Pain Elijah

What is the brand name for hydromorphone IR?

Dilaudid®

What is the brand name for oxymorphone?

Opana®

What are the brand names for morphine ER?

MS Contin® and Kadian®

What are the brand names for hydrocodone ER?

Hysingla ER® and Zohydro ER®

What is the brand name for oxycodone IR?

Roxicodone®

What is the brand name for oxycodone ER?

OxyContin®

What is the brand name for meperidine?

Demerol®

What is the brand name for tramadol?

Ultram®

What is the brand name for tapentadol?

Nucynta®

What is the brand name for the acetaminophen/codeine combination product?

Tylenol #3®

What is the brand name for the acetaminophen/hydrocodone combination product?

Norco®

What is the brand name for the acetaminophen/oxycodone combination product?

Percocet®

What is the brand name for the buprenorphine transdermal patch?

Butrans®

What is the brand name for the buprenorphine buccal film?

Belbuca®

What is the TRUE maximum daily dose (MDD) of acetaminophen, and what is the clinically preferred MDD?

True MDD = 4000 mg/day. Preferred clinical limit = 3000 mg/day.

What is the maximum daily dose of duloxetine?

120 mg/day. Note: doses above 60 mg/day increase adverse effects without significant added analgesic benefit.

What is the maximum daily dose of gabapentin, and why is higher dosing not recommended?

MDD = 3600 mg/day. Doses >2400 mg/day have decreased GI absorption due to oversaturation of the amino acid transporter — higher doses yield diminishing returns.

What is the oral morphine equianalgesic dose?

30 mg PO = 10 mg IV/IM (parenteral)

What is the oral hydromorphone equianalgesic dose?

7.5 mg PO = 1.5 mg IV/IM

What is the oral oxycodone equianalgesic dose?

20 mg PO (no parenteral form in the table)

What is the oral hydrocodone equianalgesic dose?

30 mg PO (no parenteral form available)

What is the oral oxymorphone equianalgesic dose?

10 mg PO = 1 mg IV/IM

Which opioids have NO parenteral equianalgesic value (PO only)?

Hydrocodone and oxycodone — parenteral forms are listed as N/A.

Which opioid is an atypical outlier on the equianalgesic table and why?

Methadone — no clear conversion due to highly variable and complex PK; extreme caution required; covered in Palliative Care lecture (IST7).

What are the 6 steps of opioid dose conversion?

Step 1: Look up equianalgesic doses. Step 2: Calculate total 24-hour opioid use. Step 3: Convert to oral morphine equivalents (OMEs). Step 4: Convert OMEs to the new opioid dose. Step 5: Reduce by 25–50% for incomplete cross-tolerance. Step 6: Add breakthrough dose (10–15% of total daily dose, q3–4h PRN).

When is the 25–50% cross-tolerance reduction NOT required during a dose conversion?

When you are only changing the ROUTE of the same opioid (e.g., IV morphine → PO morphine) — no cross-tolerance adjustment needed, just apply the equianalgesic ratio.

How is a breakthrough (supplemental) opioid dose calculated?

10–15% of the total daily opioid dose, dosed every 3–4 hours as needed. Use the same opioid as the long-acting agent when possible.

Opioid conversion practice: A patient is receiving IV morphine 4 mg q4h and takes all 6 doses. Convert to oral oxycodone (apply 25% cross-tolerance reduction).

Step 1: 24-hr IV morphine = 4 mg × 6 = 24 mg. Step 2: Convert to OME → 24/10 × 30 = 72 mg OME. Step 3: Convert to oral oxycodone → 72/30 × 20 = 48 mg oxycodone. Step 4: Reduce 25% → 48 × 0.75 = 36 mg/day. Divide for BID ER dosing = OxyContin 15 mg q12h + oxycodone IR 5 mg q4h PRN.

Opioid conversion practice: A patient received 25 mg IV morphine over 24 hours. What is the equivalent oral morphine dose?

25 mg IV ÷ 10 mg = 2.5 units × 30 mg = 75 mg oral morphine per day.

What Butrans (buprenorphine patch) starting dose should be used for an opioid-naïve patient or someone on <30 mg OME daily?

5 mcg/hour patch every 7 days.

What Butrans starting dose is used for a patient on 30–80 mg OME daily?

10 mcg/hour patch every 7 days.

What is the maximum dose of the Butrans patch?

20 mcg/hour.

What must be done before initiating Butrans to prevent withdrawal?

Taper the patient to ≤30 mg OME daily prior to initiation.

What is the Belbuca (buprenorphine buccal film) starting dose for a patient on <30 mg OME daily?

75 mcg once daily (QD) or q12h.

What is the Belbuca starting dose for a patient on 30–89 mg OME daily?

150 mcg q12h.

What is the Belbuca starting dose for a patient on 90–160 mg OME daily?

300 mcg q12h.

Which opioids are NOT indicated for chronic pain?

Codeine and meperidine (Demerol®) — indicated for acute pain only.

Which opioids have NO acetaminophen combination product?

Morphine, hydromorphone, oxymorphone, and meperidine.

Which opioid IR has its own brand name (IR formulation)?

Hydromorphone IR = Dilaudid®; Oxycodone IR = Roxicodone®; Meperidine = Demerol®.

Which opioids should be AVOIDED in renal impairment?

Morphine, codeine, oxymorphone, meperidine, and tramadol.

