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Pain


Which vitamin is useful in migraine prophylaxis ? Riboflavin (B2) REF

Non-opiods (non-spasmotics) for back pain ? REF

How to do a drup contract:
Go into the AVS and type .cs and put in both the agreement and the other thing.
Go to coordination note and enter Kasper, and the drug being dispensed.
Enter that UDSs will be done.
Enter that violation of any of these will result in termination. 

COX-2 Step Therapy Step-1 Drugs (Express Scripts)

 Generic of ->  Name Brand
 etodolac Lodine and Lodine XL
ibuprofen Motrin 
meloxicam Mobic 
 nabumetoneRelafen 
 naproxenNaprosyn 


Don't use NSAIDs in CHF, they cause Na & H20 retention and increase systemic vasc res. (REF)

When is digoxin indicated for afib ? (REF)

Oral to IV conversions:
Hydromorphone has a bioavailability of approximately 25%, therefore converting from oral to intravenous means dividing the dose by four. This would give him intravenous dose of approximately 0.4 mg.
Methadone has a 90% bioavailability so converting 1:1 is reasonable.

NSAIDs such as naproxen have a slight effect on platelet function, but because they inhibit prostaglandin synthesis they actually decrease the volume of menstrual flow and lessen the discomfort of pelvic cramping.  Acetaminophen would have no effect on prostaglandins. REF

131. A 60-year-old female receiving home hospice care was taking oral morphine, 15 mg every 2 
hours, to control pain. When this was no longer effective, she was transferred to an inpatient 
facility for pain control. She required 105 mg of morphine in a 24-hour period, so she was 
started on intravenous morphine, 2 mg/hr with a bolus of 2 mg, and was well controlled for 5 
days. However, her pain has worsened over the past 2 days. 
Which one of the following is the most likely cause of this patient’s increased pain? 
A) An inadequate initial morphine dose 
B) Addiction to morphine 
C) Pseudoaddiction to morphine 
D) Physical dependence on morphine 
E) Tolerance to morphine

Item 131 
ANSWER: E 
This patient has become tolerant to morphine. The intravenous dose should be a third of the oral dose, so the starting intravenous dose was adequate. Addiction is compulsive narcotic use. Pseudoaddiction is inadequate narcotic dosing that mimics addiction because of unrelieved pain. Physical dependence is seen with abrupt narcotic withdrawal. 
Ref: U3: Assessment and Treatment of Physical Pain Associated with Life-Limiting Illness. American Academy of Hospice and 
Palliative Medicine, 2008, pp 18-21.
ć
Marc Curvin,
Mar 6, 2013, 3:01 PM
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