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Advanced Clinical Nursing Theory > Analgesia: Opioids > Flashcards

Analgesia: Opioids Flashcards

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1
Q

what are opioids most commonly used for?

A

perioperative analgesia

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2
Q

why are opioids less commonly used for chronic pain management?

A

poor oral bioavailability of opioids

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3
Q

in what pain states are opioids less effective?

A

neuropathic (e.g. brachial plexus avulsion where there is significant nerve damage)

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4
Q

what are the main pharmacological effects of opioids in mammals?

A

analgesia
sedation
excitation
bradycardia
respiratory depression
nausea and vomiting
decreased GI motility
varied urinary effects
antitussive
minimal effect on inotropy
effects on the pupil

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5
Q

when is excitation most often seen following opioid administration?

A

in pain free animals when giving as a premed

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6
Q

when does opioid induced bradycardia have most effect?

A

when the patient is anaesthetised

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7
Q

why do opioids cause respiratory depression?

A

depresses bodies response to rising CO2 so that respiratory drive now comes from lack of oxygen which is physiologically abnormal

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8
Q

when are nausea and vomiting most commonly seen following opioid administration?

A

when used as a premed in pain free animals

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9
Q

what are the main urinary effects seen with opioids?

A

increased or decreased micturition
reduced sensitivity to urge to urinate

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10
Q

what is inotropy?

A

heart contractility

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11
Q

what are the effects of opioids on the pupil in dogs?

A

miosis

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12
Q

what are the effects of opioids on the pupil in cats?

A

mydriasis

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13
Q

how do opioids have effect within the body?

A

mimic naturally occurring opioid peptides (neurotransmitters)

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14
Q

what are the endogenous naturally occurring opioid peptides?

A

beta-endorphin
leucine and methionine enkephalins
dynorphins

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15
Q

where are opioid receptors mostly found?

A

brain and spinal cord

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16
Q

what are the main opioid receptors found in the brain and spinal cord?

A

mu
kappa
delta
NOP

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17
Q

what does NOP stand for?

A

nociceptin opioid peptide

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18
Q

what is the endogenous ligand for the NOP receptor?

A

nociceptin

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19
Q

what are the subtypes of the delta opioid receptors?

A

delta 1
delta 2

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20
Q

where are delta opioid receptors located?

A

brain
peripheral sensory neurones

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21
Q

what is the function of delta opioid receptors?

A

analgesia
antidepressant
convulsant
physical dependence

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22
Q

what can be modulated by delta opioid receptors?

A

mu-opioid receptor-mediated respiratory depression

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23
Q

what types of kappa opioid receptor are there?

A

kappa 1
kappa 2
kappa 3

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24
Q

where are kappa opioid receptors located?

A

brain
spinal cord
peripheral sensory neurones

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25
Q

what is the function of kappa opioid receptors?

A

analgesia
anticonvulsant
depression
dissociation/hallucinogenic
diuresis
miosis
dysphoria
neuroprotection
sedation
stress

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26
Q

what opioid receptor provides the most effective analgesia?

A

mu

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27
Q

what types of mu receptor are there?

A

mu 1
mu 2
mu 3

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28
Q

where are mu opioid receptors found?

A

brain
spinal cord
peripheral sensory neurones
intestinal tract

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29
Q

what are the functions of mu 1 receptors?

A

analgesia
physical dependance

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30
Q

what are the functions of mu 2 receptors?

A

respiratory depression
miosis
euphoria
reduced GI motility
physical dependance

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31
Q

what are the functions of mu 3 receptors?

A

possible vasodilation

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32
Q

where can morphine be obtained from?

A

directly extracted from opium which is taken from the fried latex of poppy seed pods

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33
Q

how are opioids such as methadone and pethidine produced?

A

synthetically developed

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34
Q

where do all commercially available opioid drugs act?

A

opioid receptors

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35
Q

what information will suggest how an opioid drug will act?

A

receptors or receptor subtypes they act at
mechanism of action at these receptors
pharmacokinetics
species differences

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36
Q

what does the pharmacokinetics of a drug describe?

A

what the body does with the drug, how they are taken up by the body, transported and broken down

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37
Q

what are the main mechanisms of action at opioid receptors?

A

full agonist
partial agonist
mixed agonist-antagonist
antagonist

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38
Q

what mechanism of action at an opioid receptor provides the most effective analgesia?

A

full agonist

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39
Q

what type of opioids provide the most effective analgesia?

A

full mu agonist

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40
Q

what drugs are examples of full agonists?

A

methadone
fentanyl

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41
Q

what drugs are examples of partial opioid agonists?