Which opioids are PREFERRED in renal impairment?

Buprenorphine, methadone, and fentanyl.

Which opioids should be AVOIDED in hepatic impairment?

Codeine, oxymorphone, meperidine, methadone, and tramadol.

What opioid adverse effects develop HIGH tolerance over time?

Analgesia, euphoria, mental clouding, sedation, respiratory depression, nausea/vomiting, and cough suppression.

What opioid adverse effects develop MINIMAL or NO tolerance?

Constipation, immunosuppression, and HPA axis suppression — these persist throughout therapy.

What opioid adverse effect develops MODERATE tolerance?

Pruritis — most common with morphine; caused by itch-related mediator release from cutaneous mast cells.

What makes buprenorphine unique compared to conventional opioids?

Partial µ-agonist with high affinity and slow dissociation (ceiling effect on euphoria, respiratory depression, constipation); κ/δ antagonist (↓ depression, anxiety, immunosuppression, opioid-induced hyperalgesia); ORL1 agonist (↑ spinal analgesia, ↓ supraspinal CNS analgesia).

What is the half-life of buprenorphine?

~26–28 hours (applies to both Butrans and Belbuca).

How often is the Butrans patch changed, and what are the application sites?

Every 7 days. Sites: upper outer arm, upper chest, upper back. Rotate sites; do not cut patch; fold and flush to dispose. Titrate no earlier than every 72 hours. Avoid heat exposure.

How often is Belbuca dosed, and what are the key counseling points?

Every 12 hours. Apply to moist inner cheek; allow to fully dissolve. Avoid food or drink for ≥30 minutes after administration. Titrate no earlier than every 4 days.

What is the MOA of tramadol, and what is its secondary mechanism?

Primary: inhibits reuptake of serotonin (SE >> NE). Secondary: weak µ-opioid receptor agonist. It is a CYP2D6 prodrug — the active metabolite provides the opioid effect.

What is the MOA of tapentadol, and how does it differ from tramadol?

Primary: inhibits reuptake of norepinephrine (NE >> SE). Secondary: strong µ-opioid receptor agonist. NOT a prodrug; inactivated via glucuronidation.

Which of tramadol/tapentadol carries a greater risk of serotonin syndrome and seizures?

Tramadol >> tapentadol for both serotonin syndrome and seizures. Avoid tramadol with MAOIs, SSRIs/SNRIs/TCAs, and moderate-strong CYP2D6 inhibitors (e.g., bupropion, fluoxetine, duloxetine, paroxetine).

What is the duloxetine starting dose and titration for neuropathic pain?

30 mg QD × 7 days, then increase to 60 mg/day. Max 120 mg/day. Doses above 60 mg/day increase adverse effects without significant added benefit.

What are the major contraindications/cautions for duloxetine?

Current SSRI/SNRI/TCA use (serotonin syndrome), uncontrolled HTN, chronic liver disease/cirrhosis, CrCl <30 mL/min. It is a CYP1A2 and 2D6 substrate and moderate 2D6 inhibitor.

What is the gabapentin dose range and why should the first dose be taken at bedtime?

Range: 300–2400 mg/day (TID dosing). First dose at bedtime to minimize somnolence/dizziness during initiation. Has no CYP interactions; undergoes renal elimination of unchanged drug — requires renal dose adjustment.

What is baclofen's MOA, indication, and key withdrawal concern?

MOA: GABA-B receptor agonist in spinal cord/CNS → ↓ motor neuron activity. Indication: spasticity and spasms. Abrupt discontinuation → seizures and hallucinations. Renally eliminated — requires dose adjustment in renal impairment.

What is tizanidine's MOA and key DDI?

MOA: α-2 receptor agonist → ↓ motor neuron activity. Major CYP1A2 substrate — avoid moderate-strong CYP1A2 inhibitors (ciprofloxacin, fluvoxamine). Abrupt discontinuation → rebound hypertension.

What is unique about carisoprodol among centrally acting spasmolytics?

It is metabolized to meprobamate (a barbiturate with GABA-A agonist activity) — Schedule IV controlled substance with potential for physical dependence. Abrupt discontinuation can cause withdrawal symptoms.

Which SMR should be avoided in patients with cardiac arrhythmias or glaucoma, and why?

Cyclobenzaprine — structurally related to TCAs; anticholinergic effects increase arrhythmia/conduction risk and worsen glaucoma.

Which SMR causes urine discoloration?

Methocarbamol — may cause brown, green, or black urine discoloration.

How long should SMRs be used, and what is the concern with long-term use?

Short-term only (≤4 weeks). Long-term use (>4 weeks) increases adverse effect risk, especially in elderly, and can lead to withdrawal on abrupt discontinuation (baclofen: seizures; tizanidine: rebound HTN; carisoprodol: dependence/withdrawal).

What is the first-line pharmacologic approach for mild acute or chronic nociceptive pain?

Acetaminophen and/or NSAIDs.

What is the preferred opioid class for neuropathic pain when an opioid is needed?

Tramadol or tapentadol (both have dual MOA: SNRI activity + µ-opioid agonism).

What is the difference between opioid tolerance, dependence, and addiction?

Tolerance: increased dose needed for same effect (physiologic). Dependence: withdrawal on discontinuation (physiologic). Addiction (OUD): compulsive drug seeking despite harm (behavioral + psychological + physical).