Narcotics

Question 1

MOA of narcotic full agonist

Answer 1

bind mu opioid receptor in brain causing them to produce endorphins (opioids) to give pain relief

NO CEILING for analgesic effect

Question 2

SE of full agonists at high doses & freq.

Answer 2

addiction

euphoria

Question 3

what patients do you need to use caution with when giving morphine? which drug is safest for renal insufficiency?

Answer 3

renal insufficiency use hydromorphone or methadone

morphine undergoes extensive first pass metabolism, if the liver isn’t working accumulation of toxic metabolites can lead to agitation, confusion, & delerium

Question 4

how much more potent is oxycodone than morphine? than oral codeine?

Answer 4

1. 5x morphine

9. 5x oral codeine

Question 5

what is oxycodone usually dosed with for acute pain? what version of oxycodone is used for chronic pain

Answer 5

acetaminophen

use extended release for chronic pain

Question 6

what is oxymorphone a metabolite of? how much more potent is oxymorphone than morphine?

Answer 6

oxymorphone is a metabolite of oxycodone

it is 3x more potent than morphine

Question 7

list the routes of administration for oxycodone hydromorphone and oxymorphone.

Answer 7

oxycodone: PO
oxymorphone: PO or IV
hydromorphone: IV, PR, PO

Question 8

benefit of hydromorphone over oxycodone?

Answer 8

less somnolence

Question 9

what should you do before starting transdermal use of fentanyl?

Answer 9

titrate the patient with a short acting opioid

Question 10

what increases release of drug from fentyanl patch? consequences?

Answer 10

heat (heating pad, increased exertion, fever)

can lead to respiratory depression

Question 11

why do you need to be careful when switching patients from an opioid agonist to methadone?

Answer 11

because the equivalent doses are not well known

Question 12

SE of methadone?

Answer 12

1. QT prolongation
2. torsades
3. death
4. dysphoria
5. irritability
6. tremors
7. seizures
8. antimuscarinic effects (dilated pupils & tachycardia)

4-7 are seen more frequently with PCAs and elderly with renal function

all are dose related

Question 13

use of methadone?

Answer 13

q8hours for pain with:
renal insufficiency
cancer (can be 1st line)

and…
qD for opioid withdrawl in licensed rehab centers

Question 14

meperidines onset of action is ____ than morphines.

Answer 14

faster (VERY RAPID) and so short acting as well

metabolite (normeperidine) half life of 15 to 30 hours

Question 15

what should meperidine not be mixed with? why?

Answer 15

MAOIs

can causes severe encephalopathy & death

Question 16

what drug is contraindicated in children undergoing tonsillectomy and adenoidectomy?

Answer 16

codeine

can cause death

Question 17

what happens to pt who are good/poor metabolizers (or on CYP2D6 inhibitors like fluoxetine) of codeine?

Answer 17

good: higher levels of codeine broken into morphine so increased effect

poor/on inhibitors: no effect possible

Question 18

hydrocodone is converted to what in the body? what is it often combinded with?

Answer 18

hydromorphone

often added to acetaminophen or ibuprofen

Question 19

you must wait 14 days within use of an MAOI before prescribing what opioid?

Answer 19

tapentadol

Question 20

tramadol is what type of opioid agonist? MOA?

Answer 20

centrally acting

it blocks repute of NE & serotonin, binds to narcotic receptor weakly (most analgesic effect is due to its active metabolite)

Question 21

which opioid is only partially reversed by naloxone?

Answer 21

tramadol

Question 22

what are the benefits of tramadol?

Answer 22

no effects on respiration or CVS

Question 23

SE of tramadol?

Answer 23

seizures, N, V, suicide (in suicidal, emotionally disturbed, or prone to addiction)

Question 24

what medications increase your risk of seizures with tramadol?

Answer 24

TCADs
SSRIs
MAOIs
Opioids
Antipsychotics

Question 25

contraindications to prescribing tramadol?

Answer 25

Hx seizures

on drugs than lower seizure threshold

Question 26

what controlled substance class is tramadol?

Answer 26

Class IV

Question 27

MOA of partial agonists? how does it differ

Answer 27

bind mu receptor to induce production of endorphins (but less than full agonists)

they have a ceiling affect

Question 28

distribution of opioids?

Answer 28

rapidly leave blood compartment and concentrate in highly perfused tissues

Question 29

what drugs are metabolized to M3G? normerperidine? what is the concern about M3G, normerperidine, and metabolism?

Answer 29

morphine and hydromorphine

concerned that M3G & normerperidine can cause seizures

accumulation can lead to seizures in renal failure or when high doses are given over a long period of time, especially in the elderly

presentation: agitation, confusion, delerium

Question 30

least sedation with which opioids?

Answer 30

oxycodone, hydromorphone, hydrocodone

Question 31

CNS affects of opioids?

Answer 31

euphoria
sedation
respiratory depression 
cough supression*
miosis 
N, V

Question 32

what drug majorly supresses cough?

Answer 32

codeine

Question 33

peripheral CVS effects of narcotics?

Answer 33

if pt has CVD or hypovolemic narcotics can could hypotension & dilation

meperidine has anticholinergic propertieis: can cause tachycardia

Question 34

peripheral GI effects of narcotics?

Answer 34

gallbladder contraction

decreased GI motility

Question 35

what SE of opioids do not exhibit tolerance?

Answer 35

miosis
constipation (esp. morphine)
seizures

Question 36

uterine effects of opioids?

Answer 36

decrease uterine tone potentially prolonging labor (still use them)

Question 37

skin effects of opioids?

Answer 37

flushing
warmth
urticaria 
more common with IV
not an allergic rxn

Question 38

toxicities of narcotics?

Answer 38

N, V
respiratory depression
constipation
tolerance
Physical & psych dependence

Question 39

how long until you become tolerant to narcotics?

Answer 39

2-3 weeks

Question 40

Sx of physical dependence to full/partial narcotics?

Answer 40

withdrawl Sx:
N, V, D
lacrimation
rhinorrhea
mydriasis
goose bumps
sweating
irritability
dysphoria
yawning*

Question 41

Sx of physical dependence mixed narcotics?

Answer 41

anxiety
anorexia
tachycardia

Question 42

contraindications to narcotics?

Answer 42

renal/hepatic failure
respiratory disorders
pregnancy
head trauma (ICP)

Question 43

MOAI + Narcotic =

Answer 43

HTN

Question 44

Antipsychotics + Narcotics =

Answer 44

sedation

Question 45

benzos + narcotics =

Answer 45

CNS depression

Question 46

adrenal insufficiency or hypothyroidism + narcotics =

Answer 46

exaggerated effects

Question 47

what narcotic in acute pulmonary edema?

Answer 47

IV morphine if pain decreases SOB by decreasing anxiety, preload, and after load

good for MI, CP, & pulmonary edema or LVH

if no pain: furosemide