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79 Cards in this Set
- Front
- Back
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"Fifth vital sign" |
- Pain
- Must be treated in same manner as other vital signs (inquire about, measure, and treat) |
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When to treat severe pain
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At initial onset
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Addition of non-opioids to regimen can ___________ the total opioid dose required
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Reduce
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Physiological Adaptation
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Body adapts to chronic opioid use
All patients will become physiologically adapted after repeated exposure |
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Addiction to opioids
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Involves a strong desire or compulsion to take the drug despite harm
Is manifested by drug-seeking behavior |
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Opioid Withdrawal Symptoms
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Anxiety
Tachycardia Shakiness SOB GI symptoms |
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Pseudo-addiction
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D/t poorly treated pain
Patient is often anxious about running out of drug and may have used up the medication too quickly |
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Tolerance
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Develops over time
Necessitates a higher dose to produce the same analgesic response |
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Opioid hyperalgesia
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Chronic opioid use that can worsen pain sensitivity
Occurs in some patients Switch to different opioid or to other analgesic |
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Break-through pain
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Acute pain that occurs despite use of a long-acting or scheduled opioid
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Most important predictor of respiratory depression (usual cause of fatality w/ opioid overdose)
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Sedation
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Treatment for mild pain
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NSAIDs
Acetaminophen |
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Vicodin, Norco, Lortab
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APAP/Hydrocodone
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Percocet, Endocet
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APAP/Oxycodone
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Tylenol # 2, 3, 4
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APAP/codeine
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Ultracet
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APAP/tramadol
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Ofirmev
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IV APAP
Used inpatient to enable lower opioid doses Can be used when PO routes are not available |
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Acetaminophen Dosing for Children
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10-15 mg/kg Q4-6 hours
Max of 5 doses/day |
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Acetaminophen dosing
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Comes in 325 mg, 500 mg, and 650 mg ER (soon will be gone)
325 mg - 2 tabs Q4-6 hours 500 mg - 2 tabs Q6 hours 650 mg - 2 tabs Q8 hours |
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Acetaminophen Info
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MOA - inhibits synthesis of prostaglandins in the CNS; peripherally blocks impulse generation
BLACK BOX --- hepatotoxicity SE - hepatotoxicity (alcoholics and hepatitis < 2g/d); severe skin rash (rare) DOC for pain in pregnancy |
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N-Acetylcysteine
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Acetadote - antidote for APAP overdose
MOA - restores intracellular glutathione LD - 140 mg/kg PO, then 70 mg/kg Q4hr x 17 doses Odor of rotten eggs; can cause nausea |
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Acetaminophen Drug Interactions
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DOC for use w/ warfarin
Avoid/limit alcohol d/t hepatotoxicity |
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Acetaminophen Counseling
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Contact Dr if condition worsens, lasts for > 2 days, high fever, or w/ rash, N/V, or blood in the stool
Caution on combo products that contain APAP Avoid/limit alcohol (Men < 2 drinks/d, women <1 drink/d) |
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NSAID Black Box Warnings
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- Increased risk of thrombotic events, MI, stroke
- Increased risk of serious GI issues (bleeding, ulceration, and perforation of the stomach or intestines) CONTRA --- peri-operative pain management in the setting of CABG surgery |
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Aspirin (acetylsalicylic acid)
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Bayer, Ascriptin, Bufferin, Ecotrin
Salicylic NSAID 325-650 mg dosing CONTRA - pregnancy, hypersensitivity, children < 16 y/o SE - dyspepsia, heartburn, HTN, HI bleeding, severe skin rash (rare) |