A

buprenorphine

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42
Q

what drugs are examples of mixed agonist-antagonist?

A

butorphanol

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43
Q

what drug is an example of an opioid antagonist?

A

naloxone

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44
Q

what is the difference between full and partial agonists?

A

full agonists bind to and activate a receptor with the maximum response that an agonist can elicit at that receptor
partial agonists bind to and activate a receptor but only have partial efficacy even if they bind to all receptors

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45
Q

what does the potency of a drug describe?

A

how much of a drug is required to have an effect

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46
Q

what does the efficacy of a drug describe?

A

how much effect of the drug is seen at full receptor occupancy

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47
Q

why do the formulation concentrations of methadone and buprenorphine differ so much?

A

due to differences in potency - buprenorphine is more potent so requires less mg/kg to see effect

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48
Q

why is methadone better for severe pain than buprenorphine?

A

methadone is more effective than buprenorphine

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49
Q

describe the efficacy and potency of fentanyl

A

highly effective and potent making overdose likely

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50
Q

what are the routes of administration for opioids?

A

IM
SC
IV
OTM
transdermal
epidural/spinal
(not all by all routes)

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51
Q

what opioid cannot be administered by IV injection?

A

pethidine

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52
Q

why must pethidine not be administered IV?

A

risk of allergic reaction

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53
Q

what route of administration of opioids gives poor bioavailability?

A

oral

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54
Q

why does oral administration of opioids lead to poor bio-availability?

A

significant first pass metabolism of opioids by liver so are broken down before reaching site of action

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55
Q

what route of administration of buprenorphine may be less efficacious in cats?

A

SC

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56
Q

why does oral transmucosal administration of opioids provide better bioavailability than oral?

A

bypass of liver due to absorption across oral mucous membranes rather than swallowing

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57
Q

why are opioids limited in use for chronic pain?

A

not useful when administered orally due to poor bioavailablity

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58
Q

what are the advantages and disadvantages of IV administration of opioids?

A

rapid onset, reliable uptake, painless with no volume restriction

need IV access

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59
Q

what are the advantages and disadvantages of IM administration of opioids?

A

reliable uptake

painful, especially high volumes

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60
Q

what are the advantages and disadvantages of SC administration of opioids?

A

easy to perform

unreliable uptake

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61
Q

what are the advantages and disadvantages of OTM administration of opioids?

A

easy to perform

only certain opioids (buprenorphine in cats)

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62
Q

what are the advantages and disadvantages of transdermal administration of opioids?

A

good for chronic use

no licenced products

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63
Q

what are the advantages and disadvantages of epidural/spinal administration of opioids?

A

very effective analgesia for right cases (usually intraoperative analgesia)

no licenced opioids, technically difficult

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64
Q

what needs to be considered when planning what analgesic to use?

A

efficacy
duration of action
potential for adverse events

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65
Q

what must be balanced when deciding whether to use a more efficacious opioid?

A

need for severe pain management balanced against potential side effects

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66
Q

what controls the effect of a drug irrespective of how it acts?

A

concentration of drug at the site of action

67
Q

what does the onset of action of a drug depend on?

A

route of adminstration - how long the drug will take to get to its site of action and will it all arrive at a similar time (e.g. IV fast and bolus)
potency - how much needs to be bound before effect is seen
how quickly the drug is removed form the receptors

68
Q

when is peak effect of a drug seen?

A

when all the drug is sitting in a receptor

69
Q

how long is the duration of action of fentanyl?

A

ultra short - 20mins

70
Q

what are ultra short acting opioids used for?

A

intraoperative bolus
short term infusion (CRI)

71
Q

what are the short acting opioids?

A

butorphanol, pethidine

72
Q

how long do short acting opioids such as butorphanol last for?

A

2 hours

73
Q

how long do medium acting opioids such as methadone last for?

A

2-4 hours

74
Q

what are the medium acting opioids?

A

methadone
morphine

75
Q

what are the longer acting opioids?

A

buprenorphine

76
Q

how long do longer acting opioids like buprenorphine last for?

A

6 hours

77
Q

what are short, medium and longer acting opioids used for?

A

general use for acute, pre, peri and post operative pain
part of a multimodal analgesia regimen

78
Q

what may medium and longer acting opioids be used for that short acting would not?

A

painful patient (e.g. RTA)

79
Q

what must be considered if the patient will require opioid treatment for more than a few hours?

A

frequency of re-dosing and the chance of opioid accumulation

80
Q

what effect does dose have on duration of action?

A

higher dose = duration of action increased

81
Q

what is the fomulation of all currently vet licensed opioids?

