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43 Cards in this Set
- Front
- Back
Describe somatic pain.
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It is tender and localized to the site of injury. It is usually constant, and can be throbbing or aching. Caused by burns, arthritis, cuts, etc.
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What is the most common cause of somatic pain in cancer patients?
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bone metastasis
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Describe visceral pain.
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It is poorly localized and often referred to a distant cutaneous site which may be tender. Occurs in dull colicky waves. Associated with nausea and diaphoresis.
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What are some examples of visceral pain?
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passing a renal stone
pancreatic cancer small bowel obstruction pleuritis |
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Describe neuropathic pain.
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Prolonged, severe, burning, or squeezing pain. Often associated with focal neurologic deficits. May have allodynia which is areas of exquisite sensitivity to normally innocuous stimuli.
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What type of pain is most difficult to treat?
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Neuropathic because it is resistant to opioids
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What is given to patients who are considered in step 1 of the analgesic ladder?
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NSAIDs
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What is given to patients who are considered in step 2 of the analgesic ladder?
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an opioid for mild/moderate pain such as tramadol or codeine
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What is given to patients who are considered in step 3 of the analgesic ladder?
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an opioid for moderate/severe pain such as morphine or fentanyl
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Give dose, interval, route, and maximum dose for acetaminophen.
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Dose: 500-1000 mg
Interval: q4-6h Route: PO/PR Maximum: 4000 mg |
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Give dose, interval, route, and maximum dose for ibuprofen.
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Dose: 200-600 mg
Interval: q4-6h Route: PO Daily maximum: 2400 mg |
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Give dose, interval, route, and maximum dose for naproxen.
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Dose: 250 mg
Interval: q6-8h Route: PO Daily maximum: 1250 mg |
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What are the advantages to opioid therapy?
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1. safe
2. reliable 3. multiple routes of administration 4. ease of titration |
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What is pseudoaddiction?
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It is caused by undertreatment of pain. Adequate analgesia will stop this drug seeking behavior in the non addicted patient. Most cancer patients never have problems with addiction.
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What is the advantage of using tramadol over opioids?
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It is less likely to cause respiratory depression and constipation.
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What condition is necessary before using fentanyl?
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The patient must be opioid tolerant. Fentanyl is used every 48-72 hours and begins working in 12-14 hours.
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What are the major prinicples of therapy in the patient with mild pain?
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1. Assess frequency, duration, occurrence, and etiology of pain
2. Bone pain = NSAID 3. Dose med to max before switching 4. For constant pain, dose around the clock |
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What are the major principles of therapy in the patient with mild/moderate pain?
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When using opioids, prevent constipation with a GI stimulant like Senna or bisacodyl
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What are the major principles of therapy in the patient with moderate/severe pain?
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1. Morphine is main choice
2. No practical dosing limit 3. Around the clock dosing, with controlled-release and immediate-release products 4. Utilize all possible adjuncts to minimize increases in dose 5. If patient doesn't tolerate one opioid, consider swith to another. |
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What opioids must you avoid in the presence of renal failure?
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meperidine, morphine, codeine, and tramadol
Meperidine causes CNS excitability Morphine causes prolonged narcosis Codeine and tramadole accumulate and extend effects and tramadol can lead to seizures. |
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What drugs are innapropriate for chronic use in dealing with pain?
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propoxyphene, partial opioid receptor agonists (buprenorphine and dezocine), agonists/antagonists (pentazocine, nalbuphine, and butorphanol)
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Describe how you would initiate opioid pain therapy.
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1. Short acting opioid every 2-4 hours PRN
2. Measure the 24 hour opioid requirement 3. Substitute with long-acting preparation 4. In addition about 10% of the daily requirement should be available every 2-4 hours for breakthrough pain (if PRN dosing is needed more than 3 times/day, increase the long acting opioid) |
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Describe increaing opioid doses.
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Doses should be increased by increments of 1/2 to 1/3 of the preceding dose or based upon the usage of breakthrough opioids. If side effects prevent increases consider another agent.
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Describe dosing decreases with opioids.
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Rapid discontinuation can cause withdrawal. Reducing dosing increments of less than 25 percent per week prevents withdrawal.
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Equianalgesic opioid dosages
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Fentanyl. 0.1mg
Hydrocodone. 30 mg hydromorphone IM. 1.5 mg hydromorphone PO. 7.5 mg morphine IM. 10 mg morphine PO. 30 mg oxycodone. 20 mg |
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How do you convert IV to transdermal fentanyl?
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It is done on a 1:1 basis
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Describe incomplete cross tolerance.
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Patients often require less of a new agent than they did of their previous agent. 25%-50% dose reduction of the new agent will account for this incomplete cross tolerance.
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Kadian pharmacokinetics
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Morphine SR
extended release |
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Avanzia pharmacokinetics
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Morphine ER
biphasics release (IR and ER) Q24hr |
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MS Contin pharmacokinetics
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Morphine CR
extended release |
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MSIR pharmacokinetics
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Morphine
immediate release |
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Oxycontin pharmacokinetics
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Oxycodone CR
Biphasic release (IR 38%, CR 62%) Q12hr although q8hr is common |
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Which groups of medications can be used as adjuvant analgesic therapy?
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Antidepressants, anticonvulsants, and sedatives.
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Which antidepressants are used as analgesic adjuvants and how are they helpful?
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Tricyclics are most helpful in neuropathic pain. Trazodone and SSRIs may be useful in cancer patients who are clinically depressed.
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When are sedatives used for cancer patients?
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They are especially helpful to patients and families when patients are in pain near death.
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What are the 3 approaches to treating adverse effects from opioids?
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1. Dose reduction
2. Changing to a different opioid or route of adminstration. 3. Symptomatic management |
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What would you use for nausea after a meal?
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Metoclopromide
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What would you use for nausea after movement?
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Meclizine
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What would you use for unassociated nausea?
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Phenothiazines, antihistamines, benzodiazepines
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What would you initially use for opioid constipation?
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Dulcolax, Senna, docusate, stimulant laxatives
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How would you treat constipation that develops despite prophylaxis?
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1. Rule out obstruction
2. Begin osmotic laxative: lactulose, PEG, magnesium citrate |
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What is methylnaltrexone?
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It is an opioid antagonist that treats opioid induced constipation and doesn't cross the blood brain barrier.
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How would you reverse an opiate?
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Use naloxone which is a centrally and peripherally acting opioid antagonist. Dilute 10mg/ml vial in 9 ml of 0.9% NaCl. Administer 1-3 ml every 1-2 minutes until the patient is arousable.
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