6/3/2015
Thanks to our Supporters
“Know Pain, Know Gain” Pharmacy
Patient Pain Counseling Competition
Offered by the Maryland Pharmacists
Association as part of the Annual
Conference
Sponsored by an educational grant by NASPA and Purdue Pharma, L.P.
Come Participate in the Competition
• Come pick up a raffle
ticket to compete
• 12 contestants will be
selected from the raffle
tickets to compete for a
$500 prize
Pain management is an important topic
Pain management is an important topic that pharmacists and student
pharmacists are often faced with while practicing. Often, these patients
present unique challenges to providers. It is important to review key pain
management concepts and counseling techniques in order to optimize your
patient’s treatment plan. The “Know Pain, Know Gain” Pharmacy Patient
Pain Counseling Competition will increase pharmacist awareness and
involvement in patient care opportunities involving pain management.
At the end of this presentation, participants should be able to:
1. Identify common medications and treatments used in pain management
2. Illustrate main counseling points and strategies for patients with pain
3. Describe common barriers for providing optimal pain management
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Copyright Statement
Contestant Selection....
Copyright © 2013-2014 by National Alliance of State Pharmacy Associations All
rights reserved. No part of this activity may be reproduced or transmitted in
any form or by any means, electronic or mechanical, without first obtaining
permission from National Alliance of State Pharmacy Associations.
COMPETITION FORMAT BRIEF OVERVIEW
Rapid Fire Question Elimination Round
• 12 contestants will be drawn from a raffle to
participate to compete
• Contestants will participate in an exciting
rapid-fire Q&A Session
• 3 finalists will compete by counseling a sample
patient for a chance at a $500 Prize!
• Counseling graded by a Patient Counseling
Competition Evaluation Form
• Each contestant will be asked a question by the
Moderator and have 10 seconds to provide an
answer
• They may ask for a repeat of the question but it
will not delay the 10 seconds they have to answer
unless told by the Moderator
• Should the contestant miss the question, the same
question will be redirected to the next contestant
in line and so forth until the question is answered
correctly. At this point, all contestants who missed
the question will be eliminated.
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Rapid Fire Question Elimination Round
• If the question should not be answered by all
contestants, then all contestants stay eligible
and a new question will be asked of the first
contestant
• We will review answers to questions with the
audience so all can benefit
Rapid Fire Question Elimination Round
Let’s Begin!
Easy Rapid Fire Question # 1
RAPID FIRE QUESTIONSEASY DIFFICULTY
• What is the amount of codeine in a Tylenol #4
tablet?
– Answer: 60mg
– Rationale: Could be easily confused with Tylenol
#3, which has 30mg of codeine.
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Easy Rapid Fire Question # 2
• What drug is used for opioid reversal?
– Answer: Naloxone (Narcan)
– Rationale: Naloxone is a μ-opioid receptor
competitive antagonist, and its rapid blockade of
those receptors often produces rapid onset of
withdrawal symptoms. Naloxone also has an
antagonist action, though with a lower affinity, at
κ- and δ-opioid receptors. Naloxone is a drug used
to counter the effects of opiate overdose
Easy Rapid Fire Question # 4
• How do NSAIDS inhibit the production of
prostaglandins?
– Answer: inhibiting COX1 and COX 2 enzymes.
– Rationale: Prostaglandins from the COX1 pathway can
increase GI blood flow, mucus, bicarbonate production
and epithelial growth. NSAIDs inhibiting COX1 enzyme
are increasing risk of bleeding by stopping production
of these prostaglandins. The COX 2 pathway produces
prostaglandins that increase inflammation, and pain.
Inhibiting COX 2 decreases pain and inflammation.
Risk for GI bleed increases in pts who use NSAIDs, vs
those who do not.
Easy Rapid Fire Question # 3
• After 2014 prescription combo analgesics will be
limited to how many milligrams of
acetaminophen per tablet or capsule?
– Answer: 325mg
– Rationale: The Food and Drug Administration (FDA) is
taking steps to reduce the maximum dosage unit
strength of acetaminophen in prescription drug
products. This change will provide an increased
margin of safety to help prevent liver damage due to
acetaminophen overdosing, a serious public health
problem.
Easy Rapid Fire Question # 5
• What compound can be applied topically that
is derived from chili peppers?
– Answer: Capsaicin cream
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Easy Rapid Fire Question # 6
• What is a side effect of opioids that is often
confused with an allergic reaction?
– Answer: Itching/flushing/sweating/
– Rationale: Codeine causes a histamine release
that is a “pseudoallergy” and non immunologic.
This can happen with the 1st exposure to the
drug, whereas in a true allergy, an initial exposure
would have had to happen. Important in choosing
pain therapy.
Easy Rapid Fire Question # 8
• Which 2 medications are in Vicoprofen®?
– Answer: Hydrocodone and Ibuprofen
Easy Rapid Fire Question # 7
• What is a non-pharmacologic treatment for
back pain that only involves placement of
needles?
– Answer: Acupuncture.
– Rationale: This is a possible treatment option for
patients with chronic low back pain.
Easy Rapid Fire Question # 9
• When you Increase the dosage of opioids in order to
achieve the same analgesic effect is it called
tolerance, addiction, or physical dependence?
– Answer: Tolerance
– Rationale: Tolerance is the process whereby
neuroadaptation occurs (through receptor desensitization)
resulting in reduced drug effects. Addiction is chronic,
neurobiologic disease characterized by behaviors such as:
impairment in control over substance use, compulsive
substance use, continued substance use despite harm, and
substance craving. Physical Dependence is when a patient
abruptly stops a medication or is given an antagonist
which causes physical withdrawal symptoms.
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Easy Rapid Fire Question # 10
• Which medication class is recommended for
moderate to severe osteoarthritis pain?
Easy Rapid Fire Question # 11
• Name a topical NSAID gel?
– Answer: diclofenac gel (Voltaren®)
– Answer: NSAIDs
– Rationale: American College of Rheumatology
recommends NSAIDs for moderate to severe pain
but acetaminophen for mild to moderate pain.
Easy Rapid Fire Question # 12
• What illegal substance can be made from
Sudafed® and is responsible for the increased
restrictions on obtaining pseudoephedrine
products?
– Answer: Methamphetamine
Easy Rapid Fire Question # 13
• According to WHO pain guidelines which
medications would be appropriate to use in
mild to moderate pain?
– Answer: acetaminophen (Tylenol) OR nonsteroidal
anti-inflammatory drugs (ibuprofen, naproxen,
meloxicam, diclofenac, sulindac, etc)
– Rationale: These substances adequately treat this
level of pain and can offer a better addiction
profile than opioids or better safety profile than
other drugs used to treat pain
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Easy Rapid Fire Question # 14
• What is the FDA maximum number of days or
hours that a patient can wear a fentanyl
patch?
– Answer: 3 days (72 hours)
Easy Rapid Fire Question # 16
• Which NSAID has no clinical effect on platelet
function?
– Answer: Celecoxib
– Rationale: Celecoxib due to its affinity for COX-II
sites has less binding affinity to platelets which
have more COX-I sites.
Easy Rapid Fire Question # 15
• What is the antidote to acetaminophen
overdose?
– Answer: Mucomyst (acetylcysteine)
– Rationale: Acetylcysteine effectively prevents
hepatic damage after toxic ingestion of
acetaminophen by substituting for glutathione and
by its availability as a precursor of glutathione.
Easy Rapid Fire Question # 17
• Which patch approved by the FDA for
analgesia is changed once per week?
– Answer: Buprenorphine patch is changed once per
week
– Rationale: The lidocaine patch is applied for 12
hours then removed for 12 hours, the capsaicin
patch is applied for one hour then removed, the
clonidine patch is applied once per week but only
FDA approved for hypertension.
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Easy Rapid Fire Question # 18
• Actiq is the buccal formulation of which
medication?
– Answer: Fentanyl
– Rationale: Actiq is a fentanyl lozenge for
transmucosal (buccal) use. A buccal fentanyl tablet
(Fentora) is also available.
Easy Rapid Fire Question # 20
• Name an opioid that is commercially available
as a suppository?
– Answer: Morphine or Hydromorphone
Easy Rapid Fire Question # 19
• Patients will not develop tolerance to which
opioid side effect?
– Answer: Constipation
– Rationale: They will develop tolerance over time
to all the other side effects such as nausea,
respiratory depression or sedation. Therefore,
bowel regimens are important for patients with
both acute and chronic opioid exposure
Easy Rapid Fire Question # 21
• Oxymorphone is in what schedule of
controlled drugs?
– Answer: 2
– Rationale: Oxymorphone is a schedule 2
controlled substance meaning there can be no
telephone prescriptions and no refills.
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Easy Rapid Fire Question # 22
• Which three organ systems are potentially
adversely affected by NSAIDs requiring caution
with chronic use?
– Answer: renal, cardiac, and GI
Easy Rapid Fire Question # 24
• True or False. Morphine dosages should be
reduced in patients with renal failure.
– Answer: True
– Rationale: Glucuronide metabolites may
accumulate in patients receiving morphine with
renal failure, and therefore, dose reduction or use
of an alternate agent is recommended.
Easy Rapid Fire Question # 23
• Which pain assessment tool is most appropriate
to use to assess pain in a 3 year-old child?
– Answer: “Faces” scale (Wong-Baker).
– Rationale: Generally, this type of scale shows 5 or 6
simple cartoon faces beginning with an emotionally
neutral expression on the left, progressing to a very
distressed and grimacing face on the right. As with
visual analog scales, the child is asked which face best
represents how much pain s/he feels.
Easy Rapid Fire Question #25
• Which NSAID should be avoided in a patient
with a sulfonamide allergy?
