Pharm III: Exam 8 (poison and opioids) short n sweet

How does a poisoned patient die?

CV toxicity with arrhythmia (TCAs, cocaine, amphetamines)

A bethel student unwisely decides to use cocaine recreationally, what vital signs would you expect to see?

HTN and Tachycardia

What causes the common vital sign of rapid respirations?

Salicylates, carbon monoxide, or any toxin that produces metabolic acidosis

What vital sign can occur with sympathomimetics, anticholinergics, salicylates, and drugs that cause muscular rigidity?

Hyperthermia

EYES: __________ is seen with amphetamines, cocaine, LSD, and anticholinergics.

DILATION

Constriction is opioids, clonidine, and cholinesterase inhibitors.

A neurologic side effect that is common with anticholinergics, cocaine, and sympathomimetics.

Twitching

What drugs can cause seizures as a neurologic side effect?

TCAs, cocaine, bupropion, amphetamines, theophylline, isoniazid, and diphenhydramine

Why is ipecac (induce vomiting) administration at home especially discouraged?

Late presentation and aspiration risk (vomit in lungs), especially if the child becomes lethargic.

Why is ipecac not recommended for use even in healthcare settings?

No evidence of improved outcomes, unpredictable effectiveness, and potential complications.

With what substances is ipecac specifically contraindicated?

Corrosive substances (acids/alkalis/cleaners), vomiting a second time hurts esophagus and airway even more

When is gastric lavage considered?

Rare, life-threatening ingestions (TCA OVERDOSE) that present within 60min and if the airway can be protected (ET tube) to prevent aspiration.

What is the preferred method of gastric decontamination for most acute toxic ingestions (within 1 hour)?

Activated charcoal (AC)

If the substance binds well to charcoal

Examples of substances that are NOT ABSORBED by activated charcoal.

Lithium & Iron

How does whole bowel irrigation (WBI) work?

A lot of osmotically balanced polyethylene glycol electrolyte solution to FLUSH the unabsorbed toxin from the GI tract until rectal effluent is clear

Toxin --> poly glycol electrolyte solution --> flush toxin --> clear rectal effluent

What is the key treatment modality for enhancing the elimination of specific acidic drugs (salicylates/aspirin and phenobarbital)?

Urinary alkalinization

Hemodialysis is highly effective for removing certain toxins from the bloodstream, but what is it reserved for?

Specific substances and clinical scenarios like bad toxicity, end-organ damage, or when conventional therapies fail.

To help remember dialyzable toxins... what is the mnemonic?

SLIME

Salicylates, lithium, isopropanol, methanol, ethylene glycol, and phenobarbital

The most common cause of acute liver failure in the US that is related to a single medication OD.

Acetaminophen OD

What do you administer if your patient's acetaminophen level plots on or above the "probable risk" line of the nomogram?

N-acetylcysteine (NAC)

She might have it as "acetylcysteine" on the exam.

The optimal time to administer NAC is within __ hours of ingestion, as it is nearly 100% effective in preventing ____________ if started within this window.

Administer within 8 hours to prevent hepatotoxicity!

High doses of these cause restlessness, agitation, acute psychosis, HTN, and tachycardia.

What else can occur with high doses?

Amphetamines & Sympathomimetics

Seizures & Hyperthermia can also occur

Red as a beet, full as a flask, hot as a hare, dry as a bone, blind as a bat, and mad as a hatter... what is associated with this?

anticholinergics

How do you treat cholinesterase inhibitor toxicity?

Atropine and pralidoxime

While treatment for cyanide toxicity consists of activated charcoal, what is now the 1st-line medication?

How does it work?

Hydroxocobalamin

It directly binds to cyanide to form a nontoxic compound that is excreted in the urine and can also stabilize blood pressure.

Simply: cyanide --> hydroxocobalamin --> bind to cyanide --> nontoxic compound --> pee & stable BP

What is included in the opioid toxidrome?

Treatment for opioid toxidrome?

