OPIOIDS

Question 1

Do opioids have anti-inflammatory effect?

Answer 1

No

Question 2

What are the problems that can occur with opioids?

Answer 2

• Tolerance (There is a decreased level of response despite maintaining the same dose)
• Dependence (if you stop the drug you get a psychological response)
• Side-effects
• Risk of overdose

Question 3

Opioid SEs

Answer 3

• Sedation (AVOID DRIVING)
• Nausea and vomiting
• Convulsions
• Respiratory depression
• Constipation
• Urinary retention!!
• Pupil constriction
• Suppression of cough
• CV effects (at high doses)
• Euphoric state

Dry mouth
Euphoria
Sedation
Itch
GI - CONSTIPATION
N+V
Eyes - pupils constriction
Resp depress

Question 4

List the weak opioids

Answer 4

• Codeine
• Dihydrocodeine
• Meptazinol

Question 5

Morphine

Answer 5

• Given every 4 hours (or every 12 or 24 hours if MR)
• Some brands e.g. MST Continus, Morphgesic SR, Sevredol, MXL, Zomorph,
  Oramorph
• For oral solution, anything above 13mg/5ml is considered as schedule 2 CD (and anything less is just POM)

Question 6

Morphine - common SE

Answer 6

N+V
Hypotension

Question 7

Diamorphine

Answer 7

• Causes less nausea and hypotension than morphine
• Because of its solubility, it allows effective doses to be injected in smaller volumes (its good for palliative care)

Question 8

Buprenorphine

Answer 8

• Has both opioid agonist and antagonist properties
• Unlike other opioids, its effects are only partially reversed by naltrexone

Question 9

Buprenorphine - duration of action

Answer 9

• Much longer duration of action than morphine
• Sublingually, it is active for up to 8 hours
• Can be used as maintenance therapy in the management of opioid dependence (e.g. addicts)

Question 10

What are the counseling points for buprenorphine oral lyophilisates (e.g.
Espranor)?

Answer 10

• Placed on the tongue and allowed to dissolve
• Patients should be advised not to swallow for 2 minutes
• They should not consume food or drink for at least 5 minutes after administration

Question 11

Espranor and bioavailability?

Answer 11

• Espranor does not have the same bioavailability as other buprenorphine preparations
• So becareful when switching to another preparation

Question 12

What are the cautions for transdermal use of buprenorphine
patches which requires extra monitoring?

Answer 12

• Fever
  AND
• Application site exposed to heat
  These two increase the risk of absorption (e.g. therefore side effects)

Question 13

What are the counselling points for patients on
Buprenorphine
patches?

Answer 13

• Apply to dry, non-irritated, non-hairy skin on the upper torso/upper arm (depends on which preparation)
• Change patch every 72 hours or 96 hours or 7 days
• Do not put the patch on the same area, and avoid that area for however long the
  manufacturer recommends e.g.
  7 days or 3 weeks)

Question 14

Fentanyl

Answer 14

• The main formulation is the patch which is changed every 72 hours

Question 15

What is the side-effect of IV fentanyl?

Answer 15

Muscle rigidity

Question 16

What are the counseling points for applying fentanyl patches?

Answer 16

• apply to dry, non-irritated, non-hairy skin on the upper arm or torso
• Put a new patch on a
  different area (avoid using the same area for several days)

Question 17

Are buprenorphine and fentanyl PATCHES suitable for acute pain?

Answer 17

• NO!
• Because the long time to reach the steady state prevents rapid titration of the dose

Question 18

Oxycodone

Answer 18

• Similar side-effect and efficacy to morphine
• Given every 4-6 hours, but MR is given either every 12 hours or every 24 hours

Question 19

Pethidine

Answer 19

• Produces a prompt but short-lasting effect
• It is less constipating than morphine
• Used for analgesia in labor

Question 20

Pentazocine

Answer 20

• Agonist and antagonist properties
• Precipitates withdrawal symptoms
• By injection, it is more potent than dihydrocodeine and codeine
• Avoid after MI

Question 21

Pentazocine - Injection SEs

Answer 21

• Hallucinations and thought disturbances may occur by injection

Question 22

Tapentadol

Answer 22

• Opioid antagonist and
  inhibits noradrenaline reuptake
• N&V and constipation less likley to occur with tapentadol than with other strong opioid analgesics

Question 23

Tramadol - Schedule

Answer 23

3

Question 24

Tramadol MOA

Answer 24

• Opioid antagonist and enhances serotonergic and adrenergic pathways

Question 25

Tramadol - SE

Answer 25

- Fewer typical side-effects (less respiratory depression, less constipation, and less addiction potential) - Although psychiatric reactions have been reported

Question 26

Codeine preps

Answer 26

- Available on its own or in combination with paracetamol or Ibuprofen

Question 27

Codeine avoid

Answer 27

- Not to be used in children < 12 - Not to be used in 12-18 with breathing problems - Caution in people who are ultra metabolisers (CYP2D6) = too much codeine converted into morphine which can lead to morphine toxicity

Question 28

If co-codamol is prescribed and no strength is stated

Answer 28

then 8/500mg is to be dispensed

Question 29

Dihydrocodeine

Answer 29

- Similiar to codeine - Co-Drydramol is 10/500mg Other strengths include - 20/500, 30/500. - Dihydrocodeine is available on its own as 10,20 and 30mg

Question 30

What are the cautions for use of opioids?

Answer 30

- Asthma - Impaired respiratory function (AVOID in COPD) - Obstructive bowel disorder - Hypotension

Question 31

What are the signs of opioid overdose?

Answer 31

- Coma - Respiratory depression (slow and shallow breathing) - Pinpoint pupils

Question 32

How do you treat respiratory depression?

Answer 32

- Artificial ventilation - Or reversed by Naloxone

Question 33

What is the opioid antagonist called?

Answer 33

Naloxone - Used to reverse overdose Naltrexone - Prevent relapse is substance misuse or alcohol

Question 34

How do you treat opioid-induced constipation?

Answer 34

- Osmotic laxative + stimulant - Avoid BFL