– Answer: Celecoxib.
– Rationale: Celecoxib is a nonarylamine
benzenesulfonamide derivative and does not
contain a heterocyclic ring attached to the
sulfonamide-N1 position, nor does it contain an
N4 aromatic amine group.
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Easy Rapid Fire Question # 26
Easy Rapid Fire Question # 27
• Meloxicam (Mobic) is available in what two
strengths of tablets?
• Name the three primary opioid receptors?
– Answer: Mu, Kappa, Delta.
– Answer: 7.5 mg and 15 mg
– Rationale: Meloxicam is available as 7.5 mg and
15 mg tablets, as well as a 7.5mg/5ml suspension.
Easy Rapid Fire Question # 28
• Which class of drugs is most effective for the
prevention of NSAID-induced gastric ulcers?
– Answer: Proton Pump Inhibitors (PPIs).
– Rationale: Proton Pump Inhibitors (PPIs) are the preferred
agents…however, currently, misoprostol is the only
gastroprotective agent proven to decrease risk of clinical
GI events (MUCOSA study), but this was at the expense of
significant increases in nausea, diarrhea and abdominal
pain. Otherwise, misoprostol, double-dose H2 blockers,
and PPIs are all associated with significant reductions in
risks of endoscopic gastric and duodenal ulcers when
added to nonselective NSAIDs relative to nonselective
NSAID-use alone in short-term randomized controlled
trials (RCTs)
Easy Rapid Fire Question # 29
• Which type of pain is commonly described as
being burning or electric-like pain?
– Answer: Neuropathic pain.
– Rationale: Neuropathic pain is defined as pain
due to damaged or dysfunctional nerves. It tends
to worsen after mechanical stimulation. Nerves
can become hyperactive (especially in the case of
amputees). 'Pins and needles'; 'cotton-glove
feeling'; 'tingling' are all common patient
complaints / descriptors.
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Easy Rapid Fire Question # 30
• Which opioid analgesic is available in IV,
transdermal, and transmucosal preparations?
– Answer: Fentanyl.
Easy Rapid Fire Question # 32
• Which commercially available opioid analgesic
is converted to morphine?
– Answer: Codeine.
– Rationale: Basic pharmacy knowledge. Heroin is
also converted to morphine.
Easy Rapid Fire Question # 31
• Identify two NSAIDs that are available as
intravenous preparations?
– Answer: Ketorolac(Toradol®) and
ibuprofen(Caldolor®).
Easy Rapid Fire Question # 33
• What is the generic name for Kadian®?
– Answer: Morphine.
– Rationale: Kadian® = morphine sustained release
capsules (dosed once daily or divided BID, vs.
AVINZA® = morphine extended release capsules,
dosed once daily).
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Easy Rapid Fire Question # 34
• What is the brand name of the drug used to
treat opioid addiction that is available as a
sublingual tablet or film?
– Answer: Suboxone® or Subutex®.
Easy Rapid Fire Question # 36
• Which SNRI has been FDA-approved for the
treatment of diabetic neuropathy?
– Answer: Duloxetine (Cymbalta®).
Easy Rapid Fire Question # 35
• What must be accounted for when switching a
patient from one opioid analgesic to another in
terms of dosing the new opiod agent?
– Answer: Equianalgesic dosing and incomplete crosstolerance (the patient may be more sensitive to the
new opioid because of differences in chemical
structure and receptor activity).
– Rationale: Equianalgesic dosing and incomplete crosstolerance are two of the main considerations when
looking to switch a patient between opioid regimens.
The patient may be more sensitive to the new opioid
because of differences in chemical structure and
receptor activity.
Easy Rapid Fire Question # 37
• Which anticonvulsant is the drug of choice to
treat trigeminal neuralgia?
– Answer: Carbamazepine (Tegretol®).
– Rationale: Carbamazepine is the first line drug;
second line drugs include baclofen, lamotrigine,
oxcarbazepine, phenytoin, gabapentin, and
sodium valproate.
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Easy Rapid Fire Question # 38
• Which opioid analgesic with a long half-life has been
associated with Torsades de Pointe?
– Answer: Methadone.
– Rationale: Methadone may prolong the rate-corrected QT
interval (QTc) and result in torsade de pointes. This
association recently came into focus when the U.S. Food
and Drug Administration (FDA) issued a physician safety
alert regarding increasing deaths and cardiac arrhythmias,
which was followed by a manufacturer's black box
warning. It is recommended to have baseline EKG
screening and to recommend routine EKG monitoring
(especially if other QTc-prolonging medications are being
considered for concomitant therapy).
Easy Rapid Fire Question # 40
• Pregabalin (Lyrica) is FDA approved for 4
indications. Name 2 of them.
– Answer: fibromyalgia, postherpetic neuralgia,
peripheral neuropathy, partial onset seizures
– Rationale: Pregabalin is FDA approved for:
fibromyalgia, postherpetic neuralgia, peripheral
neuropathy, and adjunctive therapy for partial
onset seizures (adults)
Easy Rapid Fire Question # 39
• Name 3 drugs used for the treatment of muscle
spasms?
– Answer: Any of the following would be correct:
carisoprodol (Soma®), chlorphenesin (Maolate®),
chlorzoxazone (Parafon Forte®), cyclobenzaprine
(Flexeril®), diazepam (Valium®), lorazepam (Ativan),
methocarbamol (Robaxin®), orphenadrine (Norflex®),
clonazepam (Klonopin®), dantrolene (Dantrium®),
tizanidine (Zanaflex®), baclofen (Lioresal®), and botulinum
toxin (BoTox®).
Easy Rapid Fire Question # 41
• True or False: Lidoderm patches may be cut
into smaller pieces.
– Answer: True
– Rationale: Lidoderm patches may be cut (with
scissors, prior to removal of release liner) to
appropriate size.
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Easy Rapid Fire Question # 42
• Which of the following medications is the
most hydrophillic? Morphine, methadone or
fentanyl.
– Answer: morphine
– Rationale: morphine (hydrophilic), while
methadone and fentanyl are very lipophillic.
Easy Rapid Fire Question # 44
• What is the active ingredient in most over the
counter liquid tooth pain remedies such as
Orajel?
Easy Rapid Fire Question # 43
• What is the active ingredient in the over-thecounter pain product, Ben Gay?
– Answer: menthol (camphor may also be
acceptable as it exudes counter irritant properties)
Easy Rapid Fire Question #45
• Which NSAID that is currently on the market
in the US is selective to inhibit only COX-2?
– Answer: Celebrex® – Celecoxib
– Answer: benzocaine
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Easy Rapid Fire Question #46
• What counseling point must be made when
discussing tizanidine?
– Answer: decrease BP
– Rationale: tizanidine is a central alpha-2
adrenergic agonist, as is clonidine and can
decrease BP, especially as the dose increases
Easy Rapid Fire Question #48
• Methadone at doses above 100mg/day is
associated with which cardiac adverse effect?
– Answer: QT prolongation
– Rationale: methadone at dose greater than
100mg/day can cause QT prolongation; recent
guidelines suggest EKG before initiating
methadone and at doses greater than 100mg/d
Easy Rapid Fire Question #47
• Which agent has analgesic and fever reducing
capacity, but no anti-inflammatory activity?
– Answer: acetaminophen
Easy Rapid Fire Question #49
• If oral ketoconazole is added to methadone
therapy, what must be monitored for?
– Answer: QT prolongation
– Rationale: Ketoconazole inhibits CYT P450 3A4
enzyme, methadone is metabolized by YT P450
3A4 enzyme
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Easy Rapid Fire Question #50
• If carbamazepine is added to oxycodone
therapy, what may you expect?
– Answer: decreased oxycodone effectiveness
– Rationale: Carbamazepine induces CYT P450 3A4
enzyme, oxycodone is metabolized by CYT P450
3A4
Easy Rapid Fire Question #52
• The NSAID that has been shown to have the
highest risk cardiovascular safety profile
– Answer: diclofenac
– Rationale: Per a recent article Ray, WA. . Editorial:
Cardiovascular safety of NSAIDs. . BMJ 2011;
342:c6618 doi: 10.1136/bmj.c6618 (Published 11
January 2011 has shown that diclofenac has the
highest cardiovascular risk profile
Easy Rapid Fire Question #51
• The NSAID that has been shown to have the
best cardiovascular safety profile
– Answer: Naproxen
– Rationale: Per a recent article Ray, WA. . Editorial:
Cardiovascular safety of NSAIDs. . BMJ 2011;
342:c6618 doi: 10.1136/bmj.c6618 (Published 11
January 2011has shown that Naprosyn has the
lowest over all cardiovascular risk
Easy Rapid Fire Question #53
• A product that consists of oxycodone and
ibuprofen is?
– Answer: Combunox
– Rationale: This combination has oxycodone 5mg
and ibuprofen 400mg
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Easy Rapid Fire Question #54
• What is the name of a central repository program to
track and store controlled prescription records for
use by licensed health care professionals or
authorized law enforcement?
– Answer: Prescription monitoring program (PMP) or
Prescription drug monitoring program (PDMP)
– Source: Alliance of States with Prescription Monitoring
Programs. Prescription Monitoring Frequently Asked
Questions (FAQ).
http://www.pmpalliance.org/content/prescriptionmonitoring-frequently-asked-questions-faq. Accessed July
18, 2013
Easy Rapid Fire Question #56
• Which of the following opioids has the longest
duration of analgesic effect?
A. methadone
B. controlled-release morphine
C. hydromorphone
D. transdermal fentanyl
Easy Rapid Fire Question #55
• What is the colchicine regimen for treatment
of an acute gouty attack in an adult?
