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Pain and Opioids
Terms in this set (25)
A 64-year-old male presents with mild to moderate musculoskeletal back pain after playing golf. He states he has tried acetaminophen and that it did not help. His past medical history includes diabetes, hypertension, hyperlipidemia, gastric ulcer (resolved), and coronary artery disease. Which of the following is the most appropriate NSAID regimen to treat this patient's pain?
-Indomethacin and Omeprazole
-Naproxen and Omeprazole
Naproxen and Omeprazole.
This patient is at high risk of future ulcers, due to the history of gastric ulcer. Therefore, using a regimen that includes an agent that is more COX-2 selective or a proton pump inhibitor is warranted. Therefore, D is incorrect. Choices A and B are incorrect because this patient has significant cardiovascular risk and a history of coronary artery disease. Naproxen is thought of as the safest NSAID regarding cardiovascular disease, thought it still can present risks. Therefore, C is correct as it uses the first-choice NSAID with the gastrointestinal protection of a proton pump inhibitor.
A 76-year-old female with renal insufficiency presents to the clinic with severe pain secondary to a compression fracture in the lumbar spine. She reports that the pain has been uncontrolled with tramadol, and it is decided to start treatment with an opioid. Which of the following is the best opioid for this patient?
-Fentanyl transdermal patch
Hydrocodone would be the best choice of the opioid given in this case. It will be very important to use a low dose and monitor closely for proper pain control and any side effects.
Meperidine should not be used for chronic pain, nor should it be used in a patient with renal insufficiency.
The transdermal patch is not a good option, since at this time, her pain would be considered acute and she is opioid-naive.
Morphine also is not the best choice in this case due to the active metabolites that can accumulate in renal insufficiency.
Which of the following statements about fentanyl is correct?
-Fentanyl is 100 times more potent than morphine.
-Its withdrawal symptoms can be relieved by naloxone.
-The active metabolites of fentanyl can cause seizures.
-It is most effective by oral administration.
Fentanyl is 100 times more potent than morphine.
Fentanyl is very selective for the μ (mu) receptor and is a very potent opioid.
Naloxone is an opioid antagonist and can precipitate withdrawal symptoms in patients currently taking opioids.
Meperidine is the opioid whose active metabolite, normeperidine, can cause seizures.
Fentanyl undergoes hepatic first-pass metabolism and is not effective via oral administration.
Due to high lipid solubility, fentanyl has been developed for many routes of administration such as buccal, transmucosal, and transdermal.
A 56-year-old patient who has suffered from severe chronic pain with radiculopathy secondary to spinal stenosis for years presents to the clinic for pain management. Over the years, this patient has failed to receive relief from the neuropathic pain from the radiculopathy with traditional agents such as tricyclics or anticonvulsants. Based on the mechanism of action, which opioid might be beneficial in this patient to treat both nociceptive and neuropathic pain?
Methadone has a unique mechanism of action in comparison to the other choices given. Methadone is a μ (mu) agonist, but it also exhibits NMDA receptor antagonism that is thought to aid in the treatment of neuropathic pain and could also aid in the prevention of opioid tolerance.
All other μ agonists could help manage neuropathic pain, but in some situations, higher doses of opioids are needed to achieve efficacy. It is much better to consider adjuvants such as tricyclics or certain anticonvulsants in the treatment of neuropathic pain.
Which of the following statements regarding methadone is correct?
-Methadone is an excellent choice for analgesia in most patients since there are limited drug-drug interactions.
-The equianalgesic potency of methadone is similar to that of morphine.
-The duration of analgesia for methadone is much shorter than the elimination half-life.
-The active metabolites of methadone accumulate in patients with renal dysfunction.
The duration of analgesia for methadone is much shorter than the elimination half-life.
The duration of analgesia is much shorter than the elimination half-life, leading to dangers of accumulation and increased potential for respiratory depression and death.
Methadone's equianalgesic potency is extremely variable based on many factors, and it is highly recommended that only prescribers very familiar with methadone should prescribe this agent.
The drug interactions associated with methadone are numerous due to the multiple enzymes in the liver that metabolize this drug.
Methadone does not have active metabolites, which does make it an option in patients with renal dysfunction.
Your ten-year-old son is running a fever of 101°F after developing a cold. To help him feel better you go to the local pharmacy to purchase a fever-lowering medication.
You recall that there are warnings about the risk of drug-induced Reye's syndrome in children given the wrong type of NSAID. Which NSAID is associated with this potentially serious condition?
