Exam 4: Opioid Analgesics-Part 2 Flashcards by Austin Shackelford

Desired Clinical Effects of Opioid Drugs…KNOW THIS, OWN IT: Potent _______….Sedation and ________…..______ suppression

analgesic…euphoria….cough

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Desired Clinical Effects of Opioid Drugs…KNOW THIS, OWN IT: GI effects- _______ smooth muscle tone, _____ propulsion and motility, used for treatment of _______.

increases….decreases….diarrhea

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Adverse Reactions: Physical _______

addiction

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Adverse Reactions: _______ depression (____ related)…dcreases brainstem sensitivity to _____.

respiratory…dose….CO2

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Adverse Reactions: Opioids directly stimulate the chemoreceptor trigger zone the in medulla to produce ______ and _______. BUT don’t worry, regular, repeated dosing prevents this by depressing its center (floor of fourth ventricle).

nausea and vomiting

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Adverse Reactions: this reason is why opiods are given to stop diarrhea (off label)…

MAD constipation yo

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Adverse Reactions: pinpoint pupils (scientifically named ______)… this is a diagnostic for addiction.

Miosis

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Adverse Reactions: When on opioids, the production of _____ is stimulated and there for you retain urine, this can be an issue if the pt has _______ problems already.

ADH….prostate

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Adverse Reactions: Opioids can occasionally stimulate _____ effects: anxiety, restlessness, nervousness, dysphoria

CNS

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Adverse Reactions of Opioid Drugs-Cardiovascular: _______ the vasomotor center and stimulates the vagus nerve so at high doses you can get _____tension, _______cardia, and syncope.

depress….HYPOtensino….tom Bradycardia

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Adverse Reactions of Opioid Drugs-Biliary tract _______

– Biliary colic (watch in patients with gallstones)

constriction

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Adverse Reactions of Opioid Drugs: ________ release! causing itching and urticaria…

histamine

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Adverse Reactions of Opioid Drugs-Pregnancy and lactation….______ labor; depress fetal _______ if given near term…..Infants born to addicts have marked depressed respiration and experience withdrawal….Cross into _______…..morphine and codeine=FDA Pregnancy category “___”

prolong….respiration….breast milk…“C”

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Adverse Reactions of Opioid Drugs–Severity of side effects is proportional to ______.

efficacy… HA I bet you thought it would be potency

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Adverse Reactions of Opioid Drugs–Overdose: Major symptom: ________ depression, Pinpoint pupils, Coma, Treated with antagonist = ________

respiratory…naloxone

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Adverse Reactions of Opioid Drugs-Withdrawl: Occurs after abrupt discontinuance of drug….Yawning, lacrimation, perspiration, rhinorrhea, gooseflesh and piloerection (“_______”), irritability, nausea, vomiting, tachycardia, tremors, chills

“cold turkey”

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Hypersensitivity Reactions to Opioids–Most are ________ – Skin rashes, urticaria…Differentiate from symptoms caused by histamine release (itching)..If true allergy, avoid…..Some preparations contain _________ (allergy to sulfites)

dermatologic…sodium bisulfite

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Clinical indications- Dentistry: ________ & ________, in medicine-those two AND _______, _______.

Analgesia, sedation….cough suppression and diarrhea

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Opium = dried juice obtained from unripe seed capsules of poppy plant (Paparer somniferous)…25% of the dried juice consists of the ______: morphine, codeine

alkaloids

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Heroin is a ________ morphine product.

synthesized

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Please name the 8 PURE agonists

1.morphine 2. oxycodone(percocet) 3.hydrocodone(vicodin) 4.codeine 5.dihydrocodeine 6.propoxyphene (withdrawn) 7.meperidine 8.fentanyl (most potent)

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What is the mixed agonist/antagonist that is Equally as potent as morphine?

METH-a-done

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What schedule is Methadone?

II (mixed agonist/antagonist for detox/chronic pain)

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Methadone inhibits _______ pain pathways.

ascending

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Methadone produces generalized _____ depression.

CNS

Mathadone has SUPERIOR ______ efficacy.

oral

Methadone has a ____ duration of action.

long (6 to 12 hours)

Methadone was initially used as a maintenance regimen for ______ abuse = FDA approved detoxication and maintenance programs & ______ therapy.

heroine..chronic pain

When you hear pure antagonist, think of the _______!!!! (reversing some of the negative effects of opioids.

Antidote

KEEP a drug of this type in the dental offices that administer sedation to reverse effects...its effects occur in ___ to ___ MINUTES and last for ___-___ hours...What are 2 examples of this?

A pure antagonist..1 to 2 minutes....1 to 4 hours....nal-ox-one & nal-trex-one

Which one is used for alcohol abstinence..naltrexone or naloxone?

naltrexone

Naloxone (Narcan)...In dental office, IV to reverse overdose of _______ and _______ (sedation).

fentanyl and meperidine

What is the PROTOTYPE Pure Agonist?