– Answer: 1.2mg at first sign of flare, followed by
0.6mg 1 hour later
– Rationale: Labeled adult dosing
Easy Rapid Fire Question #57
• Ultracet tablets contain which two
medications?
– Answer: Tramadol and acetaminophen
– Answer: D: transdermal fentanyl
– Rationale: Transdermal fentanyl provides
analgesia for up to 72 hours. The analgesic
effects of methadone do not correlate with its
longer half-life.
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Easy Rapid Fire Question #58
• What is the initial daily dose of pregabalin
(Lyrica) for fibromyalgia?
– Answer: 150mg/day
– Rationale: Patients are started on 150mg daily
divided in two doses. The max daily dose for
fibromyalgia is 450mg/day.
Easy Rapid Fire Question #60
• Define the two parties typically involved in a pain or
opioid contract.
– Answer: A pain or opioid contract is an agreement
between the prescriber of pain medications and the
patient using pain medications.
– Rationale: A pain contract has four components: 1.) the
terms and conditions of the contract are stated including
consequences for breaching the contract 2.) the prescriber
and patient are willing and able to negotiate terms of the
contract 3.) the prescriber/patient relationship is
consensual, not obligatory 4.) both the prescriber and the
patient have individual responsibilities.
Easy Rapid Fire Question #59
• True or False. Multimodal analgesics, by
definition, must have different mechanisms of
action.
– Answer: True
– Rationale: Multimodal pain management is
defined as the administration of two or more
medications that act by different mechanisms to
provide analgesia. The medications can be
administered via the same or different routes.
Easy Rapid Fire Question #61
• What schedule of controlled substances is
pregabalin (Lyrica) in?
– Answer: Schedule V medication
– Rationale: Potential for abuse that is less than the drugs in
Schedule IV.
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Easy Rapid Fire Question #62
Easy Rapid Fire Question #63
• Chronic pain affects four times the number of
Americans compared to diabetes. True or
False?
• Which type of laxative may lead to fecal
impaction and should not be used to prevent
opioid-induced constipation?
– Answer: True
– Rationale: 100 million Americans suffer from
chronic pain compared to 25.8 million Americans
who suffer from diabetes.
– Answer: bulk-forming laxatives (e.g., psyllium,
methylcellulose, polycarbophil, wheat dextrin)
– Rationale: Clinical Practice Guideline: VA/DoD
Clinical Practice Guideline for Management of
Opioid Therapy for Chronic Pain. May 2010.
http://www.healthquality.va.gov/COT_312_Fuller.pdf. Accessed September 23, 2013.
Easy Rapid Fire Question #64
Easy Rapid Fire Question #65
• Which non-opioid analgesic is considered firstline therapy by the American Geriatrics
Society to treat mild to moderate
osteoarthritis pain?
• Which anticonvulsant is approved by the FDA
for the treatment of fibromyalgia and diabetic
peripheral neuropathy?
– Answer: acetaminophen
– Rationale: American Geriatrics Society Panel on
the Pharmacological Management of Persistent
Pain in Older Persons. Pharmacological
Management of Persistent Pain in Older Persons. J
Am Geriatr Soc. 2009;57:1331-1346.
– Answer: pregabalin
– Rationale: Lyrica [package insert]. Pfizer, Inc., New
York, NY; June 2013.
http://labeling.pfizer.com/ShowLabeling.aspx?id=
561.
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Easy Rapid Fire Question #66
• Which medication is used in combination with
an NSAID for the treatment of an acute gouty
attack?
– Answer: Colchicine
– Rationale: Khanna D, Khanna PP, Fitzgerald JD, et
al. 2012 American College of Rheumatology
Guidelines for Management of Gout Part. 2:
Therapy and Antiinflammatory Prophylaxis of
Acute Gouty Arthritis. ACR 2012;64:1447-1461.
Easy Rapid Fire Question #68
• Milnacipran is associated with which Boxed
Warning?
– Answer: Increased risk of suicidal thinking and
behavior in children, adolescents, and young
adults
– Rationale: Savella [package insert]. Forest
Pharmaceuticals, Inc., New York, NY;December
2009. http://www.frx.com/pi/Savella_pi.pdf.
Easy Rapid Fire Question #67
• Which opioid analgesic is metabolized to
hydromorphone?
– Answer: hydrocodone
– Rationale: basic pharmacology knowledge
Easy Rapid Fire Question #69
• Which two skeletal muscle relaxants are
usually reserved for the treatment of
spasticity?
– Answer: Baclofen and tizanidine
– Rationale: basic pharmacology knowledge
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Easy Rapid Fire Question #70
• What is the usual daily dose of duloxetine
when used for the treatment of diabetic
neuropathy?
– Answer: 60 mg
– Rationale: Cymbalta [package insert]. Eli Lilly and
Co., Indianapolis, IN; November 2012.
http://pi.lilly.com/us/cymbalta-pi.pdf.
Easy Rapid Fire Question #71
• What is the usual daily dose of celecoxib when
used for the treatment of osteoarthritis?
– Answer: 200 mg
– Rationale: Celebrex [package insert]. Pfizer, New
York, NY; http://www.pfizerpro.com/hcp/celebrex.
Medium Rapid Fire Question # 1
• Why was propoxyphene taken off the market?
RAPID FIRE QUESTIONSMEDIUM DIFFICULTY
– Answer: increased cardiotoxicity, even at
therapeutic doses. (Qtc interval prolongation)
– Rationale: Elderly are especially at risk due to
decreased renal function and decreased clearance
of norpropoxyphene, the cardiac metabolite of
propoxyphene.
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Medium Rapid Fire Question # 2
• True or False; Gabapentin needs to be dose
adjusted in liver impairment?
Medium Rapid Fire Question # 3
• What dosage form does Butrans®
(buprenorphine) come in?
– Answer: False
– Rationale: Needs adjustment in renal impairment
– Answer: transdermal patch
Medium Rapid Fire Question # 4
Medium Rapid Fire Question # 5
• What is the generic name of the medication
Opana®?
– Answer: oxymorphone
• True or False: Glucosamine is specifically used
for patients experiencing joint pain due to
rheumatoid arthritis?
– Answer: False
– Rationale: This is more for osteoarthritis
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Medium Rapid Fire Question # 6
Medium Rapid Fire Question # 7
• What vitamin deficiency is linked to peripheral
neuropathy?
• Pain due to a stimulus that does not normally
provoke pain is the definition for what pain
term?
– Answer: Vitamin B12 OR Vitamin B6 also an
acceptable answer though it is less commonly
linked
– Rationale: Metformin can be a cause of peripheral
neuropathy because it can decrease Vitamin B12
levels. This is important because many people who
have diabetes are on metformin and the correct
diagnosis is important for proper treatment.
Medium Rapid Fire Question # 8
• What is the maximum amount of days in a
row ketorolac can be taken IM for pain?
– Answer: 5 days
– Rationale: Increased risk of SEs, including
bleeding. Max 5 days for IV/IM use or
combination.
– Answer: Allodynia
– Rationale: An example of allodynia would be in
when a light touch from a feather causes pain to a
patient. A commonly confused term would be
hyperalgesia which is increased pain from a
stimulus that normally provokes pain, such as a
small pinch causing extreme pain.
Medium Rapid Fire Question # 9
• Aspirin is derived from which part of which
tree?
– Answer: Willow bark
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Medium Rapid Fire Question # 10
• A patient on NSAID therapy and citalopram
should be counseled on the increased risk of
what?
– Answer: Bleeding
– Rationale: Platelets are another site of active
serotonin besides the brain. Serotonin is important
for platelet aggregation. SSRIs prevent serotonin
reuptake in platelets and therefore decrease
platelet aggregation and increase risk of bleeding.
Medium Rapid Fire Question # 12
• What OTC oral pain reliever would be
recommended for short term use for a patient
who is also on warfarin?
– Answer: acetaminophen
– Rationale: In general NSAIDs are not
recommended for pts who are on warfarin
therapy. APAP can still increase INR, however it is
preferred over NSAIDs.
Medium Rapid Fire Question # 11
• A patient is at in increase risk of what
neurological side effect when the maximum
amount of tramadol is exceeded?
– Answer: Seizure
– Rationale: This medication lowers the seizure
threshold
Medium Rapid Fire Question # 13
• NSAIDs increase risk of nephrotoxicity and
what other side effects in elderly patients?
– Answer: bleeding, especially gastrointestinal and
cardiovascular side effects
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Medium Rapid Fire Question # 14
• What does the acronym PCA stand for?
– Answer: Patient-controlled analgesia
Medium Rapid Fire Question # 15
• Name a medication commonly used for
migraine prophylaxis?
– Answer:
•
•
•
•
Medium Rapid Fire Question # 16
• Name ONE topical medication that can be
used for diabetic peripheral neuropathy?
propranolol (any beta-blocker),
amitriptyline (tricyclic antidepressant),
verapamil (calcium channel blocker) or
clonidine
Medium Rapid Fire Question # 17
• Suboxone® is a combination of which 2 drugs?
– Answer: buprenorphine/naloxone
– Answer: capsaisin OR lidocaine patch
25
6/3/2015
Medium Rapid Fire Question # 18
Medium Rapid Fire Question #19
• What is the maximum recommend daily dose
for sumatriptan tablets?
• What is the equivalent po oxycodone dose for
a patient receiving 60 mg po morphine?
– Answer: 200mg
Medium Rapid Fire Question # 20
– Answer: oxycodone 40 mg
– Rationale: The oral conversion is 20 mg
oxycodone to 30 mg morphine, or a 2:3
(oxycodone:morphine) ratio
Medium Rapid Fire Question # 21
• Which of these 2 medications is a controlled
substance at the federal level: fiorinal or
fioricet?
