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320 Pharmacology > Pain: Opioids > Flashcards

Pain: Opioids Flashcards

1
Q

What are some examples of pure opioid agonists?

A
  • Morphine Prototypes
    • Morphine, Codeine, Hydromorphone, Oxycodone, Hydrocodone
  • Non-morphine Prototypes
    • Methadone, Fentanyl, Meperidine, Tramadol
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2
Q

What are some examples of mixed opioid agonists?

A
  • Buprenorphine
  • Butorphanol
  • Nalbuphine
  • Pentazocine
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3
Q

Name an Opioid Antagonist (Antidote).

A

Naloxone

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4
Q

Name a Peripheral Opioid Antagonist (PAMORAs).

A

methylnaltrexone

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5
Q

Name Anti-diarrheal Drugs (Opioid).

A
  • Loperamide
  • diphenoxylate-atropine
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6
Q

What is pain?

A
  • 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”
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7
Q

What are the two types of pain rating scales? Who are they used for?

A
  • Numeric rating scale of 0-10 (ADULTS)
    0=no pain, 10=worst pain ever experienced
  • Faces of Pain Scale (PEDIATRICS)
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8
Q

How to assess numeric rating scale?

A

Score of 0 = No Pain
Score of 1-3 = “MILD” Pain
Score of 4-6 = “MODERATE” Pain
Score of 7-10 = “SEVERE” Pain

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9
Q

What can hydromorphone be defined as?

A

an OPIOID which is a type of “ANALGESIC”

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10
Q

What is an analgesic?

A
  • ANALGESIA simply means painless
  • AN= lack of something (example, Anemia= Lack of/deficiency of Red Blood Cells)
  • ALGEIN/ALGESIA= PAIN
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11
Q

What are opioids?

A

Narcotics is a term that is no longer preferred when referencing opioids
- Poppy plant/seeds → Opium → morphine
- Morpheus - Greek God of Dreams

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12
Q

What are the three main opioid receptors?

A
  • Mu (some opioids work here)
  • Kappa (some opioids work here)
  • Delta (most drugs don’t target this one)
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13
Q

Where are opioid receptors located?

A
  • 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)
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14
Q

What are examples of morphine-like drugs?

A
  • morphine
  • codeine
  • hydromorphone
  • oxycodone
  • hydrocodone
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15
Q

What is morphine and morphine-like drugs used to treat?

A
  • MODERATE and/or SEVERE PAIN (NOT mild, review the pain ladder)
  • COUGH/ANTI-TUSSIVE (prescription only, generally liquid cough syrups)
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16
Q

What is morphine combined with?

A

Frequently combined with Non-opioids
Examples:
Percocet® is Oxycodone + Acetaminophen
Norco®/Vicodin® is Hydrocodone + Acetaminophen

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17
Q

How does morphine work?

A

Agonists of opioid receptors in the CNS and periphery (Mu + Kappa)

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18
Q

What are adverse effects of morphine-like drugs?

A
  • 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
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19
Q

What to do for “Out of it” (sedated) adverse effect of morphine?

A
  • 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)
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20
Q

What to do for Respiratory Depression adverse effect of morphine?

A
  • 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)
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21
Q

What is the B & Z rule?

A
  • Don’t mix Opioids with:
    ~ BOOZE/Alcohol/EtOH
    ~ Zzzz drugs (Ambien®= zolpidem)
    ~ etc.
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22
Q

What to do for Pruritis adverse effect of morphine?

A
  • 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)
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23
Q

What to do for Hypotension/Head Pressure adverse effect of morphine?

A
  • 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)
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24
Q

What to do for Infrequency adverse effect of morphine?

A
  • 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)
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25
Q

What to do for Nausea/Narcotic adverse effect of morphine?

A
  • 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
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26
Q

Can anyone prescribe opiods?

A

Prescribers are required to have special DEA licenses
(some opioids are not allowed to have refills)

27
Q

How can nurses avoid mishandling controlled substances?

A
  • 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!
28
Q

What to do for Emesis adverse effect of morphine?

A
  • 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
29
Q

What are some other adverse effects of morphine-like drugs?

A
  • Diaphoresis/Flushing/Sweating
  • Tolerance / dependence
  • EUPHORIA/ addiction
  • Allergic Reactions (itching vs difficulty breathing!)
30
Q

What are some true allergy concerns for morphine-like drugs?

A
  • Throat Itching
  • Tongue/Lip/Eyelid Swelling (Angioedema)
  • Throat Swelling
  • Difficulty Breathing
  • Hives
31
Q

What examples of Non-Morphine Opioid Agonists?

