Opioids

Question 1

rx length

Answer 1

Up to 3 days for most things; up to 7d max

Question 2

MOA

Answer 2

Most bind to and stimulate the Mu opioid receptors (agonists). Inhibit neurotransmitter (substance P, glutamate, CGRP) release AND reduce transmission of pain signals. Hyperpolarise postysynaptic cell, so less likely to generate any further pain sensations. Raise the pain threshold at the spinal cord level (dorsal horn). Alter the brain’s perception of pain. The stronger the agonist, the greater the effect

Question 3

opioid contras

Answer 3

Use in Head Injuries (can increase intracranial pressure), Use in Pregnancy (stick to short term use), Impaired Pulmonary Function, Impaired Hepatic or Renal Function, Endocrine Disease, Undiagnosed abdominal pain

Question 4

AEs

Answer 4

nausea, constipation, respiratory depression. flushing, pruritis, hypotension from release of histamine. Pinpoint pupils that do not respond to light.

Question 5

overdose symptoms and treatment

Answer 5

Overdose: CNS depression (coma), resp depression (apnea or bradypnea), miosis. Give Narcan (opioid receptor antagonist) IV, IN, IM, or SC, onset in 2-3 min and give 2nd dose at 3 min if still not awake; effect lasts 2 hrs, so pts should be monitored for 4-6 hrs after Narcan; induces opioid withdrawal (agitation, anxiety, confusion, tachycardia, HTN.

Question 6

interactions

Answer 6

“Sedative-Hypnotics: Benzodiazepines, Diphenhydramine, Soma, tramadol
Alcohol
Antipsychotics
MOAIs”

Question 7

pt counseling - 4

Answer 7

“PO initial onset in 20 min, full benefit at 1hr.
take antinausea 20 min before
Let pt know when using combo w/ acetaminophen - caution against taking too much aceta otherwise
Avoid alcohol. don’t take benzodiazepines or diphenhydramine at same time; space out 2-4 hrs if you really need it due to extra sedative effect”

Question 8

co-prescribe

Answer 8

Co-prescribe antiemetic (Zofran) and senna + bisacodyl; also naloxone if risk factors (prior OD, substance abuse, doses >120MME/d, concomitant benzo)

Question 9

weakest agonist

Answer 9

codeine

Question 10

codeine contras

Answer 10

Absolute: <12 y/o, <18 y/o after tonsillectomy / adenoidectomy. Avoid in <18 y/o

Question 11

most constipating opioid

Answer 11

codeine

Question 12

MOA: mild-mod agonist. Targets the mu-receptor and inhibits reuptake serotonin and norepinephrine

Answer 12

tramadol

Question 13

tramadol contras

Answer 13

Caution in pts w/ seizure hz or those on TCAs or serotonergic agents

Question 14

which opioids are only partially antagonised by naloxone

Answer 14

tramadol, Tapentadol (Nucynta)

Question 15

tramadol dose adjustment for whom?

Answer 15

CrCl <30 or severe hepatic impairment, dose Q12 hours

Question 16

indications: “ped surgery/ED
extended release: neuropathic pain”

Answer 16

Tapentadol (Nucynta) PO, IV

Question 17

AEs: Low GI effects, but risk of seizures, risk of serotonin syndrome when combined with SSRIs. Partially antagonised by Naloxone

Answer 17

Tapentadol (Nucynta) PO, IV

Question 18

order of strength of the mild-mod agonists

Answer 18

oxycodone > hydrocodone > tramadol > codeine

Question 19

morphine contra

Answer 19

avoid in kidney dz

Question 20

AEs: Thought to cause more pruritus, nausea, and sedation than hydromorphone (Dilaudid) or fentanyl

Answer 20

morphine

Question 21

interactions: Tapentadol (Nucynta) PO, IV

Answer 21

SSRIs

Question 22

switch morphine non-responders to

Answer 22

oxy

Question 23

MOA: strong agonist. Synthetic - More potent than Morphine (~50-100x). Rapid onset of action: IV formulation has peak effect on average in 10 minutes.Very short acting. secreted in the stomach and reabsorbed, creating a second peak

Answer 23

fentanyl

Question 24

fentanyl dosed in

Answer 24

micrograms

Question 25

change fentanyl transdermal patch Q

Answer 25

Q72 hrs

Question 26

indication for fentanyl transdermal patch

Answer 26

chronic pain once stable

Question 27

fentanyl contras

Answer 27

Avoid in patients with obesity hypoventilation syndrome, liver failure

Question 28

pt counseling for transdermal patch

Answer 28

Patch: proper disposal in sharps container necessary to protect kids/pets

Question 29

methadone contras

Answer 29

Avoid use in older adults for pain, or older adults w/ delirium or at risk

Question 30

when is the peak of opioid withdrawal symptoms?

Answer 30

72 hrs after last pill

Question 31

do hospital providers need a x waiver to give buprenorphine to a pt in withdrawal?

Answer 31

no

Question 32

when is x waiver needed?

Answer 32

Rx for buprenorphine outside of hospital

Question 33

x waiver allows rx for how many pts

Answer 33

up to 30

Question 34

MOA: strong agonist. suppress craving and withdrawal symptoms and block the acute effects of other opioids

Answer 34

methadone

Question 35

indications: Opioid dependence. Chronic, severe pain. Neonatal withdrawal. Postanesthesia shivering, and blood product-induced rigors. IV: adjunctive sedative for procedures (less common).

Answer 35

methadone

Question 36

AEs: Risk for seizure, serotonin syndrome. at common doses, not an effective pain medication, may cause neurotoxicity including delirium, and safer analgesics are available. Prolongs QT interval, constipation, mild drowsiness, ED, low libido

Answer 36

methadone

Question 37

MOA: Mixed agonist-antagonist (partial agonist). Long-acting, partial mu agonist, delta and kappa antagonist

Answer 37

Buprenorphine (Butrans®)

Question 38

indications: "OUD / opioid withdrawal (flu-like sx, n/v/d, abd pain, HTN, mydriasis, tachycardia, hyperreflexia, insomnia, irritability, anxiety, depression). Acute pain in opioid naïve pts IM/IV"

Answer 38

Buprenorphine (Butrans®)

Question 39

MOA: opioid receptor blockade secondarily diminishes dopamine activity that is otherwise enhanced by alcohol. Mu, Kappa, Delta Antagonist

Answer 39

Naltrexone (Vivitrol) PO or long-acting IM

Question 40

indications: alcohol and opioid dependence - Maintenance treatment to prevent relapse

Answer 40

Naltrexone (Vivitrol) PO or long-acting IM