• After ingesting a hydromorphone tablet when
would you expect a patient to report the
maximal analgesic effect?
– Answer: Fiorinal
– Rationale: Fioricet is NOT a controlled substance
– Answer: Maximum analgesia should occur 60-120
minutes after ingesting a tablet
26
6/3/2015
Medium Rapid Fire Question # 22
• Which over-the-counter medication may
cause serotonin syndrome when used in
combination with a serotonin reuptake
inhibitor such as paroxetine?
– Answer: Dextromethorphan
– Rationale: Dextromethorphan and SSRIs both
inhibit the reuptake of serotonin, which puts
patients at risk of serotonin syndrome when used
in combination.
Medium Rapid Fire Question # 24
• Despite amitriptyline’s strong evidence of
efficacy, the Beer’s list recommends it be
avoided in the elderly due to what
pharmacological property?
– Answer: Anticholinergic
– Rationale: Anticholinergic activity can cause
sedation which can be problematic in the elderly
who are more susceptible to these effects.
Medium Rapid Fire Question # 23
• Myoclonic spasms may be seen with high
doses of which of the following medications:
Tizanidine, Pregabalin, Baclofen,
Methocarbamol?
– Answer: Pregabalin at higher doses may cause
myoclonic spasms
Medium Rapid Fire Question # 25
• What syndrome includes confusion, agitation,
nausea, and diaphoresis and is a possible
adverse reaction when combining
antidepressants alone or in combination with
tramadol?
– Answer: Serotonin syndrome
27
6/3/2015
Medium Rapid Fire Question # 26
• Due to its propensity to increase blood
pressure at doses needed for pain relief, this
SNRI should be avoided in patients with
uncontrolled hypertension?
– Answer: Milnacipran
Medium Rapid Fire Question # 28
• Identify one nonopioid analgesic that is safe to
use during pregnancy?
– Answer: Acetaminophen.
– Rationale: APAP is the analgesic of choice in
pregnancy. In the first or second trimester ONLY,
one could consider ibuprofen, naproxen,
ketoprofen, sulindac, piroxicam, or indomethacin.
(BRIGGS - Drugs in Pregnancy and Lactation).
Medium Rapid Fire Question # 27
• A patient taking methadone and ziprasidone
(Geodon) is at an increased risk of what
serious side effect?
– Answer: QT prolongation or Torsades de Pointes
– Rationale: Independently, ziprasidone may
prolong the QT interval and methadone has been
associated with Torsades de pointes. QT
prolongation may lead to torsades de pointes,
which is a life threatening arrhythmia.
Medium Rapid Fire Question #29
• Identify two risk factors for the development of an NSAIDinduced gastrointestinal bleed?
– Answer: Advanced age, high-dose and long-term use, concomitant
corticosteroid or anticoagulant use, smoking, alcohol intake.
– Rationale: Age, smoking, and alcohol intake all influence the (a) pH
of the stomach, and (b) the integrity of the lining of the stomach
via inflammation. Additionally, anything that slows the motility
and would leave the stomach lining exposed to the NSAID longer
would be considered a risk factor for increased ulcer formation.
Concomitant use of steroids and/or anticoagulants with NSAIDs
nearly doubles the risk of ulcer formation (American College of
Gastroenterology) Primarily due to blockade of Cox-1 ▼ mucosal
blood flow = ▼ production of mucus and bicarbonate = LESS
PROTECTION.
28
6/3/2015
Medium Rapid Fire Question # 30
• Identify two goals of therapy for the
management of chronic pain.
– Answer: to reduce pain to a level that is
acceptable for the patient; -to improve
functioning; -to improve quality of life
– Rationale: variants of these should be acceptable,
but this is the standard IASP and PainEDU.org
approach for the initial goals in pain management
patients
Medium Rapid Fire Question # 32
• Describe how a patient would use a visual
analogue pain scale to indicate their level of
pain.
– Answer: Patients draw a line or dot at a point on
a continuous scale from 1 (no pain) to 10 (worst
imaginable pain).
– Rationale: The visual analogue pain scale is a way
to help patients visualize severity of pain. It may
be useful in a variety of patients, including
nonverbal patients.
Medium Rapid Fire Question # 31
• What centrally acting analgesic is structurally
and pharmacologically similar to tramadol?
– Answer: Tapentadol (Nucynta)
– Rationale: basic pharmacology
Medium Rapid Fire Question # 33
• Identify two important counseling points for
patients who are prescribed gabapentin for
the management of neuropathic pain?
– Answer: It may take a few weeks before you
notice its effects; -Can cause drowsiness so take at
night initially if possible; -May cause fluid to build
up in your legs; -do not take gabapentin within 2
hours after taking antacids; -May take with or
without food
29
6/3/2015
Medium Rapid Fire Question # 34
• Identify two important counseling points for a
patient who is planning to use capsaicin?
– Answer: symptomatic improvement may not be
seen for weeks; -do not apply to wounds or
broken skin; -wash your hands immediately after
application; avoid touching eyes or mouth; -can
cause burning; this should subside after repeated
use; - do not use with a heating pad as this will
result in a chemical burn
Medium Rapid Fire Question # 36
• What enzyme does allopurinol block in order
to reduce serum uric acid levels?
– Answer: Xanthine oxidase
– Rationale: By blocking xanthine oxidase,
allopurinol inhibits the conversion of oxypurines
(hypoxanthine, xanthine) to uric acid. This results
in decreased serum and urine uric acid
concentrations.
Medium Rapid Fire Question # 35
• What medication is FDA approved to treat
both depression and diabetic peripheral
neuropathy.
– Answer: duloxetine (Cymbalta)
– Rationale: Duloxetine is FDA approved for DPN.
Other SNRIs including Effexor (Venlafaxine) and
desvenlafaxine (Pristiq) are not approved for DPN
yet.
Medium Rapid Fire Question # 37
• Carisoprodol (Soma) was recently added to
what schedule of controlled substances?
– Answer: 4
– Rationale: As of December 2011, the DEA added
carisoprodol to schedule 4 controlled substances
because of the abuse potential.
30
6/3/2015
Medium Rapid Fire Question # 38
• Which opioid analgesic, alone or in combination with
naloxone, is approved for the office-based treatment of opioid
addiction?
– Answer: Buprenorphine.
– Rationale: Alone as Subutex®; with naloxone as Suboxone® (tabs or
film). Prescribers must be registered with an "X" DEA # and are
required to be 'certified' through the drug company's training program
(available online). CIII legend drug. Under the Drug Addiction
Treatment Act (DATA), prescription use of this product in the
treatment of opioid dependence is limited to physicians who meet
certain qualifying requirements, and who have notified the Secretary
of Health and Human Services (HHS) of their intent to prescribe this
product for the treatment of opioid dependence and have been
assigned a unique identification number that must be included on
every prescription.
Medium Rapid Fire Question #39
• What is the only FDA approved indication for
Lidoderm patches?
– Answer: Post-herpetic neuralgia
Medium Rapid Fire Question #40
Medium Rapid Fire Question #41
• What opioid analgesic has a dual mechanism
of action including opiate agonist activity and
reuptake blockade of norepinephrine?
• Identify two risk factors for the development
of acetaminophen-induced hepatotoxicity?
– Answer: Tapentadol (Nucynta®)
– Answer: Any two of the following would be
acceptable: ingestion of greater than 4 gm/day,
presence of liver disease, concomitant enzymeinducing drugs, patients who eat irregularly (due
to decreased glutathione stores), patients who
ingest alcohol regularly (3 or more alcoholic
beverages daily),
– Rationale: Basic pathophysiology of pain.
31
6/3/2015
Medium Rapid Fire Question #42
• List 3 side effects that are reported in
frequently upon initiation of tramadol.
– Answer: Constipation (9-46%), nausea (15-40%),
dizziness (10-33%), headache (4-32%),
somnolence (7-25%) and vomiting (5-17%)
– Rationale: The use of tramadol is limited in acute
pain because often patients require a slow
titration for this medication to be tolerable and
effective.
Medium Rapid Fire Question #44
• What is the difference in active ingredients
between Fioricet and Fiorinal?
– Answer: Fioricet contains acetaminophen, while
Fiorinal contains aspirin.
– Rationale: Both Fioricet and Fiorinal contain
butalbital and caffeine, though Fioricet contains
acetaminophen and Fiorinal contains aspirin. Also
of clinical importance is the fact that Fiorinal is
also a schedule III drug.
Medium Rapid Fire Question #43
• What is the maximum daily dose of tramadol
immediate release?
– Answer: 400 mg/day
Medium Rapid Fire Question #45
• Describe the pharmacology of fentanyl that
accounts for its more favorable side effect
profile than several other opioids.
– Answer: Fentanyl binds selectively at the mu
receptor.
– Rationale: Fentanyl has a more desirable side
effect profile because it binds selectively at the
mu receptor. For example, fentanyl is more
favorable than morphine as it causes less
constipation, sedation and minimal histamine
release.
32
6/3/2015
Medium Rapid Fire Question #46
• Describe the three steps of the World Health
Organization Pain Relief Ladder and how they
relate to the numeric pain scale (1-10).
– Answer: Mild pain (1-3), Moderate pain (4-6) and
Severe pain (7-10)
– Rationale: The WHO pain scale stratifies pain
scores into mild, moderate and severe pain. It
also recommends which analgesics to give at each
step.
Medium Rapid Fire Question #48
• The dose of oral morphine, above which,
there is a significant risk of overdosing?
– Answer: 120mg morphine daily or morphine
equivalents daily (MED)
– Rationale: Based upon recent articles published,
a patient on a dose above 120 MED have 8-9
times the risk of accidental overdose as those on a
lower dose (n engl j med. 2010 363;21:1981-3.
