Opioid Management

Question 1

naturally occurring substances with morphine like properties

Answer 1

opiate

Question 2

includes synthetic substances that have affinity for opioid receptors

Answer 2

opioid

Question 3

natural opioids include

Answer 3

morphine, codeine

Question 4

semisynhetic opioids include

Answer 4

hydromorphone, oxycodone, hydrocodone, heroin

Question 5

synthetic opioids include

Answer 5

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

Question 6

opioid MOAs

Answer 6

Opioid inhibits inhibitory GABAergic neuron acting on pain inhibitory neuron at spinal cord (medulla)

are full or partial agonists of μ, δ, к receptors

Question 7

the conversion from PO to IV doses are usually

Answer 7

2x higher for PO dose

Question 8

how to approach opioid initiation

Answer 8

define goals before start
individualize opioid selection, dosing
short acting opioids may be safer
start low, go slow

Question 9

Around the clock or basal dose for opioids is usually are

Answer 9

regularly scheduled IR or CR/SR release

Question 10

breakthrough PRN dose for opioids is usually ____ of the total daily dose in IR formulation

Answer 10

10-15%

Question 11

when to adjust Short acting IV/ SQ or IR given PRN only

Answer 11

dose by dose

Question 12

when to adjust Short acting IV/SQ or IR given ATC

Answer 12

q24h

Question 13

when to adjust CR/SR dose

Answer 13

48-72hrs

Question 14

when to adjust fentanyl patch dose

Answer 14

q3-6 days

Question 15

how to calculate new dose if pt is using lots of breakthrough doses

Answer 15

total up all regular and breakthrough doses in last 24hrs, divide by 3 for new regular doses, times by 10-15% for new breakthrough doses

Question 16

it is recommended to restrict prescribed LT opioid dose for chronic noncancer pain to ____ morphine equivalents daily

Answer 16

90mg

Question 17

list 3 RF for opioid abuse/ misuse/ addiction

Answer 17

poorly defined pain condition, personal and family hx of alcohol or drug abuse, presence of psychiatric illness, cigarette use, hx of preadolescent sexual abuse, prior hx of aberrant drug related behaviours, =<45yrs, hx of legal problems, associates with others who abuse drugs

Question 18

which of the following AEs do opioid users not build tolerance to? (pick 2)
1. respiratory depression
2. constipation
3. N/V
4. cognitive effects
5. neuroendocrine and sleep effects

Answer 18

2, 5

Question 19

how to treat opioid respiratory deprsesion

Answer 19

naloxone

Question 20

how to treat opioid induced constipation

Answer 20

laxatives and methylnaltrexone

Question 21

how to treat N/V from opioids

Answer 21

dose reduction or rotation
switch to other routes of admin
dopamine antagonists
anticholinergics
ondansetron
treat constipation

Question 22

how to treat pruritius from opioids

Answer 22

antihistamines, opioid rotation, naloxone in refractory cases

Question 23

how to treat cognitive effects from opioids

Answer 23

stimulants or refrain from certain tasks

Question 24

how to treat neuroendocrine effects from opioids

Answer 24

testosterone in men

Question 25

how to treat sleep disturbances from opioids

Answer 25

appropriate sleep hygeine

Question 26

T or F: tolerance to opioid induced sleep disturbances can be build

Answer 26

F

Question 27

T or F: most opioid allergies are AEs and should not have cross sensitivity with different structural classes

Answer 27

T

Question 28

if there is a true allergy to morphine or codeine, what can be done?

Answer 28

try a synthetic or semisynthetic opioid

Question 29

opioid tolerance mechanisms

Answer 29

receptor desensitization superactivation of cAMP pathway

Question 30

opioid tolerance management

Answer 30

increase dose use longer acting opioids add nonopioid analgesics add drugs that prevent/ delay tolerance

Question 31

opioid induced hyperalgesia MOAs

Answer 31

sensitization of primary afferent neurons activation of dynorphin and central glutamatergic systems

Question 32

opioid induced hyperalgesia management

Answer 32

taper dose add NMDA agent try longer acting opioids rotate opioids

Question 33

worsening pain state MOA if the patient is on opioids (3 points)

Answer 33

disease progression neuropathic pain mechs enhanced opioid metabolism

Question 34

worsening pain state AE management strategies

Answer 34

increase dose add nonopioid analgesics treat for neuropathic pain/ other pain mechs

Question 35

opioid rotation may be useful for ________________

Answer 35

balancing analgesia and AEs if AEs are believed to be due to accum of opioid metabolites

Question 36

what is the codeine conversion factor to morphine

Answer 36

0.15

Question 37

what is the oxycodone conversion factor to morphine

Answer 37

1.5

Question 38

what si the hydromorphone conversion factor to morphine

Answer 38

5

Question 39

after getting a MEDD, what should you do to get new dose

Answer 39

reduce dose for incomplete cross tolerance

Question 40

how much should be reduced for incomplete cross tolerance if previous dose was 91MEDD and there were SEs

Answer 40

lower by 50%

Question 41

how much should be reduced for incomplete cross tolerance if previous dose was 50MEDD? give a range

Answer 41

25-40%

Question 42

4 times to stop an opioid

Answer 42

pain resolved AEs > benefits risks > benefits opioid ineffective

Question 43

should you d/c an opioid if it did little to control pain but did well in controlling anxiety

Answer 43

yes- is considered ineffective

Question 44

a rapid taper includes decreasing the dose by _____% q___d and is often completed in ____

Answer 44

10-20% q1-3d in 1-2wks

Question 45

a slow and gradual taper is decreasing the dose by ____% q___wksand is often completed in ____

Answer 45

5-10% q2-4wks in 1-6mths

Question 46

in a slow and gradual taper, once 1/3 of dose is reached, what can improve success?

Answer 46

slowing down taper to decrease of 5% q4-8wks

Question 47

a rapid taper is more for those who are

Answer 47

severe AEs highly motivated on low doses

Question 48

opioid agonist therapy may be useful for

Answer 48

tapering/ switching pts with opioid use disorder concurrent psych conditions LT opioid use (>5yrs) pregnant

Question 49

opioid drug interactions include

Answer 49

CNS depressants like ethanol and BZs serotonergic agents those that interfere with CYP3A4 and 2D6

Question 50

which opioids have serotonergic components

Answer 50

tramadol, methadone