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Ibuprofen
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Motrin, Advil --- mild-moderate pain, fever, dysmenorrhea
OTC dosing - 200-400 mg Q4-6 hours; limit self treatment to < 10 days (max 1.2 g/d) Rx dosing - 400-800 mg Q6-8 hours (max 3.2 mg/d) |
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Naproxen
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Given BID
OTC dosing 250-500 mg Q6-8 hr Rx dosing - 500-1000 mg/d in 2 divided doses Relatively lower cardiac risk than other NSAIDs |
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Vimovo
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Naproxen/Esomeprazole
- PPI is used to protect the gut from damage caused by the NSAID |
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Treximet
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Sumatriptan/Naproxen 85-500 mg
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Diclofenac
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Cataflam, Voltaren XR, Flector (patch)
50-75 mg BID Flector patch - AAA BID; remove if bathing/showering; remove for MRI |
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Arthrotec
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Misoprostol/Diclofenac 200 mcg/50 mg
CONTRA - women of childbearing potential unless woman is using effective contraceptive measures Misoprostol - increases uterine contractions, causes cramping, diarrhea Used to reduce the risk of GI damage from NSAIDs |
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Indomethacin
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Indocin
IR - 25-50 mg CR - 75 mg Used for gout High risk of CNS SEs (avoid in psych conditions), GI toxicity |
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Piroxicam
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Feldene
10-20 mg qd Used for inflammatory condition if other NSAIDs do not work; may need agent to protect gut |
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Ketorolac
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Toradol
10-20 mg PO; always star w/ IV, IM, or nasal spray before switching to oral **5 day max treatment** Contra - any situation w/ increased bleeding risk SE - GI bleeding and perforation, post-op bleeding, acute renal failure, liver failure, anaphylactic shock |
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Sulindac
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Clinoril
NSAID Preferred w/ reduced renal function if NSAID is required |
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MOA of NSAIDs
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Inhibit activity of cyclooxygenase enzymes
--- These enzymes catalyze the production of prostaglandins and thromboxane from arachidonic acid ASA - irreversible inhibitor; NSAIDs - reversible NSAIDs Decrease inflammation d/t suppression of PG formation COX-2 --- less bleeding risk, but greater CV risk |
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Celecoxib
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Celebrex
50-400 mg Osteoarthritis - 100 BID or 200 qd Rheumatoid arthritis - 100-200 BID HIGHEST COX-2 SELECTIVITY Contra - sulfonamide allergy |
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Meloxicam
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Mobic
7.5-15 mg/d COX-2 selective NSAID |
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Etodolac
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Lodine
300-500 mg Q6-8 hours COX-2 selective NSAID |
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Nabumetone
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Relafen
1-2 g QD (can be divided BID) COX-2 selective NSAID |
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NSAID Drug Interactions
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Additive bleeding risk w/ antiplatelets or anticoagulants
Avoid concurrent use of NSAIDs (except 81 mg ASA) Can increase level of lithium and methotrexate (CONTRA w/ lithium) ASA and other ototoxic agents (AMGs, IV loop diuretics, etc) |
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NSAID Counseling
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Take w/ food if upset stomach
Increased CV risk Avoid use before elective surgery Can cause ulcers, stomach bleeding Can raise blood pressure Caution/Avoid in hx of MI, heart failure (can cause edema) Limit sun exposure Contra in pregnancy |
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Opioid MOA
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Mu receptor agonists
Dose can be increased (no max dose), but there is a limitation to how much pain relief they can offer Rotate high doses w/ other opioids to reduce risk of tolerance |
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Lidocaine 5% patches
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Lidoderm - used for postherpetic neuralgia (shingles)
AAA 1-3 patches/day for up to 12 hrs/day SE - minor topical burning, itching, rash |
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Lidoderm Patient Counseling
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Can be cut into small sizes before removing backing
DON'T apply more than 3 patches at one time Safely discard patches where children/pets can't get them (fold patch in half w/ sticky side facing in) Don't cover w/ heating pads/electric blankets Don't use on broken/abraded/burned/open skin (increased amount absorbed) |
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Capsaicin