Hypothermia, bradycardia, miosis, and CNS/respiratory depression

Treat with naloxone

Along with Pepto-Bismol and topical application of keratolytics, what else can cause a salicylate OD?

oil of wintergreen

remember this

Quinidine-like effect is synonymous with _________ stabilizing and a local _____________ effect.

Membrane stabilizing and local anesthetic effect

FYI: a quinidine-like effect is basically just the cardiac side effects you would see with the quinidine drugs (torsades, prolonged QTc, and bad contractility).

Your patient has a QRS prolongation of >100ms... what therapy is indicated?

Sodium bicarb therapy

It improves conduction, increases contractility, and suppresses ventricular ectopy.

We know that opiates are drugs derived from alkaloids of the opium poppy; now, tell me about opioids.

Class that includes opiates, opiopeptins, and synthetic/semi-synthetic drugs that mimic the actions of opiates.

What receptors contribute to spinal analgesia and sedation?

Kappa

Mu mediates morphine. Delta receptors contribute to analgesia

Why are opioids CI in biliary colic?

Constricts biliary smooth muscle --> increased intrabiliary pressure

Also CI in asthmatic pt (bronchoconstrict)

In opioid side effects, tolerance develops EXCEPT to what 3 things?

Miosis, constipation, and convulsions

MOA of Morphine

(I said it earlier, do u remember??? mwahahahah)

Potent agonist at mu receptors

FYI: Prototypical opioid, weak agonist at kappa and delta. Absorbed from the gut, it undergoes extensive first-pass metabolism

POP QUIZ: WHAT CAN TOO MUCH "OIL OF WINTERGREEN" USE CAUSE???

i TOLD U TO REMEMBER BRUH

SALICYLATE OD

What is so fun and quirky about codeine? She gave a fun fact about it in class.

It is converted to morphine by the CYP-450 isoenzyme CYP-2D6.

She said it can be bought OTC, but it's mixed in solutions like cough syrup or something.

If your patient is taking codeine, what 2 specific things do you have to watch for?

Polymorphisms and ultrarapid metabolizers

What is 100x more potent than morphine?

Fentanyl

Synthetic opioid agonist at mu receptor

What synthetic opioid agonist (mu receptor) can cause serotonin syndrome, meaning you need to avoid use with other meds that can also cause serotonin increase?

Meperidine

What effects can the synthetic opioid agonist, meperidine, cause?

Antimuscarinic effects (dry mouth, blurred vision, constipation)

Meperidine is given to patients with _________ and __________ due to less effect on the sphincter of Oddi than morphine.

Pancreatitis and cholecystitis

What does meperidine have that can result in seizures?

Due to this, you have to limit use to ___ hours or less.

Toxic metabolite

Limit to 48hr or less

What has equal potency to morphine and is used to treat morphine failures and difficult cases like cancer and neuropathic pain?

Methadone

Alright smart***, exactly what is methadone?

Long-acting opioid and potent Mu receptor agonist

Blocks NMDA as well. It has a long half-life. Given PO, IV, SC, and rectally

Due to methadone having a long half-life, dependence and tolerance don't happen too fast.

What is this useful for?

Treatment of opioid abuse!

Methadone does NOT cause __________.

Euphoria

MOA of Tramadol

(not the full explanation, just what it is)

Dual-action analgesic

Used for mild/moderate pain. It activates mu receptors and stops neuronal reuptake of serotonin and norepi.

True/False: Tramadol has a HIGH potential for addiction.

FALSE: Lower addiction potential

While Tramadol has minimal respiratory and CV depression effects... what threshold does it lower?

What syndrome can it cause?

Tramadol lowers the seizure threshold and can cause Serotonin Syndrome!

This drug has mild analgesic properties, significant antitussive activity, produces less constipation than codeine, is CI with MAOI use, and can cause serotonin syndrome.

Dextromethorphan

What anti-diarrheal agent has a low abuse potential because of very poor penetration into the CNS?

