Pain: Opioids Flashcards
What are some examples of pure opioid agonists?
- Morphine Prototypes
- Morphine, Codeine, Hydromorphone, Oxycodone, Hydrocodone
- Non-morphine Prototypes
- Methadone, Fentanyl, Meperidine, Tramadol
What are some examples of mixed opioid agonists?
- Buprenorphine
- Butorphanol
- Nalbuphine
- Pentazocine
Name an Opioid Antagonist (Antidote).
Naloxone
Name a Peripheral Opioid Antagonist (PAMORAs).
methylnaltrexone
Name Anti-diarrheal Drugs (Opioid).
- Loperamide
- diphenoxylate-atropine
What is pain?
- A personal and individual experience
- Whatever the patient says it is
- Exists when the patient says it exists
- Pain is Subjective- LISTEN TO YOUR PATIENT!
- There’s no secret blood level or parameter we can objectively measure
- Pain is the “Fifth Vital Sign”
What are the two types of pain rating scales? Who are they used for?
- Numeric rating scale of 0-10 (ADULTS)
0=no pain, 10=worst pain ever experienced - Faces of Pain Scale (PEDIATRICS)
How to assess numeric rating scale?
Score of 0 = No Pain
Score of 1-3 = “MILD” Pain
Score of 4-6 = “MODERATE” Pain
Score of 7-10 = “SEVERE” Pain
What can hydromorphone be defined as?
an OPIOID which is a type of “ANALGESIC”
What is an analgesic?
- ANALGESIA simply means painless
- AN= lack of something (example, Anemia= Lack of/deficiency of Red Blood Cells)
- ALGEIN/ALGESIA= PAIN
What are opioids?
Narcotics is a term that is no longer preferred when referencing opioids
- Poppy plant/seeds → Opium → morphine
- Morpheus - Greek God of Dreams
What are the three main opioid receptors?
- Mu (some opioids work here)
- Kappa (some opioids work here)
- Delta (most drugs don’t target this one)
Where are opioid receptors located?
- Brain (Reward Pathway - DOPAMINE = Euphoria, Addiction)
- Brain Stem (Respiratory Center- slow or stop breathing)
- Spinal Cord (pain relief)
- Peripheral Neurons (pain relief)
- GI Tract (side effects like constipation/urinary retention)
What are examples of morphine-like drugs?
- morphine
- codeine
- hydromorphone
- oxycodone
- hydrocodone
What is morphine and morphine-like drugs used to treat?
- MODERATE and/or SEVERE PAIN (NOT mild, review the pain ladder)
- COUGH/ANTI-TUSSIVE (prescription only, generally liquid cough syrups)
What is morphine combined with?
Frequently combined with Non-opioids
Examples:
Percocet® is Oxycodone + Acetaminophen
Norco®/Vicodin® is Hydrocodone + Acetaminophen
How does morphine work?
Agonists of opioid receptors in the CNS and periphery (Mu + Kappa)
What are adverse effects of morphine-like drugs?
- Miosis (constriction of the pupil)
- Out of it (sedated)
- Respiratory depression
- Pruritus (common)
- Hypotension (dizzy) & Head injury(avoid!)
- Infrequency of urination and bowel movements (referring to urinary retention or constipation)
- Nausea/Narcotics
- Emesis
What to do for “Out of it” (sedated) adverse effect of morphine?
- Counsel patients NOT TO DRIVE!
- use “Sedation Scores/Scales”
- If patient slurs speech or drifts off to sleep, monitor carefully (maybe reduce opioid dose, considering holding the dose?)
- If patient is difficult/impossible to wake up, stimulate the patient, stop opioids, notify provider + rapid response team (have naloxone ready)
What to do for Respiratory Depression adverse effect of morphine?
- Opioids can work on part of the brain that controls breathing
- This is what KILLS people
- 1) Hold if respiratory rate <12 and/or Oxygen saturation <90% and notify provider
- 2) Know what drugs NOT to mix/ what drugs can INCREASE the risk for respiratory depression (B & Z rule)
What is the B & Z rule?