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Zostrix, Zostrix HP (0.025%, 0.075%)
Decreases TRPV1-expressive nociceptive nerve endings (decreases substance P levels) AAA TID-QID SE - topical burning, dissipates w/ continued use |
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Qutenza 8% patch
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Rx capsaicin patch
Given in the doctor's office only Causes topical burning, requires pre-treatment w/ lidocaine Applied for 1 hours --- lasts for months Indicated for post-herpetic neuralgia (shingles) |
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Capsaicin Patient Counseling
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Apply thin layer of cream to AA and rub in gently until fully absorbed
Best results after 2-4 wks; DON'T use prn Wash hands thoroughly after use; if treating hands, leave on for 30 min, then wash hands Will burn eyes, nasal area, mouth, genitals Never cover w/ bandages or heating pad |
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Topical Methyl Salicylate
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BenGay, Icy Hot, Precise, SalonPas, TheraGesic
Patches, creams Possibility of 1st-3rd degree burns |
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Milnacipran
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Savella
SNRI - Fibromyalgia pain BLACK BOX - Suicidal thinking SE - N/C/HA, dizziness, insomnia, hot flashes Interactions - increases levels of digoxin, increased bleeding risk w/ antiplatelets or anticoags CONTRA - methylene blue, linezolid |
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Milnacipran Dosing Schedule
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Day 1 - 12.5 mg QD
Day 2-3 - 12.5 mg BID Day 4-7 - 25 mg BID Then 50 mg BID CrCl < 30 mL/min --- max 25 mg BID |
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Pregabalin
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Lyrica - diabetic neuropathic pain, postherpetic neuralgia, fibromyalgia, spinal cord damage
75 mg BID; max 600 mg/d (decrease dose and increase interval if CrCl < 60 mL/min) SE - Dizziness, somnolence, peripheral edema, weight gain, ataxia, diplopia, blurred vision, xerostomia, mild euphoria |
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Duloxetine
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Cymbalta - Peripheral neuropathic pain, fibromyalgia, chronic musculoskeletal pain
30-60 mg/d Same SEs are SNRIs SE - nausea, dry mouth, somnolence, fatigue, decreased appetite |
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Gabapentin
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Neurontin, Gralise (postherpetic neuralgia), Horizant (postherpetic neuralgia, restless leg syndrome)
300 mg TID; max 3600 mg/d (decrease dose and increase interval if CrCl < 60 mL/min) SE - dizziness, somnolence, ataxia, peripheral edema, weight gain, diplopia, blurred vision, xerostomia ER - take w/ food Used for off-labeled uses |
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Amitriptyline
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Elavil
10-50 mg QHS SE - uncommon w/ low doses; QT prolongation w/ overdose, anticholinergic effects |
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Baclofen
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Lioresal; antispasmotic w/ analgesic effect
5-20 mg TID-QID prn BLACK BOX - avoid abrupt withdrawal SE - sedation, dizziness, confusion DON'T overdose in elderly |
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Cyclobenzaprine
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Flexmid, Amrix ER, Flexeril --- antispasmodic w/ analgesic effect
5-10 mg TID prn; ER - 15-30 mg QD SE - xerostomia Interactions --- don't combine w/ serotonergic agents, may precipitate or exacerbate cardiac arrhythmias |
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Tizanidine
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Zanaflex
MOA - central alpha-1 agonist; antispasmodic w/ analgesic effect 2-4 mg Q6-8 hours prn SE - hypotension, dizziness, xerostomia, weakness |
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Carisoprodol
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Soma --- exert effect by sedation
C IV 250-350 mg QID prn SE - drowsiness, dependence, withdrawal symptoms ** Poor CYP 2C19 metabolizers will have higher carisoprodol conc. |
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Metaxalone
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Skelaxin --- exerts effect by sedation
800 mg TID-QID prn Decreased cognitive/sedative effects Hepatotoxic |
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Methocarbamol
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Robaxin --- exert effect by sedation
1500-2000 mg QID prn SE - hypotension (monitor BP) |
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Muscle Relaxant Interactions
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- Caution w/ concurrent use of CNS depressants
*Tizanidine - CONTRA w/ cipro and fluvoxamine d/t elevated tizanidine levels |
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Muscle Relaxant Patient Counseling
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Will cause drowsiness and fatigue; do not drive while on this medication
Avoid alcohol, sleeping pills, antihistamines, sedatives, pain pills, and tranquilizers except under doctor supervision |
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Naloxone
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Opioid antagonist - used for opioid overdose