JAMA.2011;305;1315-21.)
Medium Rapid Fire Question #47
• Tapentadol’s analgesic activity is due to:
– Answer: Mu agonist and selective serotonin and
norepinephrine activity
– Rationale: Tapentadol, like tramadol, is a mu
agonist. Unlike tramadol, tapentadol inhibits the
reuptake of norepinephrine primarily and then
serotonin
Medium Rapid Fire Question #49
• Will fentanyl show up on a urine drug screen
designed to test for mu-agonists such as
morphine?
– Answer: No
– Rationale: fentanyl has a structure that is
dissimilar to traditional mu agonists
33
6/3/2015
Medium Rapid Fire Question #50
• Which agent acts topically by blocking Nachannels in nerves?
– Answer: lidocaine
Medium Rapid Fire Question #51
• Which opiate receptor is primarily responsible
for the dysphoric effects of opioids?
– Answer: kappa
– Rationale: There are 3 opiate receptors, mu,
delta, kappa; kappa receptors are primarily
responsible for dysphoric effects
Medium Rapid Fire Question #52
Medium Rapid Fire Question #53
• Methadone when combined with MAOIs may
cause?
• Which antiseizure agent may be the best
choice for an obese patient with neuropathic
pain?
– Answer: serotonin syndrome
– Rationale: methadone has weak serotonin
reuptake blockade; do not within 14 days of MAOI
use
– Answer: Topiramate
– Rationale: Topiramate has been shown to have
anorexic effects; in fact it is part of a combination
medication for weight loss
34
6/3/2015
Medium Rapid Fire Question #54
• Which patch is applied at an interval longer
than weekly?
– Answer: capsaicin patch 8% (Qutenza)
– Rationale: This is applied every 3 months
Medium Rapid Fire Question #56
• What subcutaneous injection is used to treat
opioid-induced constipation?
– Answer: Methylnaltrexone (Relistor)
– Rationale: Methylnaltrexone is a peripherally
acting opioid antagonist at the mu receptor that
does not affect opioid analgesic effects or induce
opioid withdrawal symptoms. Methylnaltrexone
decreases opioid-induced constipation by
inhibiting opioid-induced decreased GI motility
and delay in GI transit time.
Medium Rapid Fire Question #55
• Which opiate has the least lipophilicity?
– Answer: morphine
– Rationale: Morphine is one of the most
hydrophilic opiates; therefore it is one of the least
lipophilic
Medium Rapid Fire Question #57
• A patient presents to the pharmacy looking for overthe-counter medicine to treat a headache. The
patient has no previous medical diagnoses and the
headache he is experiencing is accompanied by
nausea and double vision. Can the following patient
be treated with over-the-counter pain management?
– Answer: No, refer patient to primary care provider
– Rationale: The patient is experiencing symptoms
consistent with a migraine (nausea/aura) without a
previous diagnosis of migraines which excludes the patient
from self-care
35
6/3/2015
Medium Rapid Fire Question #58
• Oral acetaminophen is inferior to intravenous
acetaminophen for postoperative dental pain.
True or False?
– Answer: False
– Rationale: Oral acetaminophen is not inferior to
intravenous acetaminophen for postoperative
analgesia.
Medium Rapid Fire Question #60
• What class of drugs is the common therapy of
choice for an acute gouty attack?
– Answer: NSAIDs
– Rationale: Fast acting NSAIDs are first line for
acute symptom relief
Medium Rapid Fire Question #59
• Can Transcutaneous Electrical Nerve
Stimulation (TENS) be used in conjunction
with oral gabapentin or pregabalin?
– Answer: Yes
– Rationale: TENS units treat pain via physical
stimulation while gabapentin and pregabalin treat
pain via chemical pathways. It is appropriate to
use TENS units in conjunction with oral pain
medications.
Medium Rapid Fire Question #61
• Naloxone and Naltrexone antagonize which
opioid receptors?
– Answer: , , and 
– Rationale: Both of these drugs antagonize all
opioid receptors, but feature the most affinity for
the mu receptor
36
6/3/2015
Medium Rapid Fire Question #62
• Linezolid should be used with caution while
taking duloxetine or milnacipran due to the
potential development of what condition?
– Answer: Serotonin Syndrome
– Rationale: Linezolid is a weak MAOI that may
potentiate the serotonergic effect of SNRI’s or
SSRI’s. Concomitant use should be avoided.
Medium Rapid Fire Question #63
• True or False? The DEA requires only a
prescriber to be compliant with schedule II eprescribing rules for the lawful dispensing of a
schedule II substance.
– Answer: False
– Rationale: The DEA requires both the prescriber
and the pharmacy receive an audit from a
qualified third party or certification from an
approved body for the legal dispensing of an eprescribed schedule II product.
Medium Rapid Fire Question #64
Medium Rapid Fire Question #65
• What class of medications has shown the
most benefit in tension headache prophylaxis?
• Which serotonin/norepinephrine reuptake
inhibitor (SNRI) is approved by the FDA for the
treatment of diabetic neuropathy,
fibromyalgia, and chronic musculoskeletal
pain?
– Answer: Tricyclic antidepressants
– Rationale: Amitriptyline is the most studied
medication with confirmed use in chronic tensiontype headaches
– Answer: duloxetine
– Rationale: Cymbalta [package insert]. Eli Lilly and
Co., Indianapolis, IN; November 2012.
http://pi.lilly.com/us/cymbalta-pi.pdf.
37
6/3/2015
Medium Rapid Fire Question #66
• Which tricyclic antidepressant (TCA) used in
the treatment of neuropathic pain is
associated with the least anticholinergic
adverse effects?
– Answer: desipramine
– Rationale: Zacharoff KL, Pujol LM, Corsini E. A
Pocket Guide to Pain Management. 4th ed.
Newton, MA: Inflexxion, Inc.;2010:245.
Medium Rapid Fire Question #67
• Which transdermal opioid preparation is
indicated for the management of persistent
moderate to severe pain and should not be
used in opioid naïve patients?
– Answer: fentanyl
– Rationale: Duragesic [package insert]. Janssen
Pharmaceuticals, Inc., Titusville, NJ; July 2012.
http://www.duragesic.com/sites/default/files/pdf/durages
ic_0.pdf. Buprenorphine (Butrans®) can be used in the
treatment of pain in both opioid naïve and opioid tolerant
patients.
Medium Rapid Fire Question #68
Medium Rapid Fire Question #69
• Which agent is a weak opioid agonist that also
inhibits the reuptake of serotonin and
norepinephrine?
• Which non opioid analgesic has an FDA
warning for rare, but serious and potentially
fatal skin reactions including Stevens-Johnson
syndrome and toxic epidermal necrolysis?
– Answer: tramadol
– Rationale: basic pharmacology knowledge
– Answer: acetaminophen
– Rationale: FDA Warns of Rare Acetaminophen
Risk. Food and Drug Administration Web site.
http://www.fda.gov/ForConsumers/ConsumerUpd
ates/ucm363010.htm. Accessed September 23,
2013.
38
6/3/2015
Medium Rapid Fire Question #70
Medium Rapid Fire Question #71
• Name the two active metabolites of morphine
• What is the maximum daily dose of pregabalin
when used in the treatment of postherpetic
neuralgia?
– Answer: morphine-3-glucuronide (M3G) and
morphine-6-glucuronide (M6G)
– Rationale: basic pharmacology knowledge
Medium Rapid Fire Question #72
• What is the maximum total daily dose of
topical diclofenac (Voltaren® Gel) when
applied over all affected areas of the body?
– Answer: 32 g
– Rationale: Voltaren Gel [package insert]. Endo
Pharmaceuticals Inc., Chadds Ford, PA; October
2009.
http://www.voltarengel.com/common/pdf/Voltar
en-PI-10-19.pdf.
– Answer: 600 mg
– Rationale: Lyrica [package insert]. Pfizer, Inc., New
York, NY; June 2013.
http://labeling.pfizer.com/ShowLabeling.aspx?id=
561.
Medium Rapid Fire Question #73
• Name two strategies that should be employed
to avoid tricyclic antidepressant (TCA)-related
adverse effects when used in the treatment of
neuropathic pain?
– Answer: Initial small doses, bedtime dosing,
and/or slow titration.
– Rationale: Bril V, England J, Franklin GM, et al; American Academy of
Neurology; American Association of Neuromuscular and Electrodiagnostic
Medicine; American Academy of Physical Medicine and Rehabilitation.
Evidence-based guideline: Treatment of painful diabetic neuropathy: report of
the American Academy of Neurology, the American Association of
Neuromuscular and Electrodiagnostic Medicine, and the American Academy
of Physical Medicine and Rehabilitation. Neurology. 2011;76:1758-65.
39
6/3/2015
Medium Rapid Fire Question #74
• What is the name of the virus that is
associated with shingles and painful
neuropathy?
– Answer: Varicella Zoster Virus
– Rationale: Centers for Disease Control and
Prevention. Shingles (Herpes Zoster).
RAPID FIRE QUESTIONSHARD DIFFICULTY
http://www.cdc.gov/shingles/about/overview.html
Hard Rapid Fire Question # 1
• What is the recommended acetaminophen
dosing range for mild to moderate pain for a
pediatric patient? Please answer in mg/kg
– Answer: 10-15 mg/kg every 4-6 hours
Hard Rapid Fire Question # 2
• Name a medication that can be used to
potentiate the analgesic efficacy of parenteral
opioids?
– Answer: hydroxyzine (Vistiril®) or
dextroamphetamine (Dexedrine®)
40
6/3/2015
Hard Rapid Fire Question # 3
• What medication antagonizes NMDA
receptors and blocks the reuptake of
serotonin and norepinephrine?