Aspirin is associated with Reye's syndrome. The initial classic features of Reye's syndrome include the development of a rash, vomiting, and signs of liver damage. It can eventually result in severe brain injury and death. The exact cause is unknown but appears to involve mitochondrial damage (at least in the liver). It most commonly occurs in patients younger than 19 years of age who take aspirin while suffering from a viral disease. It is extremely rare in adults. Other antipyretics, such as acetaminophen or ibuprofen, are recommended for fever reduction in children and adolescents.
John is a 63-year-old alcoholic with a 5-year history of ulcers. Recently when self-medicating for a back condition, John consumed 5 times the recommended daily dose of an over-the-counter pain reliever. Soon afterwards John developed a severe episode of nausea and vomiting. Twelve hours later, his wife brings him to the local emergency department. After quizzing John about the medication he took, the ER physician draws blood samples for drug analysis and administers N-acetyl cysteine (Mucomyst) 140 mg/kg orally to prevent further toxicity. What analgesic did John most likely take to cause this problem?
Highly selective COX-2 inhibitors are anti-inflammatory drugs with fewer gastrointestinal side effects compared to traditional non-selective COX inhibitors, such as aspirin. What other effect do COX-2 inhibitors lack, in contrast to aspirin?
KM is a 64-year-old male who has been hospitalized following a car accident in which he sustained a broken arm and leg. He has been converted to oral morphine for discharge. What other medications should be prescribed?
-Docusate with senna
Docusate with senna.
A bowel regimen should be prescribed with the initiation of the opioid. Docusate and senna include both a stool softener and a stimulant laxative which is recommended for opioid-induced constipation. Constipation is common with opioids and tolerance does not occur.
An 8-year-old girl has a fever and muscle aches from a presumptive viral infection. Which one of the following drugs would be most appropriate to treat her symptoms?
Aspirin should be avoided in children because of an association with Reye's syndrome.
Indomethacin has antipyretic properties but is too toxic for use in these circumstances.
Celecoxib is indicated for the alleviation of pain, and codeine has no antipyretic effects.
For which of the following conditions would aspirin be contraindicated?
Among NSAID anti-inflammatory drugs, aspirin is one of the worst for causing gastric irritation. All other indications listed are appropriate uses for aspirin.
A patient presents with a knee injury from a football game. There is no apparent swelling, and the patient prefers an oral analgesic over a topical product. Which of the following is the best choice for systemic analgesia for this patient?
If tolerance occurs in a patient who is receiving long-term opioid therapy, this means that:
-The patient has become addicted and should be referred to a drug treatment program.
-The patient has lost control over his or her use of the medication, and treatment should be discontinued.
-The patient is having a normal physiological response to the medication and will experience a withdrawal syndrome if the medication is stopped or quickly decreased.
-The patient has become tolerant to the drug, and another therapeutic category must be selected.
-The dose may need to be increased to achieve pain relief.
The dose may need to be increased to achieve pain relief.
Mrs. Jones is a 78-year-old woman with a history of diabetes, treated with oral medications. Recently, she has been complaining of pain in her feet that she describes as "numbness and tingling."
What is the most likely pathophysiologic type of pain in this case?
A patient is requesting an opiate for chronic, nonmalignant pain. Which of the following is the most appropriate response?
-Morphine IR (immediate release) is the gold standard.
-Opioids should always be avoided in chronic pain situations.
-Limited evidence exists for long-term opioid treatment for chronic pain.
-A mixed agonist/antagonist may be preferred.
-A short-acting opioid may be preferred.
Limited evidence exists for long-term opioid treatment for chronic pain.
FG is a 65-year-old man with lower back pain. He complains of numbness and electric shock-like pain localized to his lumbar region. Which of the following would be the most appropriate initial treatment for his type of pain?
-Lidocaine transdermal patch
Lidocaine transdermal patch.
RS is a 62-year-old investment banker who had been suffering from chronic low back pain for the past 2 months subsequent to a motor vehicle accident. He has been evaluated, and no pathology is noted. He is trying to adhere to a prescribed exercise plan but is limited by pain. You prescribed morphine 5 to 10 mg orally every 4 hours, which provided good relief but caused itching. RS says a total daily dose of about 45 mg of oral morphine provides good pain control.
What dose of oxycodone that will provide equivalent pain control should you prescribe?
P.S. is a 62-year-old man with tetraplegia due to a motor vehicle accident 20 years ago. He complains of intense left flank pain due to hydronephrosis of the left kidney. He rates the pain as 7 or 8 on a scale of 1 to 10 and describes it as constant. He is not a surgical candidate for the removal of the diseased kidney.