0.4-2 mg Q2-3 min or IV infusion at 0.4 mg/hr; repeat dosing may be required WIll cause acute withdrawal syndrome (pain, anxiety, tachypnea) in patients physically dependent on opioids |
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Acute Opioid Overdose S/S
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Somnolence
Respiratory depression w/ shallow breathing Cold and clammy skin Constricted (pinpoint, miosis) pupils Can lead to coma/death |
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Buprenorphine
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Buprenex inj., Butrans patch
Patch - apply to upper outer arm, upper chest, side of chest, upper back Qweekly ---- do not use same site for 3 weeks BLACK BOX (patch) - don't exceed one 20 mcg/hr patch d/t QT prolongation SE - sedation, dizziness, HA, confusion, QT prolongation, respiratory depression Don't expose patch to heat |
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Suboxone
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Buprenorphine + naloxone (tabs and SL film)
Used as alternative to methadone Prescribers must had DATA 2000 waiver to prescribe; DEA number will start w/ X |
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Opioid Drug Interactions
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- Caution w/ concurrent use of CNS depressants
- Increased risk of hypoxemia (resp. depression) w/ underlying respiratory disease and sleep apnea *Methadone - caution w/ serotonergic agents, agents that worsen cardiac function or increase arrhythmia risk *Meperidine - agents that worsen renal function, elderly, seizure hx, serotonergic agents *Tramadol, tapentadol - agents that lower seizure threshold, serotonergic agents, increased INR w/ warfarin NO ALCOHOL!!! |
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Opioid Patient Counseling
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Don't crush, chew, break, or open controlled release forms
NO ALCOHOL!!! Will cause drowsiness/fatigue --- avoid sleeping pills, antihistamines, etc. Take w/ full glass of water; take with food or milk if upset stomach DON'T stop taking suddenly if using >5-7 days Will cause constipation; increase fiber and water intake (stool softener for hard stool; stimulants for scheduled opioid patients) |
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Tramadol
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Ultram, Conzip; 50 mg tabs
1-2 tabs Q4 hours prn, max of 400 mg/d (IR) or 300 mg/d (ER) Reduce in renal impairment; ER contraindicated if CrCl < 30 mL/min SE - dizziness, N/C/HA, ataxia, flushing, insomnia, resp. depression CONTRA - seizure hx, head trauma, 2D6 inhibitors Risk of serotonin syndrome in combo w/ serotonergic agents |
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Ultracet
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Tramadol/APAP
37.5-325 mg |
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Tapentadol
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Nucynta, Nucynta ER
Schedule II IR -- 50-100 mg Q4-6 hours prn; ER -- 50-250 mg BID BLACK BOX - respiratory depression; no alcohol w/ ER form SE - dizziness, drowsiness, nausea --- less GI issues Can cause physiological dependence; risk of serotonin syndrome |
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Codeine
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Schedule II; combos are Schedule III; cough syrups are Schedule V
30 mg Q4-6 hours prn; range 15-120 mg BLACK BOX - respiratory depression (children after tonsillectomy, adenoidectomy) High degree of GI side effects -- constipation, nausea |
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Lorcet, Lortab, Vicodin, Norco
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Hydrocodone/APAP
Schedule III 2.5, 5, 7.5, 10 mg in combo w/ APAP |
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Hydrocodone
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BLACK BOX - respiratory depression, acute or severe bronchial asthma or hypercarbia, suspected of having paralytic ileum
Use lower doses w/ 3A4 inhibitors |
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Zohydro ER
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Hydrocodone ER
Schedule II 10 mg Q12 hours, range of 10-50 mg |
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Meperidine
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Demerol
Schedule II 50-150 mg Q2-4 hours --- short duration of action DON'T use chronically; in elderly patients Warnings --- renal impairment; elderly at risk for CNS toxicity; risk of serotonin syndrome; metabolite is renally cleared (can cause CNS toxicity) |
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Methadone
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Dolophine, Methadose liquid
Schedule II 2.5-10 mg Q8-12 hours; 40 mg is indicated for detox and maintenance tx of opioid-addicted patient BLACK BOX --- QTc interval prolongation; respiratory depression Variable half-life; risk of serotonin syndrome; can decrease testosterone and contribute to sexual dysfunction |
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Oxymorphone
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Opana, Opana ER
Schedule II IR - 5-10 mg prn; ER - 5-30 mg BID; take on EMPTY stomach BLACK BOX - alcohol can accelerate release of Opana ER, causing fatal levels; do not break, crush, chew, or dissolve Opana ER tablets Contra - moderate-to-severe liver impairment Decrease dose in elderly, renal or mild liver impairment |
