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PHAR 557 > Pain 2 > Flashcards

Pain 2 Flashcards

1
Q

What is the recommendation for a pt with substance use disorder suffering from non-cancer chronic pain?

A

avoid opioids (use simple analgesics and non-pharm stuff only)

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2
Q

What is the recommendation for a pt with a psychiatric disorder suffering from non-cancer chronic pain?

A

Avoid opioids until disorder is stabilized

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3
Q

What’re the upper limits of opioid dosing for chronic non-cancer pain?

A

When starting, no higher than 50mg morphine equivalents/day

If we must go up, no higher than 90mg morphine equivalents per day

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4
Q

What should we do if we increase the dose of an opioid a couple of times without any chronic pain reduction?

a. further increase the dose
b. change the opioid
c. switch to NSAIDs

A

b.

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5
Q

Opioid MOA

A

Agonist for opioid receptors in CNS and PNS > suppress neuronal firing > alters pain perception

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6
Q

T or F: Opioids reduce pain and inflammation.

A

F

They do nothing for inflammation

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7
Q

Which opioid receptor is most responsible for the analgesic effects of opioids?

A

µ (mu)

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8
Q

Name the 3 opioid receptors

A

mu, delta, kappa

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9
Q

T or F: Opioids are a subset of opiates.

A

F

Opiates are a subset of opioids

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10
Q

Advantages of opioids?

A

strong pain relief, no major organ tox

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11
Q

Disadvantages of opioids?

A

AEs (constipation, CNS depression, falls/fractures, apnea, hyperalgesia)

Addiction (OUD)

tolerance, dependence

No long-term trials (> 3 months)

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12
Q

The “big 5” opioids in Canada

A

morphine, codeine, hydromorphone, oxycodone, fentanyl

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13
Q

How does codeine provide pain relief?

A

It must be converted to morphine first via CYP2D6

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14
Q

What kind of opioid formulation should inds always be started on?

A

immediate release

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15
Q

T or F: If an ind is expected to be on opioids chronically, then using dosage forms other than IR (e.g. SR, CR, ER) are acceptable first-options.

A

F

IR is always first option regardless

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16
Q

How potent are parenteral opioids (IM, IV, SC) compared to po opioids?

A

Parenteral opioids are ~2x more potent than po opioids

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17
Q

How do we convert b/w potencies of diff types of opioids?

A

By using an oral morphine equivalent factor (ORAL and MORPHINE are the standard)

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18
Q

Why don’t some ppl experience analgesia from codeine?

A

Bc they’re deficient in the 2D6 enzyme > no morphine is produced from codeine precursor

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19
Q

Which oxycodone product was d/c’ed? Why?

A

OxyContin > it was being abused (it was v. addictive)

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20
Q

Active metabolite of morphine?

A

morphine-3-glucuronide

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21
Q

When would you consider avoiding morphine?

A

renal dysfn due to accumulation of metabolites

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22
Q

opioid of choice in CKD/renal impairment pts?

A

Dilaudid (hydromorphone)

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23
Q

MOA of tramadol?

A

mu receptor agonist AND SNRI

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24
Q

What pt pop would you avoid tramadol in? Why?

A

Seizure pts > lowers seizure threshold

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25
Q

How much stronger is fentanyl than morphine?

A

~100x

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26
Q

Dosing schedule of fentanyl patch?

A

q72h

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27
Q

T or F: Fentanyl will accumulate in renal impairment

A

F (no active metabolites)

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28
Q

What do you do if the fentanyl patch’s gel gets on your hand while applying the patch?

A

Wash your hand w/ water ONLY (soap w/ increase absorption)

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29
Q

Which strength of fentanyl patch is used for dosing titrations/tapers?

A

the 12mcg/hr patch

30
Q

Starting dose of fentanyl patch for pain?

A

25mcg/hr

31
Q

Dosing interval for methadone for pain tx

A

q8-12h (for pain relief)

32
Q

T or F: Methadone will accumulate in renal impairment

A

F

33
Q

Name 3 opioids that’re appropriate during renal impairment

A

Dilaudid (hydromorphone), fentanyl patch, methadone

34
Q

What kind of test should be performed prior to starting methadone?

A

baseline ECG

35
Q

Methadone doses can be increased no less than every ___ days

A

5

36
Q

Why is an ECG recommended when using methadone?

A

Bc there’s a risk of QT prolongation

37
Q

Why does respiratory depression insidiously develop in methadone pts?

A

bc methadone has a slow onset of action

38
Q

What is the initiating dose of methadone?

A

≤ 30mg (depending on risk of methadone tox)

39
Q

General short term AEs of opioids:

A

sedation, resp. dep, constipation, N, itching/rash

40
Q

Which opioid AEs will pts never develop tolerance for?

