Lippincott Chapter 14: Opiods Flashcards
14.1 A young woman is brought into the emergency room.
She is unconscious, and she has pupillary constriction
and depressed respiration. Based on reports, an
opioid overdose is almost certain. Which of the listed
phenanthrene opioids will exhibit a full and immediate
response to treatment with naloxone?
A. Meperidine.
B. Morphine.
C. Buprenorphine.
D. Fentanyl
Correct answer = B. A morphine overdose can be effectively
treated with naloxone, and morphine is a phenanthrene.
Naloxone antagonizes the opioid by displacing it from the
receptor, but there are cases in which naloxone is not effec-
tive. Meperidine is a phenylpiperidine, not a phenanthrene,
and the active metabolite, normeperidine, is not reversible
by naloxone. The effects of buprenorphine are only partially
reversible by naloxone. Naloxone is effective for fentanyl
overdoses; however, fentanyl is a phenylpiperidine, and not
a phenanthrene.
14.2 A 76-year-old female with renal insufficiency pres-
ents to the clinic with severe pain secondary to a
compression fracture in the lumbar spine. She reports
that the pain has been uncontrolled with tramadol, and
it is decided to start treatment with an opioid. Which of
the following is the best opioid for this patient?
A. Meperidine.
B. Fentanyl transdermal patch.
C. Hydrocodone.
D. Morphine.
Correct answer = C. Hydrocodone would be the best choice
of the opioid given in this case. It will be very important to
use a low dose and monitor closely for proper pain con-
trol and any side effects. Meperidine should not be used for
chronic pain, nor should it be used in a patient with renal
insufficiency. The transdermal patch is not a good option,
since at this time, her pain would be considered acute and
she is opioid naïve. Morphine also is not the best choice in
this case due to the active metabolites that can accumulate
in renal insufficiency.
14.3 Which of the following statements about fentanyl is
correct?
A. Fentanyl is 100 times more potent than morphine.
B. Its withdrawal symptoms can be relieved by
naloxone.
C. The active metabolites of fentanyl can cause
seizures.
D. It is most effective by oral administration.
Correct answer = A. Fentanyl is very selective for the μ recep-
tor and is a very potent opioid. Naloxone is an opioid antag-
onist and can precipitate withdrawal symptoms in patients
currently taking opioids. Meperidine is the opioid whose
active metabolite, normeperidine, can cause seizures.
Fentanyl undergoes hepatic first-pass metabolism and is not
effective via oral administration. Due to high lipid solubility,
fentanyl has been developed for many routes of administra-
tion such as buccal, transmucosal, and transdermal.
14.4 A 56-year-old patient who has suffered with severe chronic
pain with radiculopathy secondary to spinal stenosis for
years presents to the clinic for pain management. Over
the years, this patient has failed to receive relief from the
neuropathic pain from the radiculopathy with traditional
agents such as tricyclics or anticonvulsants. Based on the
mechanism of action, which opioid might be beneficial in
this patient to treat both nociceptive and neuropathic pain?
A. Meperidine.
B. Oxymorphone.
C. Morphine.
D. Methadone.
Correct answer = D. Methadone has a unique mechanism of
action in comparison to the other choices given. Methadone
is a μ agonist, but it also exhibits NMDA receptor antago-
nism that is thought to aid in the treatment of neuropathic
pain and could also aid in prevention of opioid tolerance.
All other μ agonists could help manage neuropathic pain,
but in some situations, higher doses of opioids are needed
to achieve efficacy. It is much better to consider adjuvants
such as tricyclics or certain anticonvulsants in the treatment
of neuropathic pain.
14.5 Which of the following statements regarding methadone
is correct?
A. Methadone is an excellent choice for analgesia in
most patients since there are limited drug–drug
interactions.
B. The equianalgesic potency of methadone is similar
to that of morphine.
C. The duration of analgesia for methadone is much
shorter than the elimination half-life.
D. The active metabolites of methadone accumulate in
patients with renal dysfunction.
Correct Answer = C. The duration of analgesia is much
shorter than the elimination half-life, leading to dangers
of accumulation and increased potential for respiratory
depression and death. Methadone’s equianalgesic potency
is extremely variable based on many factors, and it is highly
recommended that only prescribers very familiar with
methadone should prescribe this agent. The drug inter-
actions associated with methadone are numerous due to
the multiple enzymes in the liver that metabolize this drug.
Methadone does not have active metabolites, which does
make it an option in patients with renal dysfunction
14.6 Which of the following opioids is the LEAST lipophilic?
A. Fentanyl.
B. Methadone.
C. Meperidine.
D. Morphine.
Correct answer = D. Morphine is the least lipophilic of the
opioids listed. Fentanyl, methadone, and meperidine are all
very lipophilic opioids.
14.7 A 64-year-old male is preparing for a total knee
replacement. He is taking many medications that are
metabolized by the CYP450 enzyme system and is
worried about drug interactions with the pain medication
that will be used following his surgery. Which of the
following opioids would have the lowest chance of
interacting with his medications that are metabolized by
the CYP450 enzyme system?
A. Methadone.
B. Oxymorphone.
C. Oxycodone.
D. Hydrocodone.
Correct answer = B. Oxymorphone is metabolized via
glucuronidation and has not been shown to have any drug
interactions associated with the CYP enzyme family. All
other opioids listed are metabolized by one or more CYP
enzymes and increase the risk of drug interactions.
14.8 Which of the following opioids is the best choice
for treating pain associated with diabetic peripheral
neuropathy?
A. Morphine.
B. Tapentadol.
C. Codeine.
D. Buprenorphine
Correct answer = B. Tapentadol has a dual mechanism of
action (μ agonist and norepinephrine reuptake inhibition)
that has demonstrated effectiveness in treating neuropathic
pain. Morphine and buprenorphine could decrease some of
the pain associated with neuropathic pain, but are not the
best choices. Codeine should not be used in chronic pain
management.
14.9 KM is a 64-year-old male who has been hospitalized
following a car accident in which he sustained a
broken leg and broken arm. He has been converted
to oral morphine in anticipation of his discharge. What
other medication should he receive with his morphine
upon discharge?
A. Diphenhydramine.
B. Methylphenidate.
C. Docusate sodium with senna.
D. Docusate sodium.
Correct answer = C. A bowel regimen should be prescribed
with the initiation of the opioid. Docusate and senna include
both a stool softener and a stimulant, which is recom-
mended for opioid-induced constipation. Treatment with
docusate sodium only is ineffective. Constipation is very
common with all opioids, and tolerance does not occur.
Diphenhydramine can be used for urticaria that might occur
with the initiation of an opioid, but this is not reported in this
case. Methylphenidate has been used for opioid-induced
sedation in certain situations, but is not an issue in this case.
14.10 AN is a 57-year-old male who has been treated with
oxycodone for chronic nonmalignant pain for over
2 years. He is now reporting increased pain in the
afternoon while at work. Which of the following opioids
is a short-acting opioid and is the best choice for this
patient’s breakthrough pain?
A. Methadone.
B. Pentazocine.
C. Hydrocodone.
D. Nalbuphine.
Correct answer = C. Hydrocodone is a commonly used
short-acting agent that is commercially available in com-
bination form with either acetaminophen or ibuprofen.
Methadone should not routinely be used for breakthrough
pain due to the unique pharmacokinetics and should be
reserved for practitioners who have experience with this
agent and understand the variables associated with this
drug. Pentazocine and nalbuphine are mixed agonist/antag-
onist analgesics that could precipitate withdrawal in patients
who are currently taking a full μ agonist such as oxycodone
