pain (rogers) pt 3 Flashcards
opioid agonists/antagonists
antagonist (1)
weak agonist (2)
full agonist (7)
- naloxone
- codeine, tramadol
- morphine, hydrocodone, hydromorphone, oxycodone, meperidine, fentanyl, methadone
opioids
uses
- acute and chronic pain
SE
- antitussive, ___ , N/V, itching, orthostatic hyotension, urinary retention, sedation, ___ depression
clinical pearls
- consider staring stool softener and/or ___ laxative
- potential for tolerance, dependence and addiction
- schedule II controlled substances
- exception: ___ and ___
- constipation, respiratory
- stimulant
- tramadol, condeine
Opioids: Codeine (Tylenol #3)
available formulations
- tablet, cough syrup
clinical
- schedule V, III, or II depending on strength
- metabolized to morphine via CYP ___
2D6
Opioids: Tramadol (Ultram)
Available formulations
- capsule ER, tablet IR and ER, oral solution, combo products with acetaminophen and celecoxib available
Clinical pearls
- risk of ___ syndrome when use with other serotonergic meds
- ___ dose adusted
- Boxed warning - use of CYP ___ inducers or inhibitors and ___ inhibitors with tramadol requires careful consideration of effects on the parent drug metabolite
- schedule ___
- serotonin
- renally
- 3A4, 2D6
- IV
Opiods: Morphines
available formulations
- capsule ER, tablet IR and ER, oral solution, solution of injection, suppository
Clinical pearls
- ___ more prominent compared to other opioids
- morphine and metabolites are ___ excreted and accumulate in renal dysfunction
- avoid in ___ or ___
- Boxed warning: avoid ___ while taking ER capsules - leads to increased morphine plasma levels and potentially fatal overdose
- itching
- renally
- ESRD, AKI
- alcohol
Opioids: Hydromorphone (Dilaudid)
available formulations
- IR and ER tablets, oral solution, solution for injection, suppository
clinical pearls
- boxed warning about ___ errors
- oral solution - do not confuse mg and mL
- IV solution, so not confuse high potency solution with other solutions
- dosing
Opioids: hydrocodone +/- acetaminophen - all generic
available formulations
- oral solution, ER tablet, tablet
clinical pearls
- counsel patinets on acetaminophen use
- boxed warning - use with CYP ___ inhibitors may increase hydrocodone plasma concentrations
- 3A4
Opioids: oxycodone
available formulations
- tablet (IR and ER), capsule (IR and ER), oral solution
clinical pearls
- counsel patients on acetaminophen use with combination product
- ER capsule/tablets are abuse ___
- boxed warning: use with CYP ___ inhibitors may increase oxycodone plasma concentrations
- deterrent
- 3A4
Opioids: fentanyl (Duragesic)
available formulations
- buccal tablet, sublingual liquid, lozenge, injectable solution, patch (chronic pain)
Clinical Pearls
- Boxed warning - monitor patients receiving CYP ___ inhibitors or inducers
- can use in ___ impairment
- less ___ than morphine and hydromorphone at similar doses
- non-injectable forms are ONLY indicated for patients who are opioid ___ (taking morphine ___ mg per day (or equivalent) for at least 1 week)
- doses are NOT converted from one fentanyl product to another on a mcg per mcg basis
- 3A4
- renal
- hypotension
- tolerant, 60
Fentanyl Patch Dosing
T or F: the table should can be used to convert from transdermal fentanyl to other opioid analgesics
FALSE:
the table should NOT be used to convert from transdermal fentanyl to other opioid analgesics
can only for from oral morphine to fentanyl patch
Fentanyl patch counselling
- apply one patch every ___ days
- apply the patch to chest, back, flank, or upper arm
- do not cut patches
- do not place on ___ skin
- dont let the patch get too ___
3
broken
warm
Opioids: methadone
uses
- ___ line treatment of chronic pain
- opioid detoxification
available formulations
- oral solution, injectable solution, tablet
clinical pearls
- boxed warning: ___ prolongation (check ___ prior to initiation)
- boxed warningL monitor patients receiving CYP ___ inhibitors or inducers
- ___ t1/2 8-59 hrs
- last
- QTc, ECG
- 3A4
- long
Opioids: meperidine (Demerol)
available formulations
- injectable solution, oral solution, tablet
Clinical Pearls
- avoid in elderly, avoid in ___ impairment, caution use in ___ impairment
- boxed warning; monitor patients receiving CYP ___ inhibitors or inducers
- boxed warning: do not use within 14 days of ___
- metabolized by the ___ into an active metabolite
- accumulation of active metabolite can cause ___ and ___
- not commonly used due to adverse effects
- renal, hepatic
- 3A4
- MAOIs
- liver
- delirium, seizures
Potential Side Effects
several of the opioids have serotonergic activity and have potetnial to
1) ___ seizure threshold
2) cause serotonin syndrome when used wih other agents with serotonergic activity
main one: ___ (wouldnt use if history of seizures)
- 6 others
lower
tramadol
- oxycodone, fentanyl, methadone, meperidine, codeine, buprenorphine
Initial Dosing in Opioid Naive Patients
Allergic Cross Reaction
pt is allergic to natural opiates, lets do synthetic.
- fentanyl and tramadol the best
- methadone and meperidine kinda lame
