LidoDerm

how to use lido patch (for PHN)

apply to painful area up to 12 hours/day no more than 3 patches at ones can cut can harm children and pets

brand name capsaicin cream

Zostrix

how does capsacin work

decrease substance P

counseling for capsaicin application

do not touch genitals, nasal area, mouth, or eyes after application wash hands

brand name of trolamine

Aspercreme

Pain Flashcards

(200 cards)