Analgesics - Opioids

Question 1

Which 2 of the following drugs are part of stage 1 of the analgesic ladder for mild pain between 1-3?

1 - codeine
2 - tramadol
3 - paracetamol
4 - NSAIDs

Answer 1

3 - paracetamol
4 - NSAIDs

Question 2

Which 2 of the following drugs are part of stage 2 of the analgesic ladder for moderate pain between 4-6?

1 - codeine
2 - tramadol
3 - paracetamol
4 - NSAIDs

Answer 2

1 - codeine
2 - tramadol

Question 3

Which of the following is on stage 3 of the analgesic ladder for severe pain 7-10?

1 - codeine
2 - morphine
3 - paracetamol
4 - NSAIDs

Answer 3

2 - morphine

Question 4

NSAIDS have 3 properties: analgesic (pain-killing), anti-inflammatory and antipyretic (fever-reducing) properties. Which of the following is NOT classed as a NSAIDs?

1 - aspirin
2 - paracetamol
3 - ibuprofen
4 - diclofenac

Answer 4

2 - paracetamol

• analgesic and antipyretic only
• NOT anti-inflammatory

Question 5

A 22-year-old man presents with complaints of ankle pain and swelling from a sports injury oneday prior. X-rays are negative for a fracture and he is directed to rest the joint and allow it to heal. Which drug will provide LESS benefit in alleviating pain and inflammation of the swollen joint?

A. Celecoxib
B. Naproxen
C. Diclofenac
D. Acetaminophen

Answer 5

D. Acetaminophen
- more commonly known as paracetamol

• other 3 drugs are NSAIDS

Question 6

A patient with which of the following conditions is the most appropriate candidate for use of acetaminophen to manage chronic pain associated with osteoarthritis?

A. Chronic malnutrition
B. Obesity
C. Alcoholism
D. Viral hepatitis

Answer 6

B. Obesity
- other conditions increase risk of acetaminophen (paracetamol) related hepatotoxicity.

• acetaminophen depletes glutathione concentrations in the liver and NAPQI builds up.
• low levels of glutathione are common in malnutrition, again increasing levels of NAPQI
• alcoholism depletes endogenous glutathione
• viral hepatitis damages the liver, and could reduce levels of glutathione

Question 7

Among NSAIDs, aspirin is unique because it:

(A) Irreversibly inhibits its target enzyme
(B) Prevents episodes of gouty arthritis with long-term use
(C) Reduces fever
(D) Reduces the risk of colon cancer
(E) Selectively inhibits the COX-2 enzyme

Answer 7

(A) Irreversibly inhibits its target enzyme

• non-selective irreversibly inhibition of cyclooxygenase 1 and 2

Question 8

Which of the following is an analgesic and antipyretic drug that lacks an anti-inflammatory action?

(A) Acetaminophen
(B) Celecoxib
(C) Colchicine
(D) Indomethacin
(E) Probenecid

Answer 8

(A) Acetaminophen

Question 9

An 18-month-old boy dies from an accidental overdose of acetaminophen. Which of the following is the most likely cause of this patient’s death?

(A) Arrhythmia
(B) Haemorrhagic stroke
(C) Liver failure
(D) Noncardiogenic pulmonary edema
(E) Ventilatory failure

Answer 9

(C) Liver failure

• liver failure as a result of its conversion by hepatic cytochrome P450 enzymes to a highly reactive metabolite NAPQI

Question 10

A 54-year-old woman presented with signs and symptoms consistent with an early stage of rheumatoid arthritis. The decision was made to initiate NSAID therapy. Which of the following patient characteristics is the most compelling reason for avoiding celecoxib (selective COX-2 inhibitor) in the treatment of her arthritis?

(A) History of alcohol abuse
(B) History of gout
(C) History of myocardial infarction
(D) History of osteoporosis
(E) History of peptic ulcer disease

Answer 10

(C) History of myocardial infarction

• COX-2-selective inhibitor
• does not inhibit Thromboxane A2
• increased risk of arterial thrombotic events.
• history of MI would be a compelling reason to avoid a COX-2 inhibitor

Question 11

Which of the following statements is correct regarding morphine?

1 - Morphine is the most lipophilic opioid.
2 - Morphine is metabolised through CYP2D6 and ­CYP3A4 and has numerous drug interactions.
3 - Morphine has active metabolites that can accumulate in renal impairment, leading to clinically relevant effects.
4 - Morphine can cause opioid-induced constipation upon initiation of opioid therapy, but tolerance occurs after 1 to 2weeks of opioid exposure.

Answer 11

3 - Morphine has active metabolites that can accumulate in renal impairment, leading to clinically relevant effects.

• Morphine has two active metabolites M3G and M6G, which are renally eliminated.

Question 12

Which of the following is NOT an core opioid that we need to be aware of?

1 - Morphine sulphate
2 - Oxycodone
3 - Diclofenac
4 - Codeine phosphate
5 - Tramadol
6 - Methadone

Answer 12

3 - Diclofenac
- this is an NSAID

Question 13

The 5 core opioid that we need to be aware of are below. Which are strong and which are weak/moderate?

