Acute/Chronic Pain- Dart

2 hours

For acute pain, _______ opioids for the _________ duration are recommended if opioid use is warranted.

a. extended-release, minimum

b. immediate-release, minimum

c. extended-release, maximum

d. immediate-release, maximum

b.

What type of treatment is used for each kind of pain? (aka opioid, non-opioid)

• idk how imp

• mild: nonopioid ± adjuvant therapy

• mild-mod: weak opioids ± nonopioid ± adjuvant therapy

• mod-severe: strong opioids ± nonopioid ± adjuvant therapy

What are some non-pharm approaches to pain management?

• ice/ heat

• elevation

• rest

• immobilization

• exercise

Examples of weak opioid agonists include…

• idk how imp

• Tramadol

• codeine

• hydrocodone

• tapentadol

Examples of strong opioid agonists include…

• idk how imp

• Methadone

• fentanyl

• hydromorphone

• meperidine

• morphine

• oxycodone

• oxymorphone

What are Morphine Miligram Equivalents (MME) used to do?

used to monitor patient’s daily intake of opioids

____ MME/day is often used as a benchmark for when to use extra precaution with opioid prescriptions.

50 MME/day (risk of overdose x2 at 50 MME/day versus <20 MME/day)

Can MMEs be used to convert from one opioid to another?

NOOOO…

PRACTICE:

A pt. is currently taking oxycodone 10mg every 6 hours routinely and uses Hydromorphone 2mg for breakthrough pain. They have taken 2 doses of hydromorphone today. Calculate the pts. daily MME.

MME= strength x quantity x conversion factor

Will be given table on exam!!!!

• Oxy = 10 × 4 × 1.5

  • = 60

• Hydromorphone= 2 × 2 × 4

  • = 16

• TOTAL MME= 76

_______ is preferred due to convenience, cost-effectiveness, and flexibility as a route of administration for opioids.

a. IV

b. IM

c. transdermal

d. oral

d.

With ______ administration you get the most rapid onset of effect.

a. IV

b. IM

c. transdermal

d. oral

a.

Why is IM admin not recommended for opioids?

• painful

• variable and inconsistent absorption

What is the benefit to transdermal ROA for opioids?

less constipation compared to oral

What is a PCA?

• programmable pump for IV/SQ opioids

• gives small dose constantly and/or frequently

For PCA, the safety mechanism is a _______________.

lockout interval (max amount of med a pt. can get in an hour)

What are the pros and cons of a PCA?

PROS	CONS
superior pain relief w/ less sedation + improved sleep patterns decreased delay from requesting analgesia and getting it lower overdose potential allows docs to adjust regimen based on use	requires patient to be self-aware and able to work PCA pump (bc they have to press the button themselves) short-term solution (only in the hospital) oversedation risk with basal and bolus dosing

With intrathecal (intraspinal) opioids, ______ has a longer duration of action as it will penetrate the spinal cord, and fentanyl has a quicker onset.

Morphine

With intrathecal opioids, epidural doses are 1/____th of IV doses, but intrathecal doses are 1/____th of epidural doses.

1/10th

(Ex: morphine 10mg IV = 1mg epidural = 0.1mg intrathecal OR you can also say IV dose → Epidural (1/10) → Intrathecal (1/100))

PRACTICE:

A physician wants to start his pt. on a morphine PCA pump with a lockout amount of 6mg/hr. Which option would NOT be a possible option?

a. Morphine 1 mg/hr and 0.5 mg q10 minutes PRN

b. Morphine 1 mg/hr and 0.5 mg q5 minutes PRN

c. Morphine 0.5 mg q5 minutes PRN

d. Morphine 1 mg q10 minutes PRN

b. (0.5 mg x 12 = 6 + 1 = 7 mg, but lockout amount is 6 mg)

Clinicians should reevaluate patients __-__ weeks after starting opioid therapy.

• idk how imp

1-4

What does PDMP stand for and what is it’s purpose?

• PDMP= prescription drug monitoring program

• purpose: help prevent rx drug abuse as well as protect the community

The main difference between acute and chronic cancer pain is the duration. Acute cancer pain usually lasts how long? chronic?

