Drug/Poison Flashcards
A 74-year-old female presents to the emergency department in respiratory distress with a slightly altered mental status. Her urine drug screen is positive for opioids. The patient and her family deny opioid use. You know this patient well and also doubt she is taking opioids. She has been taking dextromethorphan, guaifenesin, azithromycin (Zithromax), and pseudoephedrine.
Which one of these could be causing a false-positive test for opioids on her urine drug screen? (check one)
Dextromethorphan
Guaifenesin
Azithromycin
Pseudoephedrine
Dextromethorphan
Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids. Pseudoephedrine can cause a false-positive test for amphetamines (SOR A).
Tramadol (Ultram) should be avoided in patients with a history of which one of the following? (check one)
Seizures
Heart failure
Ventricular dysrhythmias
Hypertension
Seizures
Tramadol lowers the seizure threshold and should be avoided in patients with seizures. It is considered a second-line treatment for mild to moderate pain (SOR B). A history of heart failure, ventricular dysrhythmias, or hypertension is not a contraindication to its use.
A 36-year-old male with a history of complex regional pain syndrome has been on oxycodone (OxyContin) for the past 5 years. His pain is well controlled.
Which one of the following side effects is most likely to occur with long-term chronic use of opioids? (check one)
Diarrhea
Sedation
Hypoalgesia
Respiratory depression
Hypogonadism
Hypogonadism
Hypogonadism is an often underrecognized and undertreated side effect of long-term opioid therapy. It is more often seen in men and in patients receiving larger doses of opioids, including intrathecally. Typical symptoms include decreased libido, erectile dysfunction, amenorrhea, or fatigue.
Constipation is not uncommon in patients on chronic opioid therapy, especially if they are elderly, have limited mobility, or are concurrently using other constipating medications. Sedation can occur in the first few weeks after starting therapy but usually tapers off. Hyperalgesia (not hypoalgesia) and allodynia are other side effects resulting from chronic opioid therapy. Respiratory depression is infrequent (SOR C).
A heroin overdose is most likely to cause acute? (check one)
Renal failure
Hepatic necrosis
Myocardial infarction
Pulmonary edema
Pelvic thrombophlebitis
Pulmonary edema
Until recently, the number of heroin overdoses had been in decline for the past few decades. Although heroin still only accounts for about 1% of drug overdoses, it has become more common in the past few years. Overdose is manifested by CNS depression and hypoventilation. Clinical clues include pupillary miosis and a decreasing respiratory rate in the presence of a semi-wakeful state. In addition to hypoventilation, a multifactorial acute lung injury occurs within 2–4 hours of the overdose and is associated with hypoxemia and a hypersensitivity reaction, resulting in noncardiogenic pulmonary edema. Findings include hypoxia, crackles on lung auscultation, and pink, frothy sputum. Treatment must include respiratory support with intubation, mechanical ventilation, and oxygen, as well as opiate reversal with naloxone, which may require repeat doses or intravenous infusion.
Arrhythmias and myocardial ischemia/infarction do not occur as direct pharmacologic effects of heroin, although they may occur as a consequence of the pulmonary toxicity or the presence of other drugs taken intentionally or otherwise (i.e., heroin cut with other agents). Acute renal injury, hepatic injury, and thromboembolic events are also not a direct result of the pharmacologic effects of heroin.
In a patient with chronic, severe, noncancer pain, which one of the following would be most
appropriate for initial opioid therapy?
(check one)
Buprenorphine (Buprenex)
Transdermal fentanyl (Duragesic)
Hydromorphone (Dilaudid)
Methadone (Dolophine)
Morphine
Morphine
Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive,
and equivalent doses can be easily calculated if the patient must later be switched to another medication.
Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not
recommended as first-line therapy because they are expensive and can produce tolerance relatively quickly
(SOR B). Methadone is another second-line option and tolerance is usually less of a problem. It is
inexpensive and long-acting but also has unique pharmacokinetics. It has a very long elimination half-life,
and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Methadone can
prolong the QT interval, especially in patients who are taking other QT-prolonging medications (SOR B).
Buprenorphine is a partial opioid agonist that is usually used for treatment of patients with opioid
addictions. Although it can be effective for treatment of pain, it is expensive and requires special prescriber
training, so it is currently not recommended as a first-line agent for treatment of chronic pain (SOR C).
What is the specific antidote used to treat methanol poisoning? (check one)
Ethanol
Haloperidol
Lorazepam (Ativan)
Naloxone
Thiamine
Ethanol
The current management of methanol intoxication, depending on its severity, includes ethanol administration to inhibit the metabolism of methanol, hemodialysis to remove alcohol and its toxins, and vigorous management of metabolic acidosis with bicarbonate therapy. Ethanol is a competitive inhibitor of toxin metabolism and slows the formation of toxic metabolites, formaldehyde, and formic acid from methanol, permitting these products to be disposed of by ordinary metabolic or excretory pathways. It has a similar effect in ethylene glycol poisoning, slowing the formation of glycoaldehyde and glycolic, glyoxylic, and oxalic acids.