A

immediate release - what you give is what you get

82
Q

what are the 4 main misconceptions around opioid administration?

A

opioids cause mania in cats
opioids cannot be re-dosed within expected duration of action
respiratory depression can occur
opioids cannot be combined with other classes of analgesic drug

83
Q

how can the common misconception that opioids cause mania in cats be challenged?

A

only seen at very high doses and in pain free patients (e.g. as part of a premed)

84
Q

how can the common misconception that opioids cannot be re-dosed within their expected duration of action be challenged?

A

if analgesic effect has worn off the patient can be redosed

85
Q

how can the common misconception that opioids cause respiratory depression be challenged?

A

less significant than in humans
mostly an issue under GA when the patient should have a controlled airway and could e ventilated anyway

86
Q

how can the common misconception that opioids should not be combined with other classes of analgesic drug be challenged?

A

great for multimodal analgesia
don’t usually give different opioids together though

87
Q

what opioids are ultra short acting full mu agonists?

A

fentanyl
alfentanil
sufentanil
remifentanil

88
Q

what species is fentanyl licenced for?

A

dogs
cats
horses
rabbits

89
Q

what opioids are medium acting full mu agonists?

A

morphine
methadone
pethidine

90
Q

what species is methadone licenced for?

A

dogs
cats

91
Q

what species is morphine licensed for?

A

dogs
cats
horses

92
Q

what opioids are longer acting partial mu agonists?

A

buprenorphine

93
Q

what species is buprenorphine licensed for?

A

dogs
cats
rabbits

94
Q

what opioids are short acting mixed kappa agonist mu antagonists?

A

butorphanol

95
Q

what species is butorphanol licensed in?

A

dogs
cats
rabbits

96
Q

why are opioids controlled drugs?

A

due to risk of abuse by humans rather thn clinical safety

97
Q

what is a significant advantage of opioids?

A

can re-dose until desired effect is achieved
wide safe dosage range

98
Q

what do side effects of opioids relate to?

A

potency

99
Q

what opioids have the greatest likelihood of side effects?

A

those with the greatest analgesic efficiency

100
Q

when are side effects of opioids more likely?

A

when the animal is not in pain

101
Q

what are the useful clinical effects of opioids?

A

analgesia
sedation
antitussive (less evidence then in humans)

102
Q

what are the main side effects of opioids that cause concern?

A

respiratory depression
bradycardia

103
Q

is opioid mediated respiratory depression usually clinically significant in awake patients?

A

no - only really seen under GA

104
Q

what is bradycardia following opioid administration mediated by?

A

vagus nerve

105
Q

what can vagally mediated bradycardia following opioid administration be treated with?

A

anticholinergic

106
Q

what is an example of an anticholinergic that may be used to treat vagally mediated bradycardia following opioid administration?

A

atropine
glycopyrrolate

107
Q

is atropine licensed for veterinary use to treat vagally mediated bradycardia following opioid administration?

A

yes

108
Q

is glycopyrrolate licensed for veterinary use to treat vagally mediated bradycardia following opioid administration?

A

no

109
Q

what may low dose anticholinergic cause when given for vagally mediated bradycardia following opioid administration?

A

worsening of brady cardia

110
Q

what may high dose anticholinergic cause when given for vagally mediated bradycardia following opioid administration?

A

tachycardia

111
Q

what is the ideal way to treat vagally mediated bradycardia following opioid administration?

A

atropine IM

112
Q

what should you do if the patient remains bradycardic following administration of an anticholinergic to treat vagally mediated bradycardia?

A

give more

113
Q

what should you do if the patient becomes tachycardic following administration of an anticholinergic to treat vagally mediated bradycardia?

A

wait!

114
Q

what are the less concerning side effects of opioids?

A

sedation (sometimes desirable)
excitation
gut stasis
nausea and vomiting (patient dependent)

115
Q

when may sedation following opioid administration be an issue?

A

if drugs are accumulating when the patient has been given opioids for a longer period

116
Q

how can sedation following long periods of opioid dosing be avoided?

A

decrease frequency of dosing

117
Q

what can be done to reduce the risk of excitation as a side effect of opioid administration?

A

IM
titrate opioid dose to pain level

118
Q

what must be balanced when considering gut stasis as a side effect of opioid administration?

A

pain also leads to gut stasis so must be balanced

119
Q

list the analgesic efficacy of opioids from most to least effective

A

fentanyl
methadone and morphine
pethidine
buprenorphine
butorphanol

120
Q

when is morphine more likely to be used than methadone clinically?

A

CRI

121
Q

what are the main side effects of fentanyl?