• acute= <3 months

• chronic= >3 months

Describe what kind of analgesics should be used for each type of cancer pain (aka non opioids or opioids):

• mild pain

• mod-severe pain

• severe pain/ pain crisis

• mild pain: focus on nonopioids + adjuvant therapies

• mod-severe pain: nonopioids, adjuvants, and short-acting opioids q3-4 hrs PRN

  • consider long-acting if need short-acting a lot

• severe pain/ pain crisis: consider hospice

What is “breakthrough pain”?

pain flare—> usually associated with cancer pain

Typical breakthrough dose for breakthrough pain is ___-___% of the total daily opioid use every 2-6 hours as needed.

5-20%

What are the steps to converting opioids?

1. calculate TDD of all opioids within last 24 hrs

2. use opioid conversion chart to determine dose of new agent

3. if changing opioid agent, must dose reduce to account for incomplete cross tolerability

   • adjust for pts. with chronic pain

   • dependent on current pain control:

     • controlled—> 50-75% of calculated new dose

     • not controlled—> 75-100% of calculated new dose

4. divide new TDD into individual dosages

When might you consider titrating from a short term opioid to long term opioid?

• if requiring >/=2-3 breakthrough doses within 24 hours

• if >25% of TDD take for breakthrough pain

Are adjuvants opioids?

no—> co-analgesics that are nonopioids

T/F: adjuvants contain APAP or an NSAID.

FALSE—> do not contain

Examples of adjuvants?

• antidepressants

• anticonvulsants

• benzos

• bisphosphonates

• NMDA receptor antagonists

• skeletal muscle relaxants

• steroids

• topical agents

Why do we taper opioids?

to avoid withdrawal in pts. on long term opioids

First line medication for pain management in pregnancy is _______.

Acetaminophen

When can NSAIDs technically be used in pregnancy?

only in 1st or 2nd trimester

What are the 4A’s of pain?

• adverse effects

• analgesia

• ADLs

• abuse issues

Compare tolerance, dependence, and addiction:

	Description
Tolerance
Dependence
Addiction

	Description
Tolerance	reduced response compared to when 1st taking the drug→ need higher or more doses to get same effect
Dependence	occurs due to repeated use causing neurons to adapt→ can’t fxn normally w/out drug absence of drug= physiologic rxns
Addiction	chronic, relapsing disease uses drug-seeking behavior and drug use that is compulsive or uncontrollable long-lasting effects on brain

What are the 3 medications recommended to manage OUD?

1. methadone

2. naltrexone

3. buprenorphine

Answer the following about methadone:

• agonist or antagonist?

• used for mild, mod, or severe pain?

• why is it used for withdrawal/ OUD?

• full agonist

• synthetic opioid used for severe pain

• long half life and slow absorption—> reduces “high” sensation and slow elimination—> avoids emergence of withdrawal symptoms

Patients need to be fully withdrawn before ______ can be initiated to avoid precipitated withdrawal.

Naltrexone

_______ is an opioid receptor partial agonist and the most widely prescribed OUD medication.

Buprenorphine

Naloxone is an opioid ________ that rapidly temporarily reverses the effects of opioids. (fyi: do not confuse naltrexone with naloxone)

a. antagonist

b. agonist

a.

Which of the following about naloxone is INCORRECT?

a. can repeat dose q2-3 minutes if pt. doesn’t wake up

b. affects patients that do not have opioids in their system

c. comes in a nasal spray or injection

d. opioid antagonist

b. (does NOT affect pts. that do not have opioids in their system)

What did PA Act 139 do?

• provides (limited) immunity from charges/prosecution

• “good samaritan”

• allows 1st responders to administer naloxone

• allows non-profits to distribute naloxone

PRACTICE:

JZ has a history of OUD was recently admitted into the hospital. She takes methadone 120mg daily. Pharmacy has been consulted to make recommendations to improve her lower back pain. Which recommendation below would be a priority for this patient?

a. Increase home methadone dose to 140 mg and add topical agents

b. Decrease methadone dose to 5 mg every 8 hours for pain control

c. Hold home methadone and start oxycodone 10 mg every 6 hours

d. Continue home methadone 120 mg in addition to other pain management agents

d.