Opioids

Question 1

What is the MOA for opioids

Answer 1

Simulate opioid receptors (mu, kappa, and delta) in the CNS

Question 2

What are the major AEs of the opioid analgesics (general)

Answer 2

Dependence
Decreased GI motility 
Respiratory depression
Somnolence
Stimulation of CTZ
Mood changes
Increase in sphincter tone
Tolerance
Histamine release

Pneumonic: D(D)R. S(S)MITH

Question 3

Opiod most common AEs and the most severe

Answer 3

MC: drowsiness, nausea, vomiting, contipation, pruritis

Most severe: Decrease respiratory rate

Question 4

Opioid withdrawal symptoms

Answer 4

Minor: rhinorhhea, lacrimation, excessive yawning, mild irritability, mild N/V
Major: increasing reslessness, tremors, abdominal cramps, anxiety, persistent N/V, increased HR, BP, hot or cold flashes, fever

Question 5

4 types of opioid and receptor drugs

Answer 5

Agonists (bind to mu receptor; best reponse)
Partial agonists (submax response at the receptor)
Agonist/antagonists (has an analgesia ceiling)
Antagonist (reverse/inhibit effects; good for tx OD/substance abuse)

Question 6

Moderate pain agents related to Morphine (Phenanthrenes)

Answer 6

Codeine
Codeine/APAP (Tylenol #3)
Hydrocodone
Hydrocodone/APAP (Vicodin)
Oxycodone (Oxycontin)
Oxycodone/APAP (Percocet)

Question 7

Moderate pain agents: other opioid agonists

Answer 7

Meperidine (Demerol)
Tramadol (Ultram)
Tramadol/APAP
Tapentadol (Nucynta)

Question 8

Severe pain agents related to Morphine

Answer 8

Morphine
Hydromorphone (Dilaudid)
Levorphanol
Oxymorphone

Question 9

Severe pain agents: other opioid agents

Answer 9

Fentanyl (Sublimaze)

Methadone

Question 10

Mixed mu agonists/antagonists

Answer 10

Butorphanol (Stadol)
Nalbuphine (Nubain)
Pentazocine (Talwin)

Question 11

Mu partial agonists

Answer 11

Buprenorphine

Question 12

Mu antagonists

Answer 12

Naloxone (Narcan)

Naltrexone (Depade)

Question 13

Important info to know about codeine, hydrocodone, and oxycodone

Answer 13

They all metabolize to morphine

CYP2D6 metabolizers have increased risk of toxicity (codeine) or CYP3A4 substrate (hydrocodone, oxycodone)

Question 14

Important info to know about Meperidine

Answer 14

Metabolite is a direct CNS irritant that can lead to seizures
Only use short term
Do not use with MAOI could lead to hypertensive crisis

Question 15

Important info about Tramadol

Answer 15

1/3 of actions effect the mu and other 2/3 have actions on NE and seratonin reuptake

Question 16

Important info about morphine

Answer 16

Gold standard for potent opioids

Question 17

Pain management options if pseudoallergy to opioids

Answer 17

Nonopioid, avoid opioids, use more potent opioids that are less likely to release histamine, if necessary give with diphenhydramine, if tolerable reduce dose

Question 18

Pain management options if true allergy to opioids

Answer 18

nonopioid analgesic
opioid in a diff chemical class with close monitoring

Question 19

Adjuvent analgesics

Answer 19

Caffeine, hydroxyzine, corticosteroids

Question 20

S/s of persistent pain

Answer 20

depression, anxiety, sleep disturbances, frustration, anger, decreased self esteem, decreased involvement in social activities, financial stresses, decreased libido, work issues, etc

Question 21

Non-pharm options for persistent pain

Answer 21

TENS, biofeedback, physical therapy

Question 22

Important info to remember about using Opioids for persistent pain

Answer 22

Use scheduled regular release product
As needed, use regular release product for breakthrough pain
Consider changing to sustained release product when adequate schedule dose is established
Start bowel program (fluids, fiber, stool softener (bisacodyl)

Question 23

Pharm management for chronic low back pain

Answer 23

Nonopioid: APAP
Opioids: Short term use for mild to mod flare ups
Other meds: Tramadol. TCAs, AEDs

Question 24

Pharm management for fibromyalgia

Answer 24

Nonopioid: APAP. NSAIDs
Opioid: Long term use not recommended
Other meds: Tramadol. TCAs, AEDs, SNRIs

Question 25

Pharm management for neuropathic pain

Answer 25

Nonopioids: APAP and NSAIDs are rarely effective
Opioids: Considered 2nd line therapy (after other meds)
Other meds: TCAs, AEDs, SNRIs, tramadol. topical