Morphine

Morphine- Acts like internal _______/_______.

enkephalins/endorphins

Morphine- ______ mediated receptor function.

G-protein

Morphine- Decreased ___________ in pain | pathways and it acts ______.

neurotransmitter...centrally

What is the most widely used route of administration for morphine?

Oral morphine is ______ absorbed....Not used in _______

poorly....dentistry

Morphine has the ______ ring structure = which is ___ sided...Needed to bind to opiate (___) receptor

Piperidine...6....mu

What is the most widely abused opiate in hospital personnel? WHY?

Mep-er-id-ine (Dem-erol)...Does not cause MIOSIS (masks the pinpoint pupils

Meperidine (Demerol) is an Excellent analgesic, but its _______.

addictive

Meperidine (Demerol) does not have mitosis, but does display _______, which is an atopine effect.

My-dri-asis

Meperidine (Demerol)-synthetic or natural?...How much sedation/euphoria compared to morphine/heroin?

synthetic.. Not as much sedation and euphoria as | with morphine or heroin

Meperidine (Demerol)...What are the 2 primary side effects?

1. Nausea 2.Respiratory Depression

How is meperidine (Demerol) mainly used in dentistry?

IV sedation

meperidine (Demerol)-Not as _______ as fentanyl, Not as much risk for ________ as with fentanyl

potent...respiratory depression

meperidine (Demerol)- has a ______ margin of safety with a ___ mg dose, administered via _______.

wider..25 mg..IV

meperidine (Demerol)-can be given ______ for moderate to severe pain, ____-____ mg every 4 hours as needed (so ___ hours of duration)

orally...50-100mg...4

What is one of the most frequently prescribed opioids in dentistry?

codeine!

Codeine-Not used as ____- agent in dentistry = moderate efficacy, but many _______ side effects...used in combination products with ________ or ________.

sole...GI...acetaminophen or aspirin

Codeine-has 1/__ the potency of morphine, so 10 mg of morphine = ____ mg of codeine

1/6th....60 mg codeine

Codeine-What is the OPTIMUM dose?..if exceeded no greater ________ effect, but more _______!

60 mg...analgesic...side effects

Oral morphine is poorly absorbed, so we use ________, given orally, instead. BUT, there is risk for _______.

codeine...addiction

Codeine is indicated for _______ to moderately ______ pain...not indicated for _______ pain!

moderate to moderately severe...severe!

What is the drug of choice for cough suppression?

Codeine

Codeine, rather typical side effects like nausea, dizziness, constipation, hypersensitivity, but _______ is an odd one.

excitability

Codeine dosing- __ to __ mg every 4-6 hours...#1=__ mg, #2=___ mg, #3= __ mg, #4=___ = 60 mg

15-60mg every 4-6 hours....#1=8mg (OTC in Canada!! Yay Canada!)....#2=15mg....#3=30mg....#4=60mg

What is the MOST WIDELY prescribed codeine product by dentists? What schedule is it?

Tylenol #3-300 mg acetaminophen and 30mg codeine..schedule 3

This is a good product for tension headaches!- C-III • butalbital 50 mg (barbiturate) • aspirin 325 mg • caffeine 40 mg

Ms. Fior-in-al with Codeine

What drug is 3 times more potent than codeine, has low incidence of side effects, and is typically assoc with acetaminophen?

HydroCodone

What type of drug is Vicodin?

Hydrocodone (5mg) + Acetaminophen (500 mg)

What kind of drug is Lorcet/Lortab?

Hydrocodone (5mg) + Acetaminophen (500mg)

What does the term "CET" wedged into a drug name indicate?

That it has aCETaminophen!!

What is in our New Drug, Norco? What is a great FDA approved benefit? How does it still work?

10mg of hydrocodone and 325 mg acetaminophen..FDA likes the less amount of acetaminophen to guard against acute liver damage...works with a bit higher opiate dose

What is Vicodin's brand new schedule?

C-II, thanks DEA...

What are 2 examples of hydrocodone + ibuprofen? (hint they have some part of ibuprofen in their names)

1. Vico-Profen 2. Ibu-done

In hydrocodone + ibuprofen, the ibuprofen dose stays consistent at ____ mg...but many clinicians want to it the ibuprofen ceiling, so they will add ___ mg.

200mg...supplement with 200 more mg to get the 400 mg ceiling

Dihydrocodeine has the same efficacy/potentcy as _______, so its no more effective then ________.

codeine..Tylenol #3

What is an example of dihydrocoeine?

Synalgos DC (dihydrocodeine, aspirin, caffeine)

What is AS potent as morphine and is HIGHLY addictive? There for it is more potent then ______, which means more ______.