A

constipation and miosis (pin-point pupils)

41
Q

What’s important to know about resp dep and opioid tolerance?

A

Tolerance to resp dep is lost quickly > if a pt goes w/o opioids for ≥ 3 days, their tolerance has decreased and can die if they take the same dose they’ve been taking previously

42
Q

When does opioid tolerance to sedation begin?

A

3-4 days after initiating tx

43
Q

Opioid CIs?

A
  1. allergy
  2. co-admin of a drug that interacts w/ it which could have important consequences for pt’s health (e.g. rifampin)
  3. active diversion of ctrled substances
44
Q

General long term AEs of opioids:

A
  1. hypogonadism
  2. sleep apnea
  3. opioid-induced hyperalgesia
  4. opioid use disorder
45
Q

How do opioids affect the hypothalamic-pituitary-gonadal axis?

A

Over the long term, opioids cause a DECREASE in LH, FSH, testosterone, and estrogen

It also causes an INCREASE in prolactin

46
Q

How do opioids affect the hypothalamic-pituitary-adrenal axis?

A

they decrease plasma cortisol levels over time

47
Q

What sx’s of hypogonadism are expected from chronic opioid use?

A

reduced libido, aggression, amenorrhea, irregular menses; and galactorrhea

48
Q

T or F: The sx’s of sleep apnea caused by opioids is similar to obstructive sleep apnea sx’s.

A

T

49
Q

When would hyperalgesia be more likely to develop?

A

With higher doses of opioids, and when opioids are used for longer periods of time

50
Q

T or F: Decreasing doses of opioids helps w/ hyperalgesia.

A

T

51
Q

T or F: Many inds on opioid tx for chronic pain will develop opioid use disorder.

A

T

52
Q

What is first line for tx of opioid use disorder?

A

Suboxone (buprenorphine/naloxone)

53
Q

MOA of naltrexone?

A

full antagonist of opioid receptor

54
Q

MOA of methadone?

A

full agonist of opioid receptor

55
Q

MOA of Suboxone?

A

partial agonist of opioid receptor

56
Q

Most likely to get an overdose w/:

  1. full opioid agonist
  2. partial opioid agonist
  3. opioid antagonist
A

full opioid agonist

57
Q

What’s an advantage of bupenorphine being a partial agonist?

A

Safer in overdose due to ceiling effect

58
Q

What’s the advantage of having naloxone in Suboxone?

A

It blocks the effects of buprenorphine if injected (i.e. it makes injection futile)

59
Q

T or F: Naloxone is absorbed along with buprenorphine, making it slightly less effective.

A

F

naloxone is NOT absorbed po or SL

60
Q

Advantages of Suboxone over methadone?

A
  1. less risk of overdose
  2. less AEs
  3. reduced risk of diversion
  4. less DIs
  5. milder withdrawal sx’s when discontinued
61
Q

What is the first thing we need to do when switching from one opioid to another?

A

Calculate TOTAL DAILY OPIOID USE (inc. avg. PRN use)

62
Q

After we have the total daily opioid use, what do we do next?

A

Convert it to total daily oral morphine equivalent

63
Q

When converting to total daily oral morphine equivalent, what should we keep in mind?

A

potency diffs b/w po and parenteral opioids (i.e. if we are starting with an injectable, then multiply the total daily oral morphine equivalent by 2)

64
Q

After calculating our total daily oral morphine equivalent, what do we do?

A 
Reduce dose (to account for incomplete cross tolerance)...
a. if total daily oral morphine equivalent is ≥ 200mg, reduce by 50%

a. if total daily oral morphine equivalent is < 200mg, then reduce by 25%

65
Q

Ok, now we have our final total daily oral morphine equivalent after reducing to account for incomplete cross tolerance. What do we do now?

A

Convert it to new opioid daily dose (interval is the same as previous opioid’s interval)

66
Q

How do we calculate the new PRN dose?

A

New opioid daily dose * 10% (i.e. new prn dose is 10% of new opioid daily dose)

PRN dosing interval is also the same (if none, then q4-6h)

67
Q

If converting total daily morphine dose to total daily oral morphine equivalent, what do we multiply it by?

A

1

68
Q

If converting total daily codeine dose to total daily oral morphine equivalent, what do we multiply it by?

A

0.15

69
Q

If converting total daily oxycodone dose to total daily oral morphine equivalent, what do we multiply it by?

A

1.5

70
Q

If converting total daily hydromorphone dose to total daily oral morphine equivalent, what do we multiply it by?

A

5

71
Q

When may we switch a pt to a fentanyl patch ?

A

When the pt has been on 60mg/d of total oral morphine equivalence for two consecutive weeks

PHAR 557 (36 decks)

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