An 82-year-old female with terminal breast cancer has been admitted to hospice care. She is having severe pain that you will manage with opioids.
Which one of the following would be appropriate to recommend for preventing constipation?
(check one)
Fiber supplements
Docusate (Colace
Metoclopramide (Reglan)
Polyethylene glycol (MiraLax)
No preventive measures, and treatment only if constipation develops
Polyethylene glycol (MiraLax)
Constipation is a very common side effect of opioids that does not resolve with time, unlike many other adverse effects. Constipation is easier to prevent than to treat, so it is important to start an appropriate bowel regimen with the initiation of opioid therapy. Fiber supplements and detergents (such as docusate) are inadequate for the prevention of opioid-induced constipation. Metoclopramide is used for nausea and increases gastric motility, but is not indicated in the treatment of constipation. Polyethylene glycol, lactulose, magnesium hydroxide, and senna with docusate are all appropriate in this situation.
False-positive urine screens for drug abuse can occur as a result of (check one)
passive inhalation of crack cocaine
passive inhalation of marijuana smoke
eating poppy seed muffins
consuming products containing hemp
use of black cohosh
eating poppy seed muffins
Eating as little as one poppy seed muffin can produce amounts of morphine and codeine detectable by immunoassay, as well as by gas chromatography and mass spectrometry. Passively inhaled crack cocaine or marijuana (unless an extreme amount is inhaled), and ingested products containing hemp or other common herbal preparations do not produce positive urine drug screens. In addition to poppy seeds, substances reported to cause false-positive urine drug screens include selegiline, Vicks inhalers, NSAIDs, oxaprozin, fluoroquinolones, rifampin, venlafaxine, and dextromethorphan
A 28-year-old female comes to your office for follow-up after learning during an emergency department visit that she is pregnant. Ultrasonography reveals an estimated gestational age of 14 weeks and 4 days. She has been using increasing dosages of oxycodone (OxyContin) daily for the past 7 months and gets sick whenever she tries to stop. She reports using 90 mg daily without a prescription, and stealing when necessary to obtain the drug. She wishes to continue her pregnancy and is worried about the safety of her developing fetus.
Which one of the following is most appropriate for this patient? (check one)
A prescription for oxycodone, 90 mg daily
Buprenorphine/naloxone (Suboxone) therapy
Outpatient detoxification with a clonidine-based protocol
Inpatient detoxification with a clonidine-based protocol
Buprenorphine/naloxone (Suboxone) therapy
Treatment with buprenorphine/naloxone, along with counseling, is considered optimal care for all pregnant women with active opioid addiction. Benefits include the avoidance of cycles of withdrawal and intoxication and a decrease in high-risk behaviors associated with opioid dependence and associated medical complications. A prescription for oxycodone would not be appropriate for this patient. Medically supervised withdrawal is associated with dramatically higher rates of relapse, and should only be offered to women who refuse maintenance therapy or are unable to access such therapy.
A 42-year-old male with a history of chronic low back pain managed with extended-release morphine sulfate (MS Contin) comes to your office to discuss fatigue. Among other causes, you consider the impact that long-term opioid therapy may have on the endocrine system.
Which one of the following endocrine conditions is most commonly associated with long-term opioid therapy? (check one)
Hyperprolactinemia
Hypocortisolism
Hypogonadism
Hypoparathyroidism
Hypothyroidism
Hypogonadism
Long-term opioid therapy is associated with several endocrine conditions, the most common of which is hypogonadism. A 2020 systematic review and meta-analysis that included 52 studies on the endocrine effects of opioids found hypogonadism in 69% of male patients. Lower androgen levels were also found in women, while estradiol was not affected. Menstrual cycle disorders were noted in 87% of premenopausal women taking opioids chronically. Seven of the included studies assessed prolactin levels, which were elevated in 40% of participants. Adrenal insufficiency was noted in 24% of patients. Parathyroid disorders were not included in this manuscript and have not been reported to have an association with opioid use. Two included studies showed lower free T4 levels in those taking opioids, with an estimated incidence of 34%.
A 52-year-old female nurse sees you for the first time. She was previously a patient of a recently retired physician in your practice. Her history is significant for a Roux-en-Y gastric bypass, degenerative joint disease of both knees and shoulders, and chronic low back pain. She takes oxycodone (Roxicodone), 5–10 mg every 4 hours. She tells you that she has been taking this for almost 10 years as treatment for various pains. She says that acetaminophen just “does not touch the pain” and that physical therapy has not worked. She asks you to continue this medication.
