opioids 2

Question 1

can you use fentanyl in opioid naive patients

Answer 1

NO - MHRA ADVICE!
contraindicated in opioid naive pt. other anagesics and other opioids for non malignant pain need to be used first. there is considerable risk of respiratory depression with the use of fentanyl, especially in opioid-naïve patients, and significant risk with too rapid an escalation of dose, even in long-term opioid-tolerant patients.

Question 2

are fentanyl patches suitable for acute pain or in pt whose analgesic requirements are changing rapidly

Answer 2

no because long time to steady state prevents rapid titration of dose

Question 3

why should you give repeated intra op doses of fentanyl with care

Answer 3

resulting resp depression can persist postop and occasionally it may become apparent for the first time postop when monitoring of the pt might be less intensive

Question 4

true or false - muscle rigidity can occur with IV admin of fentanyl

Answer 4

true

Question 5

IV admin of fentanyl may cause muscle rigidity, which may involve the thoracic (chest) muscles. how can you avoid this

Answer 5

manufacturer advises admin by slow IV injection to avoid
higher doses may require premed with BZDPN and muscle relaxants

Question 6

patient who is on fenttanyl patches says they are unwell. what should you do

Answer 6

if fever is present, monitor them for increased SE as increased absorption is possible

Question 7

how many days are fentanyl patches

Answer 7

3 days (72h)

Question 8

directions for administration of fentanyl patches

Answer 8

apply to dry non irritated non irradiated non hairy skin on torso or upper arm
remove after 72h and site replacement patch on diff area
avoid using same area for several days

Question 9

when should pt immediately remove fentanyl patches

Answer 9

breathing difficulties
marked drowsiness
confusion
dizziness
impaired speech
seek prompt medical attention

Question 10

indication for hydromorphine

Answer 10

severe pain in cancer

Question 11

morphine is used in these 2 unlicensed indications for palliative care

Answer 11

treatment of cough and breathlessness at rest in palliative care

Question 12

Name the 24h MR prep of morphine

Answer 12

MXL

Question 13

MHRA - tapentadol (hint sero- and seiz-)

Answer 13

risk of seizures and reports of serotonin syndrome when given with other drugs
can induce seizures; caution in epilepsy or seizure disorders

Question 14

what is the side effect of tapendatol being taken with SSRIs, SNRIs or TCAs, antipsychotics

Answer 14

these drugs lower seizure risk
so increased risk of seizure
also serotonin syndrome

Question 15

side effects of prolonged use of strong opiates (e.g. morphine, diamorphine, methadone etc)

• 3 SE

Answer 15

hypogonadism (sex glands produce little to no sex hormones)
adrenal insufficiency
hyperalgesia (aka smaller sensations are more painful = high er dose needed)

Question 16

dose to give for break through pain

Answer 16

1/6 to 1/10 of total daily dose every 2-4 hours prn

Question 17

how much can you increase dose of an opiate by each day

Answer 17

1/2 to 1/3

Question 18

WHO pain ladder - what section does tramadol go into

Answer 18

mild to moderate
codeine, dihydrocodeine, tramadol (FOR MODERDATE)

Question 19

Which opioids are safe alt to morphine in RI

Answer 19

For pt with RI, lower dose or less frequent administration of morphine - or different opioid. e.g. An alt is oxycodone, or diamorphine if pt emaciated.

Question 20

What are the safest opioids in RI

Answer 20

Fentanyl, alfentanil and buprenorphine are the safest opioids for use in RI.

Question 21

what is breakthrough pain for opioids and how often

Answer 21

Breakthrough pain: 1/6th to 1/10th of total daily dose every 2-4 hours prn

Question 22

How much can you increase dose of opiate by daily?

Answer 22

Increase doses of opiate by 1/2 to 1/3 each day

Question 23

How much do you reduce dose of opiate by when switching between opiates and why?

Answer 23

Reduce dose by 1/2 to 1/3 when switching between opiates (e.g. morphine 30 to oxycodone) to prevent overdose

Question 24

Which one is more potent - oxycodone or morphine

Answer 24

• Oxycodone more potent than morphine
  ○ More appropriate in pt who cannot consume large qty due to nausea

Question 25

Patient wants to stop taking gabapentin. How should it be stopped?
Reduce by half every day and stop within 3 days
Stop next day for non-epilepsy indications
Reduced over minimum one week

Answer 25

• Answer = reduced over a minimum of one week for gabapentin and pregabalin