Opiates

What is your biggest concern in everyone taking opiates?

respiratory depression

What is euphoria?

Disinhibition of dopamine containing neurons which leads to increased dopamine in nucleus accumbens; produces sense of well-being

Why do opiates cause respiratory depression?

reduces responsiveness of medullary respiration center to carbon dioxide

What do morphine and codiene have that affects the cough reflex?

antitussive properties by depressing the cough reflex

What is miosis, and what casues it?

pinpoint pupil with morphine use

Why is it crucial to understand that morphine causes pinpoint pupils?

diagnostically important because most other causes of coma and respiratory depression produce dialation of the pupil

What is the biggest GI issue opiates can cause?

severe constipation

What is used to help with constipation in opiate use, and what is the goal?

stimulant laxative ± osmotic laxative, with a goal of a BM q 1-2 days

When is morphine typically CI?

head trauma/severe brain injury

What is pseudo-addiction?

behavioral changes in patients that seem similar to those in patients with opiod depndence of addiction but are secondary to inadequate pain control

What are the CIs of opiates?

• allergy to opiod or any other pharmaceutical constituents

• severe asthma, breath problems, or severe lung disease (COPD)

• Use of an MAOi in the past 14 days

• patients with medical comorbidty such as renal and hepatic disease should be given opiods cautiously

What are warnings/precautions of prescribing opiates?

• life-threatening respiratory depression in COPD, elderly, cachexia, or debilitated

• serotonin syndrome

• adrenal insufficiency

• severe hypotension

• increased ICP/brain tumors/head injury/impaired conciousness

What is the gold standard opioid?

morphine

What administration style produces the most reliable response in morphine?

Sub-Q and IV dosing

What side effects does tolerance occur for in morphine use, and what side effects won’t change?

tolerance: respiratory depression, euphoria, sedation, and urinary retention

no tolerance: miosis or constipation

What’s one of the best components of codeine?

good anti-tussive effects at doses that do not tcause analgesia

What CS level is codeine?

CS III-V

What are the main SEs of meperidine (demerol)?

Neurotoxic metabolite (normeperidine), which leads to derlirum, hyper-reflexia, myoclonus, and seizures

What level CS is methadone?

CS II

Why must the methadone doses be decreased over time?

release of methadone from tissue resorvoirs necessitates dose decrease

When should dose reductions of methadone be done?

Every 5-7 days until steady state is acheived

What happens if methadone doses aren’t decreased over time?

methadone accumulation to toxicity if does not reduced

What’s important to know about naloxone?

it only partially reverses overdoses and can cause seizures

What CS level is tramadol?

CS IV

What type of drug is buprenorphine?

mixed agonist/antagonist

What type of receptors does buprenorphine work with (or against)?

partial µ receptor agonist & Ќ and δ receptor antagonist

What is needed to prescribe buprenorphine?

special DEA number and education to prescribe and need f/u documentation

What can be used when doing a non-cognitive assessment of pain for sympathetic nervous system stimulation?

• Hypertension - help

• Tachycardia - the

• Mydriasis - MD

• Diaphoresis - diagnose

• Pallor - pain

• Respiration - reliably

When initiating opioids, what type of formulation should be used for acute pain?

choose immediate release (IR) formulations over long-acting (ER) formulations

What should not be given post-op for dental pain?

fentanyl patches

How should opioid use be prescribed for acute pain?

as needed and not scheduled for acute pain

How long should the evaluation of acute pain after onset occur?

no longer than 1-4 weeks after onset

How often should chronic pain be followed?

at minimum every 3 months

How often must patients be seen when on opioid therapy?

in person in office with no less than ever 6 months

What must you always have before starting opioids?

have an “exit strategy”

What drug pairing with opioids should you be extremely cautious about?

when paired with benzos or muscle relaxers

What should accompany an opioid prescription?

stimulant laxative

What are some opiate-induced adverse effects?

• opiate-induced myoclonus

• opiate-induced endocrine effects

• opiate-induced immun modulation

Who is opiate-induced myoclonus common in?

dose-dependent; common in chronic use as dose is increased

What should be done if opiate-induced endocrine effects begin to occur?

dose-dependent; decrease the dose or switch the opiate at this time

What are the opiate-induced endocrine effects?

• decreased TSH and testosterone

• increased prolactin

• alter menstrual cycle

What can a narcotic overdose mimic or vice versa?

can mimic cardiac arrest from all causes by sharing symptoms with narcotic overdose

What are the s/sxs of both cardiac arrest of all causes and narcotic overdose?

• unresponsiveness

• not breathing

• snoring/gurgling sounds

• blue skin/nail beds

Dose escalations of what % should be avoided to avoid respiratory depression in opiates?

>50%

What is the main DDI of opiates that leads to respiratory depression if not cautious?

caution w/ use of multpile CNS depressants

What may be sufficient to prevent significant hypoventilation in moderate overdose?

physical stimulation

When have fewer patients succumbed to respiratory depression?

while awake or being force to stay awake (“irritated”)

What are the two biggest signs of opiate abstience syndrome?

tachycardia and diaphoresis

What can precipitate withdrawal in chronic opiate users?

mixed agonist/antagonists:

• levophanol

• nalbuphine

• pentazocine

• butophanol

What can be added for patients who have opiate abstinence syndrome and persistent autonomic sxs?

clonidine

Why is an opiate allergy often mistaken for other complaints?

opiates have a propensity to cause histamine release

What are the 2 chemically distinct opioid groups?

1. morphine/thebaine group: hydromorphone, oxymoprhone, codeine, hydrocodone, oxycodone, butophanol, nalbuphrine

2. meperidine group: fentanyl, sufentanil, alfentanil

True or False: there’s no ceiling dose for opioids

true, patients can be on massive doses that build over time

What may be the best options outside of non-opiates?

meperidine or fentanyl

What type of opiates are best for a transmucosal route?

favors lipophilic opiates (buprenorphine, fentanyl, methadone)

What type of opiates are best for an intranasal/inhalation route?

favors lipophilic opiates

How do refills work for CS II?

zero refills in all cases

How do refills work for CS III-V?

MAX of 5 refills within 6 months of write date

When do opiate prescriptions expire in all cases?

6 months after being written in all cases

What combinations does the DEA place a high emphasis on filling being inappropriate?

• combination of opiate, benzodiazepine, and muscle relaxant

• combination of opiate and stimulant

• stimulants and benzodiazepines

What can methadone commonly be used for?

used for pain (at low doses and titrated very slowly) if a long-acting medication is needed

What must be documented on a methadone prescription?

FOR PAIN

What antidepressants can be used for neuropathic pain?

• duloxetine

• venlafaxine

• amitriptyline

• TCADs

What anticonvulsants can be used for neuropathic pain?

• carbamazepine

• oxacrbazepine

• lamotrigine

What GABA modulators can be used for neuropathic pain?

• pregablin

• gabapentin

True or False: Cannabis can be used for neuropathic pain

true

What topicals can be used for neuropathic pain?

capsaicin/lidocaine

What opiate-combo can be used for neuropathic pain?

opiates w/ SSRI or SNRI effects (tramadol, methadone)

What would be used as the final resort for patients with constipation?

If a stimulant laxative ± osmotic laxatives fail, refractory OIC is next (naldemedine, naloxegol, methylnatrexone)