- Don’t mix Opioids with:
~ BOOZE/Alcohol/EtOH
~ Zzzz drugs (Ambien®= zolpidem)
~ etc.
What to do for Pruritis adverse effect of morphine?
- Some opioids can cause the release of histamine which can cause itching
- This is NOT an allergic reaction
- Some prescribers may order antihistamines to help counter act this….. But now we run into the B & Z rule!
- This may lower blood pressure + HR. Do not give if a patient is HYPOTENSIVE (SBP<90, DBP<60) or BRADYCARDIA (HR<60)
What to do for Hypotension/Head Pressure adverse effect of morphine?
- Histamine release may lower blood pressure. Do not give if a patient is HYPOTENSIVE (SBP<90, DBP<60)
- This may also drop the heart rate too! (do not give if HR<60)
- Dizziness can occur! Change positions SLOWLY (Fall RISK!)
- Due to vessel dilation from histamine, this may cause cerebrovascular dilation = elevated intracranial pressure (^ ICP)
What to do for Infrequency adverse effect of morphine?
- Opioids will cause CONSTIPATION
- Patients will never ADAPT to this, you will always have constipation
- The rule is “All MUSH, no PUSH”
- This means that patients have soft stools, but their intestinal muscles aren’t working
- Opioids also impair the bladder and patients may also have difficulty peeing (urinate every 4 hours)
What to do for Nausea/Narcotic adverse effect of morphine?
- Opioids stimulate receptors in the GUT and BRAIN and can make patients feel nauseated
- Prescribers often are proactive and have if needed anti-nausea drugs (called anti-emetics) ordered
- TAKE WITH FOOD
Can anyone prescribe opiods?
Prescribers are required to have special DEA licenses
(some opioids are not allowed to have refills)
How can nurses avoid mishandling controlled substances?
- ALWAYS double count opioids. They are LOCKED UP. Keep them in SECURE AREAS
- If drawing up partial doses (oral liquid/IV syringe) ALWAYS have a WITNESS!
What to do for Emesis adverse effect of morphine?
- Opioids stimulate receptors in the GUT and BRAIN and can make patients feel nauseated
- Prescribers often are proactive and have if needed anti-nausea drugs (called anti-emetics) ordered
- TAKE WITH FOOD
What are some other adverse effects of morphine-like drugs?
- Diaphoresis/Flushing/Sweating
- Tolerance / dependence
- EUPHORIA/ addiction
- Allergic Reactions (itching vs difficulty breathing!)
What are some true allergy concerns for morphine-like drugs?
- Throat Itching
- Tongue/Lip/Eyelid Swelling (Angioedema)
- Throat Swelling
- Difficulty Breathing
- Hives
What examples of Non-Morphine Opioid Agonists?
- methadone
- fentanyl
- meperidine
- tramadol
What are non-morphine opioid agonists used to treat?
- These drugs are still OPIOIDS
- MODERATE/SEVERE PAIN
- However, each of these drugs is unique
What can non-morphine opioid agonists be combined with?
- Frequently given with Non-Opioids as a multi-modal pain approach
- Example: Ultracet® is Tramadol + Acetaminophen
What are adverse effects of non-morphine opioid agonists?
- “MORPHINE”
- seizures
- serotonin syndrome
What are contraindications of non-morphine opioid agonists?
- Breastfeeding (codeine + tramadol)
- Biliary colic, Elevated Intracranial Pressure (ICP)
- History of Seizures (Caution, not contra-indication)
What are some unique adverse effects of TRAMADOL?
- Can increase risk for SEIZURES and SEROTONIN SYNDROME
What does MEPERIDINE treat?
- Moderate/Severe Pain
- May seen used in the OR to reduce SHIVERING!
What are some unique adverse effects of MEPERIDINE?