Which of the following would be the best recommendation for the treatment of P.S.'s visceral pain?
You consider switching the tramadol to a full opioid agonist for this patient to manage his pain. What does the evidence reveal about opioid therapy for the treatment of chronic pain?
-Not well supported by the evidence
-Only effective for low back pain and headache
-None of the above
Not well supported by the evidence.
The benefits of long-term opioid therapy for chronic pain are NOT well supported by evidence. Short-term benefits are small to moderate for pain; inconsistent for function. There is insufficient evidence for long-term benefits in low back pain, headache, and fibromyalgia.
Nevertheless, you consider switching the tramadol to a full opioid agonist for this patient to manage his pain, given he is not ready for surgery at this point. What are the steps when starting opioid therapy?
-Set realistic goals for pain and function based on the diagnosis (physical activity or continue to work).
-Discuss benefits and risks (addiction and overdose) of opioid therapy with the patient.
-Evaluate for risk of harm or misuse of opioids before prescribing opioids.
-All of the above
All of the above.
The CDC has multiple resources available to help practitioners safely prescribe opioids for chronic pain. One resource if the "checklist" for prescribing opioids for chronic pain available at CDC website. Based on this resource, all of the above would be the correct answer.
To check for risk of harm or misuse, risk factors (e.g., use of alcohol, family history of addiction) should be evaluated, you should check the Prescription Drug Monitoring Program to determine whether he has recently received opioids, and a urine toxicology can be checked at baseline and periodically.
Another important step in evaluating a patient before prescribing opioid therapy for chronic pain is to verify that all non-opioid modalities have been tired and optimized, yet the patient is still experiencing significant pain. Do you believe this patient has exhausted all non-opioid options at this point?
-Need more information
Yes. With the exception of surgery (which is invasive and he is currently not prepared for), he has tried numerous non-opioid medications (e.g., naproxen, celecoxib, and tramadol), as well as, procedures such as intra-articular injections with steroid and hyaluronic acid. He has also lost weight and continues to report exercising.Non-opioid medications, physical treatments, behavioral therapies (e.g., CBT) and the use of procedures are all non-opioid therapies that should be tried and maximized before treatment with an opioid is considered.
In addition to assessing the patient's baseline pain and function using a validated scale, such as the PEG scale, what other actions will you take?
-Schedule a follow-up appointment with the patient 6 months after the opioid is started.
-Explain that as long as the medication is taken as directed, the patient will never develop an addiction.
-Prescribe a long-acting opioid such as OxyContin or MS Contin.
-Review an opioid agreement with the patient that includes criteria for continuing opioids, as well as, stopping opioids if no benefit is realized.
Review an opioid agreement with the patient that includes criteria for continuing opioids, as well as, stopping opioids if no benefit is realized.
An initial reassessment should be done within a month of the opioid prescribing. It is not true that addiction only develops with misuse. A short-acting opioid at the lowest effective dosage should be prescribed before using a long-acting agent. Opioid agreements are meant to ensure patients understand their role and responsibilities regarding their treatment the conditions under which their treatment may be terminated, and the responsibilities of the health care provider are recommended for patients on opioids for chronic pain.
See this resource at www.drugabuse.gov for more information.
He has normal renal and hepatic function. Which opioid medication would you choose for him?
Given the amount of tramadol he has been using morphine would be the best option of the choices listed. Hydromorphone is potent. Fentanyl is potent and is a long-acting opioid used for opioid-tolerant patients. Codeine is generally a poor opioid analgesic choice given interpatient variation in drug metabolism.
You decide to prescribe morphine for your patient. What dose and frequency should you prescribe?
HINT: Consider the amount of tramadol has was previously receiving.
-5 mg PO q4 to 6 hours PRN.
-10 mg PO q4 to 6 hours PRN.
-20 mg PO q4 to 6 hours PRN.
-30 mg PO q4 to 6 hours PRN.
5 mg PO q4 to 6 hours PRN..
Conversion math: Tramadol 300 mg PO equals oxycodone 50 mg equals morphine 75 mg. But you should decrease the total daily dose of opioids by 25% for cross-tolerance, resulting in oxycodone 5 mg PO Q4-6H PRN.
How would you manage constipation that will likely occur with the use of chronic opioids?
-Senna + Docusate
The morphine will cause slowed GI motility due to the binding of mu receptors in the GI tract, thus senna (a stimulant laxative) will be required. Some patients, who complain of hard stools despite a stimulant laxative, may also benefit from the addition of docusate. Docusate alone will likely be ineffective.
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