Hard Rapid Fire Question # 4
• Name the metabolite of meperidine that
accumulates and can stimulate seizures?
– Answer: Normeperidine
– Answer: methadone (Dolophine®)
Hard Rapid Fire Question # 5
• Name a class of medications used as an
adjuvant to opioids for bone cancer pain?
– Answer: bisphosphonates, NSAIDs, steroids,
gabapentin, pregabalin
Hard Rapid Fire Question # 6
• What is the maximum daily dose of tramadol
for moderate to moderately severe pain?
– Answer: 400mg/day
41
6/3/2015
Hard Rapid Fire Question # 7
• What is Savella® (milnacipran) FDA approved
to treat?
– Answer: Fibromyalgia
Hard Rapid Fire Question # 9
• Hydromet is an oral solution of hydrocodone
and what other medication?
– Answer: Homatropine
Hard Rapid Fire Question # 8
• What pharmacological class does Savella®
(milnacipran) belong to?
– Answer: SNRI
Hard Rapid Fire Question # 10
• Would tramadol likely test positive for an
opioid in a drug screen?
– Answer: No
– Rationale: it is not chemically related to codeine
or morphine so it is unlikely
42
6/3/2015
Hard Rapid Fire Question # 11
• What addictive metabolite is carisoprodol
(Soma®) broken down to in the body?
– Answer: Meprobamate
Hard Rapid Fire Question # 13
• What is an estimate of the half-life range for
methadone?
– Answer: The half-life of methadone is 24-48 hours
or longer
Hard Rapid Fire Question # 12
• What drug is referred to as Hillbilly Heroin?
– Answer: Oxycontin®
– Rationale: the slang term hillbilly heroin (which
originally referred to hydromorphone) for
OxyContin® refers to the occurrence of the
earliest reported cases of Oxycontin® abuse in the
U.S. in rural areas such as Appalachia.
Hard Rapid Fire Question # 14
• What is the equivalent po hydromorphone
dose for a patient receiving 2 mg IV
hydromorphone?
– Answer: 8-10 mg po hydromorphone
– Rationale: The IV to PO conversion of
hydromorphone is 1.5mg IV = 7.5 mg PO, or a 1:5
(IV:PO) ratio
43
6/3/2015
Hard Rapid Fire Question # 15
• Name an opioid that will not prolong the QTc
interval on the electrocardiogram?
– Answer: Fentanyl, Hydromorphone, Hydrocodone,
Oxycodone, Oxymorphone, Meperidine, and
Morphine will not prolong the QTc interval on the
ECG
Hard Rapid Fire Question # 17
• Which of the following analgesics will not
precipitate withdrawal if given to a patient
taking high doses of opioids chronically:
Levorphanol tablets, Pentazocine tablets,
Suboxone sublingual film, Butorphanol Nasal
spray?
Hard Rapid Fire Question # 16
• Which of the following opioids on this list is
considered the most hydrophilic:
Hydromorphone, Hydrocodone, Morphine,
Fentanyl?
– Answer: Morphine
– Rationale: Morphine is the most water soluble,
fentanyl is the least water soluble and
hydrocodone/hydromorphone are in between
those two
Hard Rapid Fire Question # 18
• Which NSAID pro-drug has the least effect on
lithium levels compared to other NSAIDs?
– Answer: Sulindac
– Answer: Levorphanol is a mu opioid agonist.
– Rationale: All the others listed are
agonists/antagonists that will cause withdrawal if
given to a patient taking high doses of opioids
chronically
44
6/3/2015
Hard Rapid Fire Question # 19
• Name the only medication available in the
United States that is part of the opioid
chemical class of diphenylheptanes.
Hard Rapid Fire Question # 20
• What anticonvulsant is associated with
tremors, pancreatitis, and liver dysfunction?
– Answer: Valproic acid
– Answer: methadone
– Rationale: The diphenylheptanes include both
methadone and propoxyphene. Propoxyphene is
no longer available in the US.
Hard Rapid Fire Question # 21
• For what length of time does aspirin affect
platelet function after discontinuation?
– Answer: 7 days
– Rationale: Generally speaking, traditional NSAIDs
continue to affect platelet function for no longer
than 48 hours after discontinuation. Because
aspirin irreversibly inactivates cyclooxygenase in
platelets, its effect lasts throughout the life span
of platelets, which is approximately 1 week.
Hard Rapid Fire Question # 22
• Pregabalin and gabapentin modulate voltagegated calcium channels by combining with
what receptor?
– Answer: alpha-2-delta subunit
45
6/3/2015
Hard Rapid Fire Question # 23
• What medication can be used as an antidote
for serotonergic agents or to increase libido
for designated periods such as weekends in
patients adversely affected by their SSRI?
Hard Rapid Fire Question # 24
• Identify the 4 processes involved in the pain
pathway.
• Answer: Transduction, transmission,
modulation, perception.
– Answer: cyproheptadine
Hard Rapid Fire Question # 25
• Place the following opioid analgesics in order
based on their duration of action (shortest to
longest): transdermal fentanyl, MS Contin®,
and hydromorphone?
– Answer: Hydromorphone, MS Contin®,
transdermal fentanyl.
– Rationale: Hydromorphone = 3-4 hours, MS
Contin® = 6-10 hours, transdermal fentanyl = 3696 hours
Hard Rapid Fire Question # 26
• Which class of drugs is contraindicated in a
patient taking meperidine?
– Answer: Monoamine oxidase inhibitors (MAOIs).
– Rationale: Increased risk of serotonin syndrome
(hyperthermia, hyperreflexia, myoclonus, mental
status changes).
46
6/3/2015
Hard Rapid Fire Question # 27
• Identify two classes of drugs that should be avoided in
patients taking tramadol?
– Answer: SSRIs (serotonin syndrome), SNRIs (serotonin
syndrome), opioids (duplicate therapy, increased CNS
depression), Tricyclic antidepressants (duplicate therapy),
buproprion (lowers seizure threshold).
– Rationale: Opioids in combination would worsen CNS
depression and increase the risk of respiratory depression.
Combination with SSRIs and SNRIs is theorized to increase
the potential for serotonin syndrome (though this is rare, it
could occur rapidly in the right situation). Serotonin
syndrome = hypertension, hyperthermia, myoclonus,
mental status changes.
Hard Rapid Fire Question # 28
• What is the risk of cross-sensitivity to an
NSAID in a patient with aspirin
hypersensitivity?
– Answer: 20% to 50% has been reported.
– Rationale: www.allergy.org reports that 'up to 1 in
5' could have cross-reactivity.
Hard Rapid Fire Question # 29
Hard Rapid Fire Question # 30
• A hospitalized patient is being discharged today on oral
oxycodone. His total daily dose is calculated as being
180 mg/day. What is an appropriate dosing regimen for
this patient if the doctor plans to prescribe immediaterelease tablets?
• A patient has been receiving morphine 10 mg IV
every 4 hours. The physician would like to switch
the patient to oral morphine. How much oral
morphine should this patient receive per dose?
– Answer: Oxycodone IR 30 mg po every 4 hours.
– Rationale: IR oxycodone would be appropriately
prescribed every 3 - 4 hours (can be as often as every 1-2
based on PK). Thus, taking the total daily dose (TDD) of
180 mg and dividing it into 4 hour intervals, 30 mg q4h is
appropriate. Staying with the same drug, but a different
formulation, does NOT necessitate a % dose reduction
because there is no cross-sensitivity to account for.
– Answer: Morphine oral:IV ratio is 3:1 so patient
should receive morphine 30 mg per dose.
– Rationale: Total Daily Dose (TDD) of IV morphine = 60
mg. Using a 3:1 ratio of oral:po morphine, the patient
would warrant an oral TDD of morphine of 180mg, or
30 mg po q4h
47
6/3/2015
Hard Rapid Fire Question # 31
• What would be an appropriate regimen of
immediate-release morphine for the
management of breakthrough pain in a patient
who is taking MS Contin® 45 mg po BID?
– Answer: Breakthrough pain is calculated as 10 to 15%
of the total daily dose. This patient is taking 90 mg per
day (10% would be ~9 mg, rounded to 10 mg).
Therefore, the patient should receive 10 mg po every
4 hours as needed.
– Rationale: Breakthrough doses should ideally utilize
an immediate release formulation of the same
medication as the scheduled, maintenance dosing.
Hard Rapid Fire Question # 33
• Which muscle relaxant can be used to treat
intractable hiccups and trigeminal neuralgia?
– Answer: Baclofen.
– Rationale: The key word here is 'intractable
hiccups'. Baclofen is known to be useful for the
treatment of this disorder.
Hard Rapid Fire Question # 32
• If a patient has an ileostomy, which long acting opioids are the most
appropriate?
– Answer: Fentanyl patch and Methadone.
– Rationale: An ileostomy is a surgical opening constructed by bringing
the end or loop of small intestine (the ileum) out onto the surface of
the skin. Intestinal waste passes out of the ileostomy and is collected
in an external pouching system stuck to the skin. Ileostomies are
usually sited above the groin on the right hand side of the abdomen.
This would have a significant impact on drug delivery / excretion
because of the effect on the GI tract that tends to result in a more
rapid transit time. Slow-release medications are NOT a good choice.
Transdermal medications are preferred, but a number of publications
have pointed to methadone as the oral opioid of choice in these
patients for its good absorption profile.
Hard Rapid Fire Question # 34
• A patient is admitted to the hospital and is
NPO due to a bowel obstruction. The patient
usually takes methadone 120mg daily. What
is equivalent IV daily dose?