Which one of the following would be the most appropriate management of this patient? (check one)
Add an NSAID to the current regimen
Initiate weekly urine drug screens
Taper oxycodone by 5%–10% every 1–4 weeks
Discontinue oxycodone
Taper oxycodone by 5%–10% every 1–4 weeks
According to the Choosing Wisely recommendations from the American Society of Anesthesiologists, opioids should not be used as first-line therapy for chronic noncancer pain. However, more than one-half of patients who receive continuous opioids for 90 days are still receiving them after 4 years. Chronic opioids should not be abruptly discontinued. When discontinuing chronic opioid therapy, the best practice is to reduce the dosage by 5%–10% every 1–4 weeks, but even this may be too fast for some patients.
While controlled substance prescribing plans are considered good practice for long-term opioid use, continuing opioids for this patient would not be good practice given the indication of chronic noncancer pain and the need for safety in her work. Because her use of opioids should be tapered, weekly urine drug screens would continue to be positive and therefore would not be an appropriate management strategy for this patient. NSAIDs are not indicated for this patient due to her history of gastric bypass.
The drug class of choice for the management of breathlessness in end-of-life care is (check one)
anticholinergics
antipsychotics
benzodiazepines
corticosteroids
opiates
opiates
When administered at appropriate doses, opiates do not reduce or compromise respiratory status and do not hasten dying. Opiates help to reduce the sense of air hunger in patients with dyspnea. The use of opiates for palliative therapy in advanced pulmonary disease is supported by clinical guidelines from the American Thoracic Society.
Which one of the following is the most reliable measure to protect children from lead toxicity in the United States? (check one)
Anticipatory guidance for parents and caregivers during well child visits
Checking the serum lead level after a known exposure
Eliminating the sources of lead in the community
Iron and calcium supplementation to reduce lead absorption
Providing appropriate cleaning equipment to families with known lead in the home
Eliminating the sources of lead in the community
Although lead poisoning in children has decreased over the past few decades it is still a problem in the pediatric population. The most reliable and cost-effective way to protect U.S. children from lead toxicity is primary prevention, which includes reducing or eliminating the sources of lead in the community. Checking serum lead levels after exposures, anticipatory guidance regarding hand washing or dust control, iron and calcium supplementation, and providing cleaning equipment have been shown to have either little or no effect, or they address high lead levels only after the lead poisoning has occurred.
You are notified by the nurse that a 66-year-old female who was admitted for pain control for her bone metastases is still having breakthrough pain. You gave her 10 mg of immediate-release oxycodone (Roxicodone) 15 minutes ago.
You are hoping to optimize pain control and minimize sedation, so you advise the nurse that the last dose will have its peak effect
(check one)
now
1 hour after it was given
2 hours after it was given
4 hours after it was given
1 hour after it was given
Most orally administered immediate-release opioids such as morphine, oxycodone, and hydromorphone reach their peak effect at about 1 hour, at which time additional medication can be given if the patient is still in pain. Intravenous opioids reach their peak effect at about 10 minutes and intramuscular and subcutaneous opioids at about 20–30 minutes. Additional medication may therefore be given at those intervals if additional pain relief is required.
A 45-year-old female sees you because of an increase in fibromyalgia pain. On examination she has a BMI of 35 kg/m2 and normal vital signs except for a blood pressure of 156/91 mm Hg. Her other medical problems include obstructive sleep apnea, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder. She smokes one pack of cigarettes daily and does not drink alcohol. She is currently taking metformin (Glucophage), 500 mg twice daily; lisinopril (Prinivil, Zestril), 10 mg daily; gabapentin (Neurontin), 300 mg 3 times daily; oxycodone (OxyContin), 10 mg every 6 hours; and lorazepam (Ativan), 1 mg 3 times daily.
Which one of the following findings in this patient’s history greatly increases her risk of an accidental overdose? (check one)
Tobacco use
Morbid obesity
Use of oxycodone
Use of oxycodone and lorazepam
Use of lorazepam and gabapentin
Use of oxycodone and lorazepam
The increase in opiate-related accidental overdoses has become a significant concern in recent years, prompting the CDC to release updated guidelines for the use of narcotic medications for chronic noncancer pain. There are several concerning issues in this patient’s care. Her obstructive sleep apnea, psychiatric ailments, and concurrent use of opiates and benzodiazepines all increase the risk of an accidental overdose. The CDC also warns against using opiates in patients with heart failure, chronic pulmonary diseases, and a personal history of drug or alcohol abuse.
These risks are so great that the CDC recommends that chronic noncancer pain be primarily treated with nonpharmacologic and nonopiate medications. The use of opioids should be reserved for recalcitrant cases under close supervision at the lowest effective dose for the shortest time possible. The CDC also recommends against using opiates in fibromyalgia and neuropathy due to limited efficacy and side-effect profiles (SOR B). The concurrent use of opiates and benzodiazepines should be avoided in nearly all situations (SOR C). Safety should never be compromised for reduced pain and increased functionality.