Loperamide

Synthetic opioid, partial mu agonist, kappa receptor antagonist, long duration of action (slow dissociation from mu receptors), used in opioid withdrawal, and is RESISTANT TO NALOXONE!!

Buprenorphine

Along with buprenorphine, what kappa receptor agonist is resistant to naloxone?

Nalbuphine

__________ produces significantly greater analgesia in women than men.

Butorphanol

Why would a repeat dose of naloxone be required?

short duration of action (1-2hr)

Compared to naloxone, how is nalmefene different?

Long duration of action (8-10hr)

What is the duration of action of naltrexone?

24-48 hours after PO, it's long-acting

BTW, naltrexone is used for opioid addiction management!

What all is naltrexone used for?

Decrease alcohol cravings and decrease cravings/psychological dependence in opioid abuse

It is used with bupropion for obesity

Primary psychoactive substance in marijuana.

Delta-9-tetrahydrocannabinol (THC)

What is hashish?

The dried resin from the top of the female cannabis plant

Physiological Effects of Cannabis? (3 italicized, 5 on list)

Decreased IOP, antiemesis, and pain relief

Anticonvulsant and sleep effects are included

What drug causes colored visions of tunnels, spirals, and lattice shapes that move?

LSD

What was PCP developed as in 1963 by Parke-Davis?

Dissociative anesthetic-analgesic

What is the MOA of PCP?

Antagonist at the NMDA receptor for glutamate

MC physical findings of PCP that occur in 57% of patients

HTN and Nystagmus

Treatment for PCP complications?

Benzos

What is present in more than 200 species of psychedelic mushrooms?

Psilocybin

What can psilocybin cause in large doses?

Psychosis

Maybe seizures and coma

The first local anesthetic and CNS stimulant

Cocaine

Explain what happens with combined use of cocaine and ethanol.

Produces cocaethylene (2hr half-life)

What is the metabolite, cocaethylene, much more toxic to?

brain and heart

The stuff on this slide was highlighted in blue, so idk if she wanted us to know it or not.

Cocaine side effects/complications?

- Chest pain, MI, arrhythmias, myocarditis, HTN, sudden death

- Coronary vasospasm and Acute aortic/papillary muscle rupture

What to AVOID in Cocaine CNS Toxicity.

AVOID BETA-BLOCKERS: results in unopposed alpha activation and profound HTN.

Use NTG or CCB for HTN and benzos for sedation instead

Use __________ to treat vasospasms and vasoconstriction caused by amphetamines.

Nitroglycerin

MDMA:

- What is the tablet form called?

- What is the pure powder form (snorted) called?

Tablet: Ecstasy

Powder: Molly

MDMA:

- Who made and patented it?

- When did it start being used?

- Made/patented by Merck in 1914

- Never until on the street (1960s)

You have a patient come in to the ER from a local music festival. You somehow find out he has been doing MDMA for a LONG time; you astutely remember that chronic MDMA use causes...?

Irreversible depletion & deterioration of serotonergic neurons

Sleep disorders, depression, anxiety, impulsive, and hostile

Nicotine causes an arousal in brain wave activity and stimulates the sympathetic system, yet smokers report that smoking makes them feel relaxed.

What is this called?

Nesbitt's Paradox

What symptoms does nicotine poisoning present with?

Nicotine poisoning --> sx of cholinergic excess

When do most people begin smoking?

teens

Smoking can cause an increased ___________ and spontaneous __________ in women.

increased prematurity and spontaneous abortions

Drug to help with smoking cessation.

Bupropion

MOA of varenicline (Chantix)

Partial nicotinic acetylcholine receptor agonist

Along with nausea, insomnia, and HA, what else can varenicline cause (adverse effects)?

Nicotine withdrawal symptoms

Aerosol propellant toxicity can result in cardiac arrest because of...?

Either ventricular arrhythmia or asphyxiation

What are anabolic steroids CLASSIFIED as?

Schedule III drugs