– Answer: 60mg, given as 20mg IV q8h
– Rationale: The ratio of oral to IV methadone is
2:1. Therefore, since the oral dose was 120mg/d,
the IV equivalent dose would be 60mg/day.
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Hard Rapid Fire Question # 35
Hard Rapid Fire Question # 36
• Identify two opioid analgesics commonly used
in patient-controlled analgesia (PCA) devices.
• When dispensing a prescription for Flexeril®
(Cyclobenzaprine), you should ask the patient whether they
have what two important medical conditions?
– Answer: Any two of the following: Morphine,
fentanyl, hydromorphone.
– Rationale: Meperidine was once used, but has
fallen out of favor overall as an opioid analgesic
for its various adverse effects and neurotoxicities.
Hard Rapid Fire Question # 37
• Ultra rapid metabolizers of CYP2D6 substrates
should not receive this opioid while
breastfeeding due to the risk of opioid toxicity
in the infant.
– Answer: Codeine
– Rationale: Mothers receiving codeine at
recommended doses may result in opioid toxicity
to breastfed infants. If codeine is used in nursing
mothers, the lowest dose for the shortest amount
of time should be given.
– Answer: Urinary hesitancy and angle closure glaucoma.
– Rationale: Anticholinergic-like adverse effects. Counseling
points are listed as: Do not use alcohol, prescriptive or OTC
antidepressants, sedatives, or pain medications without
consulting prescriber. You may experience drowsiness, dizziness,
lightheadedness (avoid driving or engaging in tasks that require
alertness until response to drug is known); or urinary retention
(void before taking medication). Report excessive drowsiness or
mental agitation, chest pain, skin rash, swelling of mouth/face,
difficulty speaking, ringing in ears, or blurred vision.
Hard Rapid Fire Question # 38
• An adverse effect that has traditionally been linked
to aromatic anticonvulsants such as phenytoin,
phenobarbital and carbamezapine has also been
associated with medications used for pain such as
gabapentin, allopurinol and certain NSAIDS. This
adverse effect is characterized by skin rash, fever,
enlarged lymph nodes and organ impairment. What
is this adverse effect?
– Answer: Dress Syndrome – Drug Rash with
Eosinophilia and Systemic Symptoms
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Hard Rapid Fire Question # 39
• Which herbal drug has Level A evidence for use in
migraine prevention?
– Answer: Petasites (Butterbar)
– Rationale: Petasites (Butterbar) was given a level A rating
of evidence meaning there are at least 2 high quality
randomized, controlled trials demonstrating efficacy in the
2012 Prevention of Episodic Migraine guidelines released
from the American Headache Society and the American
Academy of Neurology. Doses of 50-75mg po BID are
recommended
Hard Rapid Fire Question # 41
• What is the pain reliever in the over-thecounter product, Neosporin plus pain relief?
– Answer: pramoxine
– Rationale: Pramoxine 1% is a topical analgesic
found in several topical pain products.
Hard Rapid Fire Question # 40
• Which three beta-blockers have level A
evidence for use in migraine prevention?
– Answer: propranolol, timolol, and metoprolol
– Rationale: propranolol and timolol were rated
Level A in the 2000 guidelines, though metoprolol
is new to this category in 2012. Atenolol is
considered Level B (probably effective.
Hard Rapid Fire Question # 42
• Given the choice between morphine and hydromorphone for
use in a patient with renal impairment, which one would be
the safest option and why?
– Answer: Hydromorphone, no opioid active metabolite
– Rationale: Morphine has 2 active metabolites, morphine3-glucuronide (M3G) and morphine-6-glucuronide (M6G),
both of which are eliminated renally. M3G does not bind to
opioid receptors but is responsible for adverse effects.
M6G exhibits opioid activity and can can accumulate in
renal failure. Hydromorphone does not have an opioid
active metabolite.
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Hard Rapid Fire Question # 43
• A patient is taking hydrocodone. __________
may also be appropriately found in the urine
drug screen
– Answer: Hydromorphone
– Rationale: The primary metabolite of
hydrocodone is hydromorphone
Hard Rapid Fire Question # 45
• Qutenza (capsaicin patch) should be used with
caution in patients with?
– Answer: Hypertension
– Rationale: There have been increases in blood
pressure secondary to treatment related pain
Hard Rapid Fire Question # 44
• An equivalent daily dose of parenteral
morphine to fentanyl 100 mcg/h patch is?
– Answer: 120 mg/day
– Rationale: 100 mcg/h fentanyl patch is equal to
120mg parenteral morphine per day according to
equianalgesic dosing tables.
Hard Rapid Fire Question # 46
• With Qutenza the patch how should it be
removed?
– Answer: slowly and gently
– Rationale: To avoid aerosolization of capsaicin; if
contents are inhaled and SOB develops medical
care is required
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Hard Rapid Fire Question # 47
• What agent is used to “reverse” opioid
hyperalgesia?
– Answer: Ketamine, Methadone
– Rationale: Ketamine and Methadone have been
used to reverse opioid hyperalgesia and tolerance;
this is a non FDA approved use
Hard Rapid Fire Question # 49
• Which fiber transmits a sharp, well localized
pain?
– Answer: A-Delta
Hard Rapid Fire Question # 48
• Neuropathic pain is partially mediated by this
receptor which causes the “wind-up”
phenomenon?
– Answer: N-methyl-d-aspartate receptor
– Rationale: With continued stimulation the Nmethyl-d-aspartate receptor becomes sensitized
and continues to fire with minimal stimulation.
NMDA receptor antagonists such as methadone,
ketamine, dextromethorphan work by blocking
this receptor.
Hard Rapid Fire Question # 50
• Which organ is used as a central processing
station for reception and processing of
nociceptive information
– Answer: Thalamus
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Hard Rapid Fire Question # 51
• What metabolite of heroin is used as a
confirmatory test for heroin?
– Answer: 6-mono-acetyl-morphine (6-MAM)
– Rationale: 6-MAM is the longer acting heroin
metabolite and is often used as a confirmatory
test for heroin
Hard Rapid Fire Question # 53
• What is the maximum number of Lidoderm
patches that can be applied in a single
application?
– Answer: 3 patches
– Rationale: Drug Monograph
Hard Rapid Fire Question # 52
• What is the equivalent oxycodone conversion
dose for a patient receiving a oxymorphone
20mg?
– Answer: 40mg
– Rationale: Per manufacturer, 10mg of
oxymorphone is equivalent to 20mg of
oxycodone; therefore, 20mg of oxymorphone is
equivalent to 40mg of oxycodone.
Hard Rapid Fire Question # 54
• NSAIDs may lead to drug-induced renal
insufficiency through what mechanism?
– Answer: Impairment of vasodilation of the
glomerular afferent arteriole
– Rationale: NSAIDs inhibit prostaglandins which
can lead to vasoconstriction within the afferent
arteriole. This can result in reduced glomerular
filtration pressure and damage to the kidneys.
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Hard Rapid Fire Question # 55
Hard Rapid Fire Question # 56
• Which glucuronide metabolite of morphine is
responsible for toxic effects?
• What is the only opioid with a labeled
indication for relief of anxiety in patients with
dyspnea associated with pulmonary edema?
– Answer:Morphine-3-glucuronide
– Rationale: Effects of the metabolite Morphine-3glucuronide contributes to excitatory effects while
morphine-6-glucuronide has effects
indistinguishable from morphine
Hard Rapid Fire Question # 57
• Which alpha2-adrenergic agonist is given by
epidural infusion for severe, intractable pain in
adult cancer patients?
– Answer: Clonidine
– Rationale: Clonidine is used via epidural infusion
starting at 30mcg/hour; max 40 mcg/hour. Should
be used as an adjunctive to opioid therapy.
– Answer: Oxymorphone
– Rationale: Drug monograph
Hard Rapid Fire Question # 58
• Which nerve fibers produce dull, aching,
generalized pain?
– Answer: C fibers
– Rationale: C fibers produce dull, aching, poorly
localized pain while A-delta fibers produce sharp,
well-localized pain.
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Hard Rapid Fire Question # 59
• Can an intrathecal anesthetic and an
intrathecal opioid be administered
simultaneously?
– Answer: Yes
– Rationale: Epidural and intrathecal anesthetics
can be administered simultaneously with epidural
and intrathecal opioids, and has been proven to
be both safe and effective.
Hard Rapid Fire Question # 61
• At what QTc interval should methadone be
discontinued or reduced to avoid Torsades de
Pointes?
– Answer: QTc interval ≥500 msecs
– Rationale: Clinical Practice Guideline: VA/DoD
Clinical Practice Guideline for Management of
Opioid Therapy for Chronic Pain. May 2010.
http://www.healthquality.va.gov/COT_312_Fuller.pdf. Accessed September 23, 2013.
Hard Rapid Fire Question # 60
• What behavior pattern is a result of
unrelieved pain and resembles that of
addictive behavior?
– Answer: Pseudoaddiction
– Rationale: Pseudoaddiction is a behavior pattern
characterized by the seeking of pain relief that
resembles addictive behavior.
Hard Rapid Fire Question # 62
• Which chloride channel activator is approved
by the FDA for the treatment of opioidinduced constipation?
– Answer: lubiprostone
– Rationale: Amitiza [package insert]. Takeda
Pharmaceuticals America, Inc., Deerfield, IL; April
2013. http://www.amitiza.com/default.aspx.
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Hard Rapid Fire Question # 63
• Which topical patch is used in the treatment
of postherpetic neuralgia and must be applied
by a health care professional?
– Answer: capsaicin patch 8% (Qutenza™)
– Rationale: Qutenza [package insert]. Acorda
Therapeutics, Inc., Ardsley, NY; July 2013.
http://www.qutenza.com/_docs/qutenza_full_PI_
.pdf.
