Lecture 3-4

Question 1

Name natural opioids ?

Answer 1

Morphine
Codeine

Question 2

Name semi-synthetic opioids?

Answer 2

hydromorphone, oxycodone, hydrocodone ( heroin)

Question 3

Name synthetic opioids .

Answer 3

fentanyl, methadone, buprenorphine, meperidine,
tramadol, pentazocine, diphenoxylate, loperamide

Question 4

Are all opioids analgesics ?

Answer 4

Not all are analgesics
Can be agonist or antagonist

Question 5

What is the MOA of opioids Analgesics ?

Answer 5

Agonist or partial agonist to mu, delta and kappa receptors in the whole PNS/CNS

Question 6

Which receptors PURE agonist like to bind ?

Answer 6

mu

Question 7

What is the INITIAL ADULT DOSE for morphine ?

Answer 7

5-20 mg

Question 8

What is the INITIAL ADULT DOSE for oxycodone ?

Answer 8

5-15mg

Question 9

What is the INITIAL ADULT DOSE for hydromorphone ?

Answer 9

1-4 mg

Question 10

What are the tools for opioid risk assessment ?

Answer 10

CAGE and opiod risk tools

Question 11

What is ATC or basal dose ?

Answer 11

regular schedule IR / CR / SR opioids
** depends on the nature of the pain

Question 12

What are the steps for titration of opioid ?

Answer 12

Repeat pain assessment

Total 24hrs dose → new TTD

Divide the new TDD in regular dose + BTB dose ( 10-15% of ATC)

Question 13

What is the RECOMMENDED dose of morphine equivalent for long term noncancer chronic patients ?

Answer 13

< 90 mg

Question 14

What are the different examples of ADR of opioids ?

Answer 14

N/V, constipation, tolerance, overdose, sedation, respiratory depression, hyperalgesia → leading to neurotoxicity

Question 15

What is the solution to respiratory depression ?

Answer 15

Naloxone

Question 16

What are the solutions for N/V from opioid ?

Answer 16

Dose reduction
Rotation
Dopamine antagonist
Anticholinergics
Ondansetron

Question 17

Which of the ADR is NOT tolerance developed ?

Answer 17

Constipation
neuroendocrine effects
sleep disturbance

Question 18

If you are “allergic” to an opioid , can you switch to another ?

Answer 18

YES, unlikely to have cross-sensitivity
but is allergies to the PURE opioids, careful to switch

Question 19

Why would want to add a NMDA antagonist ?

Answer 19

Opioid Induced hyperalgesia

Question 20

what are the various solutions to opioid induced hyperplasia ?

Answer 20

Increase/ Decrease the dose
Rotation → fentanyl, buprenorphine, methadone
Add NMDA antagonist, antidepressant, anticonvulsants and NSAIDs
Non-pharm

Question 21

What are the steps of opioid rotation ?

Answer 21

Assessment
Opioid total daily dose TDD
Morphine Equi Daily Dose (MEDD)
Convert to new agent
Reduce for incomplete cross-tolerance
>= 90 MEDD = ⬇50%
<90 MEDD = ⬇25-40%
Choose the appropriate regimen

Question 22

What are the dose equivalence with the common 3 opioids ?

Answer 22

Morphine - 30 mg
Oxycodone - 20 mg
Hydromorphone - 6 mg

Question 23

When would you STOP opioid tx ?

Answer 23

Pain has resolved / risks > benefits / AD > benefits
/ opioid ineffective

Question 24

How to discontinue opioid if a patient takes > 1 weeks ?

Answer 24

Include non-opiod
Takes 1-3 weeks
⬇TDD <=25% q2-3d

Question 25

What are the withdrawal symptoms for opioid ?

Answer 25

drug craving anxiety, insomnia, abdominal pain, vomiting, diarrhea, tremors

Question 26

What is a rapid taper ?

Answer 26

High ADR risk
⬇ dose 10-20% q1-3 days (1-2wk)

Question 27

What is a SLOW taper ?

Answer 27

⬇dose 5-10% q2-4wks ( 1-6 months)
Change formulation

Question 28

Which opiods should i double check for DDI ? ( serotonogenic effect

Answer 28

methadone and tramadol

Question 29

what are the PK for opiods ( DDI) ?

Answer 29

CYP 3A4 and 2D6