1 - Morphine sulphate
2 - Oxycodone
3 - Codeine phosphate
5 - Tramadol
6 - Methadone

Answer 13

• strong = morphine sulphate, oxycodone and methadone
• weak/moderate = codeine phosphate and tramadol

Question 14

Of the 5 core opioid that we need to be aware of are below, which are prodrugs that need to be metabolised in the liver?

1 - Morphine sulphate
2 - Oxycodone
3 - Codeine phosphate
5 - Tramadol
6 - Methadone

Answer 14

3 - Codeine phosphate
5 - Tramadol

• metabolised to become morphine or dihydromorphine

Question 15

Which of the following is NOT an opioid receptor?

1 - Mu
2 - Kappa
3 - Delta
4 - Alpha

Answer 15

4 - Alpha

Question 16

Which endogenous opioid (made in the body) can bind with opioid receptors which then inhibits GABA release and allows neurotransmitters such as dopamine, serotonin and noradrenaline to be released?

1 - endorphins
2 - methadone
3 - heroin
4 - fentanyl

Answer 16

1 - endorphins

Question 17

Once opioid receptors are activated this inhibits GABA in the brain at specific locations. Those locations are pain processing regions of the brain. Which 2 of the following neurotransmitters are released in the pain processing regions and thus reduce sensitivity to pain?

1 - dopamine
2 - serotonin
3 - noradrenaline
4 - GABA

Answer 17

2 - serotonin
3 - noradrenaline

Question 18

Once opioid receptors are activated this inhibits GABA in the brain at specific locations. This location can be in the reward pathways creating a calming effect. Which neurotransmitters is released in the reward pathway regions of the brain?

1 - dopamine
2 - serotonin
3 - noradrenaline
4 - GABA

Answer 18

1 - dopamine

Question 19

Opioids are indicted in acute pain, in all of the following EXCEPT which one?

1 - trauma
2 - surgery
3 - acute coronary syndrome
4 - acute pulmonary oedema

Answer 19

4 - acute pulmonary oedema

Question 20

Opioids are indicted in chronic pain, but only when what has happened?

1 - patient is elderly
2 - patient has multiple comorbidities
3 - milder analgesics have failed to alleviate pain
4 - patient requests opioids

Answer 20

3 - milder analgesics have failed to alleviate pain

• if pain management fails we move up the ladder

Question 21

Opioids are indicated for which of the following?

1 - pain following major surgery
2 - breathlessness in palliative care
3 - broken bone
4 - GIT obstruction

Answer 21

2 - breathlessness in palliative care

Question 22

Opioids are indicated for acute pulmonary oedema alongside 3 other medications. Which one is NOT indicated here?

1 - oxygen
2 - furosemide
3 - tramadol
4 - nitrates

Answer 22

3 - tramadol

Question 23

Specifically in pain processing regions, which opioid receptor do opioids bind with to reduce pain?

1 - alpha
2 - delta
3 - mu
4 - kappa

Answer 23

3 - mu

• these are GPCR

Question 24

In addition to alleviating pain, opioids can have a significant affect on other factors. Which of the following actions do opioids perform?

1 - inhibit respiratory drive and breathlessness
2 - attenuate response to hypoxia and hypercapnia
3 - reduce pain and associated anxiety
4 - reduce sympathetic drive
5 - reduce cardiac workload and O2 demand (acute coronary syndrome)
6 - all of the above

Answer 24

6 - all of the above

Question 25

Opioids can have which of the following adverse events in the brain or brain stem? 1 - respiratory depression 2 - neurological depression 3 - activate chemoreceptor trigger zone and vomiting centre, inducing nausea and vomiting 4 - pupillary constriction due to stimulation of the Edinger-Westphal nucleus 5 - all of the above

Answer 25

5 - all of the above

Question 26

Opioids have a high risk of patients becoming dependent on them. Which medication can be given to reduce withdrawal symptoms? 1 - alprazolam 2 - methadone 3 - amphetamines 4 - methylphenidate

Answer 26

2 - methadone - weak opioid with short half life - good for withdrawal from morphine - all other drugs here are also addictive

Question 27

In addition to locations in the brain or brain stem, which of the following are adverse events from opioids in the peripheral tissues? 1 - constipation (u receptors) 2 - itching 3 - hyperalgesia (increased sensitivity to pain) 4 - all of the above

Answer 27

4 - all of the above

Question 28

Which of the following conditions should the doses of opioids be reduced in? 1 - hepatic failure 2 - renal impairment 3 - older patients 4 - all of the above

Answer 28

4 - all of the above - liver and renal are responsible for elimination, so if not cleared they can become toxic - older patients livers and kidneys do not functional as well

Question 29

Should opioids ever be given to patients with respiratory failure?

Answer 29

- generally no - unless under direct supervision

Question 30

Opioids should not be prescribed alongside the following medications: anti-psychotics, benzodiazepines and tricyclic antidepressants. Why is this? 1 - increase risk of dependence 2 - extrapyramidal effects 3 - increase risk of toxicity 4 - accentuate sedation of opioids

Answer 30

4 - accentuate sedation of opioids - if used they must be under direct supervision

Question 31

What other medication should be prescribed alongside opioids? 1 - laxatives 2 - anticholinergics 3 - Beta blockers 4 - PPIs

Answer 31

1 - laxatives - senna is most commonly used - due to risk of constipation