Hard Rapid Fire Question # 65
• What is the term used to describe a state of
adaptation and an abstinence syndrome
following discontinuation of an opioid?
– Answer: physical dependence
– Rationale: Zacharoff KL, Pujol LM, Corsini E, A
Pocket Guide to Pain Management. 4th ed.
Newton, MA: Inflexxion, Inc.;2010:245. It is not
tolerance and it is not addiction.
Hard Rapid Fire Question # 64
• Which partial opioid agonist is approved by
the FDA for the treatment of both moderate
to severe pain and opioid addiction?
– Answer: buprenorphine
– Rationale: Butrans [package insert]. Purdue
Pharma, L.P., Stamford, CT; July 2013.
http://app.purduepharma.com/xmlpublishing/pi.
aspx?id=b. Methadone is an opioid agonist.
Hard Rapid Fire Question # 66
• What is the recommended maximum daily
dose and length of therapy for meperidine
when used as an analgesic in patients with
normal renal function?
– Answer: Doses should not exceed 600mg in 24
hours and treatment should be limited to ≤48
hours
– Rationale: Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain.
American Pain Society 6th ed. 2008;32.
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Hard Rapid Fire Question # 67
• Name the two most common local adverse
effects of sublingual buprenorphine plus
naloxone (Suboxone®)?
– Answer: Oral hypoesthesia, glossodynia, and/or
oral mucosal erythema.
– Rationale: Suboxone [package insert]. Reckitt
Benckiser Pharmaceuticals, Inc., Richmond, VA;
August 2012.
http://suboxone.com/pdfs/SuboxonePI.pdf.
Hard Rapid Fire Question # 69
• Besides the increased risk of bleeding and
gastrointestinal ulcers, why should low-dose
aspirin and ibuprofen not be taken
concomitantly?
– Answer: Ibuprofen may render aspirin less
effective when used for cardioprotection and
stroke prevention
– Rationale: Hochberg MC, Altman RD, April KT, et al; American College of
Rheumatology. American College of Rheumatology 2012 recommendations for
the use of non pharmacological and pharmacological therapies in
osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken).
2012;64:465-74.
Hard Rapid Fire Question # 68
• Name two long-term adverse effects of
chronic opioid therapy.
– Answer: Hypogonadism and Osteoporosis
– Rationale: pharmacology knowledge
Hard Rapid Fire Question # 70
• Name the two most valid and reliable
behavioral pain scales for monitoring pain in
adult ICU patients who are unable to selfreport?
– Answer: The Behavioral Pain Scale (BPS) and the
Critical Care Pain Observation Tool (CPOT)
– Rationale: Barr J, Fraser GL, Puntillo K, et al; American College of
Critical Care Medicine. Clinical practice guidelines for the management
of pain, agitation, and delirium in adult patients in the intensive care
unit. Crit Care Med. 2013;41:263-306.
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Finalist Pain Patient Counseling
Finalist Instructions
• You will be presented the case for the patient sitting in
front of you who just entered your pharmacy with
prescriptions to fill. You will have 2 minutes to review the
case handout
• You will have a total of 5 minutes to counsel once I indicate
that the case presentation is over and for you to begin.
• You will be alerted when you have 3 minutes, 2 minutes, 1
minute and 30 seconds left
• You should focus on asking 3 key questions of the patient as
judges will be judging off these questions. Good luck.
Case #1 — Mr. Robertson
Case #2-Mrs. Choi
Mr. Robertson is a 43-year old African-American
man who presents to the pharmacy with RX for:
Mrs. Choi is a 67-year old Asian female who
presents to the pharmacy with RX for:
•Oxycontin® 40mg; Take one tab tid #90
•Gabapentin 600mg; Take one tab tid #90
•Baclofen 20mg; Take one tab tid #90
•Dilaudid® 4mg tab, Take 1-2 tabs q4h prn # 90
• Senokot-S®; Take two tabs bid
• Tylenol #3 (Acetaminophen 300mg/Codeine
30mg); Take 1-2 tabs q4 hour prn
• Valsartan 160 mg; Take one tab qd
• HCTZ 25 mg; Take one tab qd
• Atorvastatin 20 mg; Take one tab qd
• Tylenol Arthritis 650 mg; take 1-2 tabs qd prn
• ASA 81 mg, Take one tab qAM
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Case #3-Mr. Krumpky
Mr. Krumpky is a 52-year old Caucasian man
who presents to the pharmacy with refill RX for:
• MS Contin 30 mg; Take one tab q12h; Quantity: #60
• Morphine Sulfate IR 10 mg; Take one tab q4-6 h prn;
Quantity: #120
• Tramadol 50 mg, Take 1-2 tabs q 6 hours prn;
Quantity: #60
• Docusate 100 mg, Take one capsule bid
• ASA 81 mg, Take one tab qAM
Case #4-Ms. Gutierrez
Ms. Gutierrez is a 32-year old Hispanic woman
who presents to the pharmacy with RX for:
• Opana ER 5 mg; Take one tab q12h for 3 days;
Quantity: #5
• Opana ER 10 mg; Take one tab q12h; Quantity:
#60
• Docusate 100 mg, Take one capsule bid
Case #5-Mr. Smith
Case #6-Mr. Croner
• Mr. Smith is a 63 year old male with a history of
pancreatic cancer who presents to the pharmacy
with RX for:
• Mr. Croner is a 45-year old male who presents
to the pharmacy with RX for:
– Fentanyl 25mcg Apply 1 patch every 72 hours #10
– morphine IR 15mg 1 tab BID prn breakthrough pain,
#30
• He picked up from the pharmacy 15 days ago the
following medications:
–
–
–
–
HCTZ 25mg 1 po qd #30
MS Contin 60mg 1 po BID #60
lisinopril 10mg 1 po qd #30
morphine IR 15mg 1 tab po BID prn BTP #60
– Fentanyl patches 50mcg/hr, Apply one patch every
3 days, # 10 patches
– Hydromorphone 2mg tabs, Take 1-2 tabs q3h PRN
pain #60 tablets
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Case #7-Mrs. Lewis
• Mrs. Lewis is a 45-year old Hispanic female who
presents to the pharmacy with RX for:
– Oxycodone sustained release 20mg q12h,Take one tab
every twelve hours # 60 tablets
– Oxycodone/acetaminophen 5/325, Take 1-2 tabs q4h
PRN # 90 tablets
– Gabapentin 300mg, Take one tablet three times per
day, # 90 tablets
– Baclofen 10mg, Take one tablet three times per day, #
90 tablets
– Naproxen 500mg, Take one tablet q12h, # 60 tablets
Case #8-Ms. Everly
• Ms. Everly is a 58-year old woman who
presents to the pharmacy with RX for:
– Febuxostat 40mg: Take one tablet daily #30
– Percocet 5/325mg: Take one tablet every 4 hours
as needed for lower back pain #20
– Senokot-S: Take one tablet bid
Case #9–Mr. Sanderson
• Mr. Sanderson is a 37-year old man who
presents to the pharmacy with RX for:
– Cyclobenzaprine 10mg: Take one tablet TID prn
spasms #90
– Hydrocodone 5/APAP 325mg: Take 1-2 tablets
every 4 hours as needed for lower back pain #30
– Senokot-S: Take one tablet bid
– OTC: Naproxen 220mg 2 tablets po BID; #28
Case #10–Mr. Garcia
• Mr. Garcia a retired, guitarist for a rock band. He is Hispanic,
64 y/o. He has had diabetes Type II for the past 20 years. His
last A1C was 9. He has a bandage on his foot to protect a cut
he received while walking. He realized he had the cut ~ 2
hours after the event happened. Two years ago he injured his
back while exercising at the gym. Since the original injury, his
medication has not been evaluated or changed
•
His current medications include:
– Metformin 500mg bid
– ASA 325 mg q day
– Lisinopril 20 mg q day
– Senokot-S®; Take two tabs bid
– Hydrocodone/APAP 10/325 1 qid
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Case #11–Mr. Perry
• Mr. Perry is a 53-year old male who presents to the
pharmacy with RX for:
– Oxycontin 60mg tid, #90, mac 3 tab/day
– Oxycodone 30mg q 4hrs, #180, max 6 tab/day
• The profile on your pharmacy states that he is
allergic to morphine, methadone, fentanyl,
hydrocodone, codeine. The profile also states that
Mr. Perry is being treated for lower back pain from
degenerative disk disease
Case #13-Mr. Grant
• Mr. Grant is a 72-year old Caucasian man who
presents to the pharmacy with RX for:
– Lidocaine patch 5%; Apply patch to most painful area. Up
to 3 patches may be applied in a single application.
Patch(es) may remain in place for up to 12 hours in any 24hour period. #120
– Gabapentin 300mg; 1 capsule daily on Day 1, 1 capsule
twice daily on Day 2, 1 capsule three times daily on Day 3,
continue this dose. Call MD if pain relief is inadequate.
#90
Case #12-Mrs. Jones
• Mrs. Jones is a 46-year old Caucasian female
who presents to the pharmacy with RX for:
– Tramadol 50mg one tablet Q4-6 hours PRN (max 8
tablets per 24 hours)
• Current medications include:
– Dicyclomine 40mg QID; Quantity #120
– Duloxetine 60mg qd; Quantity #30
Case #13-Mr. Grant (cont’d)
– Hydrocodone/acetaminophen 5mg/325mg; 1-2
tablets every 4 hours as needed for pain # 60
• Current medications include:
– ASA 81mg 1 tablet daily
– CONTINUED NEXT SLIDE
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Final Judge Evaluation and
Announcement of the Winner
CASE REVIEW
Thank you for your participation
Acknowledgments for this activity
Maryland Pharmacists Association
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