Oxycodone...codeine...side effects

What is the schedule for Oxycodone? How is it usually paired in dentistry?

C-II...usually combined with an NSAID

What are the 3 oxycodone drugs that have oxycodone and acetaminophen/aspirin/ibuprofen?

PercoCET (acetamin), Percodan(aspirin), RoxiCET (acetamin), Combunox (ibu)

What is the NEW drug with oxycodone and ibuprofen? How much of each?

COMB-UN-OX.. 5 mg oxycodone, 400 mg ibuprofen

Combunox-Short term management of acute, | moderate-to-_____ dental pain, Use for __-__ days only, ______ available

severe....3-5 days..generic

fentanyl is ____ times more potent than morphine! AND ____ times more potent then meperidine.

100 times!!!....500 times

In dentistry, fentanyl is used for __________ only*, via which 3 ways?

conscious sedation...via IV, transdermal, or a LOLLIPOP

What is the great dental opiate not scheduled by DEA (May be scheduled in certain states)...for moderate to moderately-severe pain

tram-a-dol

Tramadol-Use for ≤___ days for acute dental pain

Tramadol-Binds to ____ opiate receptors in CNS, which inhibits ________ pain pathways, altering perception of and response to pain

mu....ascending

Tramadol-Also inhibits the reuptake of ________ and ________....

norepi and serotonin

What is a brand name for tramadol?

Ultram

tramadol-Immediate release given 50-100 mg every 4 to 6 hours, not to exceed ____ mg/day = titrate up

400 mg/day

tramadol-a rare complication:_________ and it is also associated with ________.

are complication = anaphylaxis.....Associated with seizures

PLEASE DONT CRUSH YOUR tramadol!!!!!!!Rapid release and absorption of extended release formulation if broken, crushed or chewed can lead to potentially lethal ________.

overdose

Ultracet is a combination of _______ and _______. What ingredient dictates the max daily dose?

acetaminophen (325 mg ) and tramadol (37.5 mg)...acetaminophen dictates

What is our kick ass NSAID that provides analgesia at the opioid level? Therefore its indicated for moderate to _______ dental pain

ket-or-olac (Tor-a-dol)...severe

ket-or-olac (Tor-a-dol)- SHORT term use, less than or equal to ___ days of use.

5 days

ket-or-olac (Tor-a-dol)- since its an NSAID, watch for ______ and _______ complications.

bleeding...GI

Prescribing Considerations-Most patients are better managed with _______ (anti- inflammatory effect)

NSAIDs

Prescribing Considerations- Start with ________ preparations (containing codeine or hydrocodone)

combination

Prescribing Considerations- Only prescribe stronger opioids for ______ periods of time, then switch to something else

SHORT

Prescribing Considerations- rescribe ______ quantities without ______.

SMALL....REFILLS

Prescribing Considerations- should be straight forward, but prescribe only if patient has received _________.

dental treatment

Prescribing Considerations- If _____ persists, bring patient back for evaluation and local treatment

pain

Prescribing Considerations- If patient demands more drugs, refer to a _______ (chronic pain). Because it is managed differently!

pain clinic

Key Points to Remember- Opiates are ________ substances in the US

scheduled

Key Points to Remember-We write for limited quantities due to the potential for ________ – **Limit use to ___-___ days (acute pain only)

addiction...3 to 5 days

Key Points to Remember-__________ with ________ is most widely used opiate agent for the management of dental pain (Vicodin or Lorcet)

hydrocodone with acetaminophen

Key Points to Remember-Of the codeine preparations, _______ is the most widely prescribed in dentistry

Tylenol #3

Key Points to Remember-________ with __________ is used to treat the more SEVERE degrees of pain

oxycodone with acetaminophen

Key Points to Remember- __________ is useful for patients with a history of CODEINE ALLERGY.

meperidine (Demerol)

Key Points to Remember- ______ and _________ (Dilaudid) are NOT indicated as analgesics in ANY dental situation!

morphine...hydromorphone

Key Points to Remember- Whenever possible, an ______ is preferred to a opiate agent for pain management – Opiates do not reduce ________, which is the most common etiology for dental pain – Treating inflammation will reduce _____

NSAID....inflammation...pain

Key Points to Remember- All opiates will cause _______ in most patients, ________ is another common complaint

nausea...constipation

Key Points to Remember- _______ patients: use caution – NSAIDS and GI bleeding– Aspirin and hemorrhage– Opiates and constipation– Opiates and CNS effects = disorientation, falling– Liver and renal function = start lowest dose, titrate up

Elderly

LAST BUT NOT LEAST- please rank the opiates by potency (from highest to lowest) (7)

1.fentanyl 2.morphine 3.oxycodone (tie w/morphine) 4.meperidine 5.hydrocodone 6.codeine 7.dihydrocodeine (tie w/morphine)