A
  • methadone
  • fentanyl
  • meperidine
  • tramadol
32
Q

What are non-morphine opioid agonists used to treat?

A
  • These drugs are still OPIOIDS
  • MODERATE/SEVERE PAIN
  • However, each of these drugs is unique
33
Q

What can non-morphine opioid agonists be combined with?

A
  • Frequently given with Non-Opioids as a multi-modal pain approach
  • Example: Ultracet® is Tramadol + Acetaminophen
34
Q

What are adverse effects of non-morphine opioid agonists?

A
  • “MORPHINE”
  • seizures
  • serotonin syndrome
35
Q

What are contraindications of non-morphine opioid agonists?

A
  • Breastfeeding (codeine + tramadol)
  • Biliary colic, Elevated Intracranial Pressure (ICP)
  • History of Seizures (Caution, not contra-indication)
36
Q

What are some unique adverse effects of TRAMADOL?

A
  • Can increase risk for SEIZURES and SEROTONIN SYNDROME
37
Q

What does MEPERIDINE treat?

A
  • Moderate/Severe Pain
  • May seen used in the OR to reduce SHIVERING!
38
Q

What are some unique adverse effects of MEPERIDINE?

A
  • Can cause SEIZURES (max use is 48-72 hours)
  • Can increase risk for SEROTONIN SYNDROME
39
Q

What is serotonin syndrome?

A

Dangerous consequence of using multiple drugs that increase SEROTONIN levels

40
Q

What drugs to be aware of to avoid serotonin syndrome?

A

Never mix an MAO-I (phenelzine is a prototype) with:

  • Opioids (Tramadol and Meperidine)
  • Antidepressants
  • Dextromethorphan (DM) Cough Suppressant
  • Linezolid (Antibiotic)
  • “Triptans” (migraine medication)
41
Q

What does METHADONE treat?

A
  • moderate/severe pain
  • substance use disorders (ex: heroin usage)
42
Q

What are some unique adverse effects of METHADONE?

A
  • Can prolong the QT interval (dysrhythmia risk)
  • Require periodic EKGs
43
Q

What is the strongest opioid group?

A

fentanyl

44
Q

What are the different routes for fentanyl?

A
  • 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
45
Q

What are partial/mixed opioid agonists?

A

They only cause PARTIAL opioid receptor activation

46
Q

What are some partial/mixed opioid agonists?

A
  • Buprenorphine
  • Butorphanol
  • Nalbuphine
  • Pentazocine
47
Q

What do partial/mixed opioid agonists treat?

A
  • Pain management
  • BUPRENORPHINE- Addiction management (Substance Use Disorders)
48
Q

What are adverse effects of partial/mixed opioid agonists?

A
  • “MORPHINE”
  • Partial Pain Relief
  • Partial Withdrawal
  • Partial Respiratory Depression
49
Q

What happens when a patient is taking oxycodone and then takes Buprenorphine?

A

Partial Agonists have a HIGH AFFINITY for opioid receptors
- Buprenorphine will bind to the opioid receptor and knock off the oxycodone

50
Q

What are the three primary symptoms of opioid overdose?

A
  • Respiratory Depression
  • Miosis
  • Coma
51
Q

What is an antidote to opioid overdose?

A

Opioid Antagonist:Naloxone aka Narcan®

52
Q

How does Naloxone treat opioid overdose?

A

Competitive antagonist at opioid receptors (has an extremely high affinity)

53
Q

What are adverse effects of Naloxone?

A

Nothing worth noting. This will NOT harm someone. Don’t be afraid to use it when in doubt.

54
Q

What to know about Naloxone?

A
  • 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)
55
Q

Name a Peripheral Mu Opioid Antagonist (PAMORA).

A

Methylnaltrexone

56
Q

What does Methylnaltrexone treat?

A
  • Opioid Induced Constipation (OIC)
  • MethylnaltreXone = X out the Opioids in the GI Tract
57
Q

What are adverse effects of Methylnaltrexone?

A
  • abdominal bloating
  • cramping because GI tract starts back up
58
Q

Name some Anti-Diarrheal Opioids.

A
  • Loperamide
  • Diphenoxylate
59
Q

What do anti-diarrheal opioids treat?

A

diarrhea

60
Q

What are adverse effects of loperamide and diphenoxylate?

A
  • 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
61
Q

What is opioid tolerance?

A

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)

62
Q

What are characteristics of opioid withdrawal syndrome?

A
  • 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.
63
Q

How to help opioid withdrawal syndrome?

A
  • Clonidine (drug for hypertension) helps slow down autonomic hyperactivity
  • Methadone + Buprenorphine

320 Pharmacology (36 decks)

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