- Can cause SEIZURES (max use is 48-72 hours)
- Can increase risk for SEROTONIN SYNDROME
What is serotonin syndrome?
Dangerous consequence of using multiple drugs that increase SEROTONIN levels
What drugs to be aware of to avoid serotonin syndrome?
Never mix an MAO-I (phenelzine is a prototype) with:
- Opioids (Tramadol and Meperidine)
- Antidepressants
- Dextromethorphan (DM) Cough Suppressant
- Linezolid (Antibiotic)
- “Triptans” (migraine medication)
What does METHADONE treat?
- moderate/severe pain
- substance use disorders (ex: heroin usage)
What are some unique adverse effects of METHADONE?
- Can prolong the QT interval (dysrhythmia risk)
- Require periodic EKGs
What is the strongest opioid group?
fentanyl
What are the different routes for fentanyl?
- IV is only allowed in critical care areas (ICU, OR, ED)
- Oral Pill = NONE
- Sublingual/Buccal= Lollipops
- works FAST for extreme pain
- Patch
- does not work fast
What are partial/mixed opioid agonists?
They only cause PARTIAL opioid receptor activation
What are some partial/mixed opioid agonists?
- Buprenorphine
- Butorphanol
- Nalbuphine
- Pentazocine
What do partial/mixed opioid agonists treat?
- Pain management
- BUPRENORPHINE- Addiction management (Substance Use Disorders)
What are adverse effects of partial/mixed opioid agonists?
- “MORPHINE”
- Partial Pain Relief
- Partial Withdrawal
- Partial Respiratory Depression
What happens when a patient is taking oxycodone and then takes Buprenorphine?
Partial Agonists have a HIGH AFFINITY for opioid receptors
- Buprenorphine will bind to the opioid receptor and knock off the oxycodone
What are the three primary symptoms of opioid overdose?
- Respiratory Depression
- Miosis
- Coma
What is an antidote to opioid overdose?
Opioid Antagonist:Naloxone aka Narcan®
How does Naloxone treat opioid overdose?
Competitive antagonist at opioid receptors (has an extremely high affinity)
What are adverse effects of Naloxone?
Nothing worth noting. This will NOT harm someone. Don’t be afraid to use it when in doubt.
What to know about Naloxone?
- Only works for opioids
- If it didn’t work, feel free to give another dose
- It will NOT harm someone
- Has short half life (less than 1 hour)
Name a Peripheral Mu Opioid Antagonist (PAMORA).
Methylnaltrexone
What does Methylnaltrexone treat?
- Opioid Induced Constipation (OIC)
- MethylnaltreXone = X out the Opioids in the GI Tract
What are adverse effects of Methylnaltrexone?
- abdominal bloating
- cramping because GI tract starts back up
Name some Anti-Diarrheal Opioids.
- Loperamide
- Diphenoxylate
What do anti-diarrheal opioids treat?
diarrhea
What are adverse effects of loperamide and diphenoxylate?
- Taking these drugs can rapidly cause Constipation!
- Extreme usage/misuse = bowel obstruction
- Do NOT use if a patient is infected with c. diff
- C.diff creates a toxin which needs to be excreted or it can kill someone
What is opioid tolerance?
Adaptation to the opioid. Patients may require higher doses of an opioid over time to achieve the same effect (pain relief)
- Opioid tolerance and physical dependence are expected with long-term opioid treatment. Do not be confused with psychologic dependence (addiction)
What are characteristics of opioid withdrawal syndrome?
- agitation, anxiety, insomnia, flu‑like manifestations, opioid cravings
- rhinorrhea, yawning, sweating, pilo-erection (goose bumps), abdominal cramping, and diarrhea.
- hypertension, tachycardia
- Manifestations are non‑life‑threatening, although suicidal thoughts can occur.
How to help opioid withdrawal syndrome?
- Clonidine (drug for hypertension) helps slow down autonomic hyperactivity
- Methadone + Buprenorphine