A

some dose dependent respiratory depression
likely to induce bradycardia

122
Q

when is fentanyl most useful?

A

CRI as short acting

123
Q

how effective is methadone compared to morphine?

A

equi or more efficatious

124
Q

is nausea and vomiting increased or decreased with methadone compared to morphine?

A

reduced

125
Q

is methadone linked to histamine release when given IV?

A

no concerns

126
Q

why may morphine be better in a CRI than methadone?

A

may be less accumulative

127
Q

what are the respiratory and CVS side effects of methadone?

A

minimal

128
Q

how does methadone interact with NMDA receptors?

A

antagonist - helps with chronic pain and prevention of upregulation of pain response

129
Q

what is the role of an NMDA receptor antagonist?

A

bind to glutamate binding sites on NMDA and prevent release of calcium

130
Q

where are NMDA receptors found?

A

CNS

131
Q

what limits pethidine post operative use?

A

short acting

132
Q

what is the issue with giving pethidine IM?

A

painful - large volume

133
Q

what is the issue with giving pethidine IV?

A

histamine release caused

134
Q

why may there be pain on buprenorphine injection?

A

multi-dose formulation uses preservative which stings and not palatable OTM in cats

135
Q

what route may buprenorphine be less effective?

A

SC

136
Q

what is the onset of action of buprenorphine?

A

delayed for analgesia and sedation

137
Q

where should buprenorphine be stored?

A

in with controlled drugs and usage recorded

138
Q

what schedule is buprenorphine?

A

3

139
Q

what schedule are all other opioids?

A

2

140
Q

what is the analgesic efficacy of butorphanol like?

A

questionable
short-lived and likely to require high doses

141
Q

what is a disadvantage of using butorphanol if patient is more painful than thought?

A

may interfere with any subsequent full agonist administration

142
Q

what is the sedation provided by butorphanol like?

A

good

143
Q

is butorphanol subject to controlled drugs regulations?

A

no

144
Q

what is naloxone used for?

A

specific antagonist so can reverse effects of an opioid (e.g. if significant side effects)

145
Q

what must be done if naloxone is given?

A

alternative analgesia provided as analgesia reversed

146
Q

what are the key areas of perioperative analgesia planning?

A

plan based on patients current and anticipated pain
provide analgesia before it is needed
pain score regularly
consider multimodal analgesia

147
Q

what is preventative analgesia?

A

provision of analgesia before it is needed

148
Q

when selecting an opioid for premed of a patient with moderate to severe pain (e.g. fracture repair) which would you chose?

A

methadone

149
Q

when selecting an opioid for premed of a patient with moderate pain (e.g. ex lap) which would you chose?

A

methadone
pethidine

150
Q

when selecting an opioid for premed of a patient with mild pain (e.g. castration) which would you chose?

A

buprenorphine

151
Q

when selecting an opioid for premed of a patient for sedation only which would you chose?

A

butrophanol

152
Q

what must be balanced when choosing which opioid to use?

A

side effects against analgesia needed

153
Q

when selecting an opioid for intraoperative management of moderate to severe pain which would you chose?

A

methadone
fentanyl (bolus or CRI)
epidural (morphine)

154
Q

when selecting an opioid for intraoperative management of moderate pain which would you chose?

A

methadone
fentanyl (bolus or CRI)

155
Q

when selecting an opioid for intraoperative management of mild pain which would you chose?

A

unnecessary

156
Q

what are alternative options to additional opioids for intraoperative analgesia?

A

regional or local anaesthetic techniques
adjunctive drugs (ketamine/alpha 2)

157
Q

what is the benefit of using local / regional anaesthetic techniques during anaesthesia?

A

increased CVS stability
MAC sparing

158
Q

what are the main considerations for postoperative analgesia?

A

optimal route of administration
dosing intervals

159
Q

what is the dosing interval for methadone?

A

4-5 hours

160
Q

what is the dosing interval for buprenorphine?

A

every 6 hours

161
Q

what can be done to prevent accumulation of methadone if being administered repeatedly over days?

A

increase time interval to 12-18 hours

162
Q

describe the opioid ladder

A

mild post op pain: buprenorphine and NSAIDs
more invasive techniques: buprenorphine and NSAIDs with adjunctive techniques
Moderate pain: methadone, NSAIDs and adjunctive analgesia
severe pain: CRI with morphine
if this is inadequate switch to fentanyl or add additional drug like dexmed, ketamine or lidocaine

163
Q

what is the benefit of a CRI for severe pain management?

A

avoids peaks and troughs in analgesia which occur with bolus dosing

Advanced Clinical Nursing Theory (36 decks)

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