Therapeutics Iii Exam 3 - Cancer Pain Management Questions

Front 1

Describe somatic pain.

Back 1

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.

Front 2

What is the most common cause of somatic pain in cancer patients?

Back 2

bone metastasis

Front 3

Describe visceral pain.

Back 3

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.

Front 4

What are some examples of visceral pain?

Back 4

passing a renal stone
pancreatic cancer
small bowel obstruction
pleuritis

Front 5

Describe neuropathic pain.

Back 5

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.

Front 6

What type of pain is most difficult to treat?

Back 6

Neuropathic because it is resistant to opioids

Front 7

What is given to patients who are considered in step 1 of the analgesic ladder?

Back 7

NSAIDs

Front 8

What is given to patients who are considered in step 2 of the analgesic ladder?

Back 8

an opioid for mild/moderate pain such as tramadol or codeine

Front 9

What is given to patients who are considered in step 3 of the analgesic ladder?

Back 9

an opioid for moderate/severe pain such as morphine or fentanyl

Front 10

Give dose, interval, route, and maximum dose for acetaminophen.

Back 10

Dose: 500-1000 mg
Interval: q4-6h
Route: PO/PR
Maximum: 4000 mg

Front 11

Give dose, interval, route, and maximum dose for ibuprofen.

Back 11

Dose: 200-600 mg
Interval: q4-6h
Route: PO
Daily maximum: 2400 mg

Front 12

Give dose, interval, route, and maximum dose for naproxen.

Back 12

Dose: 250 mg
Interval: q6-8h
Route: PO
Daily maximum: 1250 mg

Front 13

What are the advantages to opioid therapy?

Back 13

1. safe
2. reliable
3. multiple routes of administration
4. ease of titration

Front 14

What is pseudoaddiction?

Back 14

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.

Front 15

What is the advantage of using tramadol over opioids?

Back 15

It is less likely to cause respiratory depression and constipation.

Front 16

What condition is necessary before using fentanyl?

Back 16

The patient must be opioid tolerant. Fentanyl is used every 48-72 hours and begins working in 12-14 hours.

Front 17

What are the major prinicples of therapy in the patient with mild pain?

Back 17

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

Front 18

What are the major principles of therapy in the patient with mild/moderate pain?

Back 18

When using opioids, prevent constipation with a GI stimulant like Senna or bisacodyl

Front 19

What are the major principles of therapy in the patient with moderate/severe pain?

Back 19

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.

Front 20

What opioids must you avoid in the presence of renal failure?

Back 20

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.

Front 21

What drugs are innapropriate for chronic use in dealing with pain?

Back 21

propoxyphene, partial opioid receptor agonists (buprenorphine and dezocine), agonists/antagonists (pentazocine, nalbuphine, and butorphanol)

Front 22

Describe how you would initiate opioid pain therapy.

Back 22

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)

Front 23

Describe increaing opioid doses.

Back 23

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.

Front 24

Describe dosing decreases with opioids.

Back 24

Rapid discontinuation can cause withdrawal. Reducing dosing increments of less than 25 percent per week prevents withdrawal.

Front 25

Equianalgesic opioid dosages

Back 25

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

Front 26

How do you convert IV to transdermal fentanyl?

Back 26

It is done on a 1:1 basis

Front 27

Describe incomplete cross tolerance.

Back 27

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.

Front 28

Kadian pharmacokinetics

Back 28

Morphine SR
extended release

Front 29

Avanzia pharmacokinetics

Back 29

Morphine ER
biphasics release (IR and ER)
Q24hr

Front 30

MS Contin pharmacokinetics

Back 30

Morphine CR
extended release

Front 31

MSIR pharmacokinetics

Back 31

Morphine
immediate release

Front 32

Oxycontin pharmacokinetics

Back 32

Oxycodone CR
Biphasic release (IR 38%, CR 62%)
Q12hr although q8hr is common

Front 33

Which groups of medications can be used as adjuvant analgesic therapy?

Back 33

Antidepressants, anticonvulsants, and sedatives.

Front 34

Which antidepressants are used as analgesic adjuvants and how are they helpful?

Back 34

Tricyclics are most helpful in neuropathic pain. Trazodone and SSRIs may be useful in cancer patients who are clinically depressed.

Front 35

When are sedatives used for cancer patients?

Back 35

They are especially helpful to patients and families when patients are in pain near death.

Front 36

What are the 3 approaches to treating adverse effects from opioids?

Back 36

1. Dose reduction
2. Changing to a different opioid or route of adminstration.
3. Symptomatic management

Front 37

What would you use for nausea after a meal?

Back 37

Metoclopromide

Front 38

What would you use for nausea after movement?

Back 38

Meclizine

Front 39

What would you use for unassociated nausea?

Back 39

Phenothiazines, antihistamines, benzodiazepines

Front 40

What would you initially use for opioid constipation?

Back 40

Dulcolax, Senna, docusate, stimulant laxatives

Front 41

How would you treat constipation that develops despite prophylaxis?

Back 41

1. Rule out obstruction
2. Begin osmotic laxative: lactulose, PEG, magnesium citrate

Front 42

What is methylnaltrexone?

Back 42

It is an opioid antagonist that treats opioid induced constipation and doesn't cross the blood brain barrier.

Front 43

How would you reverse an opiate?

Back 43

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.