Term
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Definition
| supraspinal, spinal, incx2 respiratory depression, reduce gi motility, euphoria/sedation, incx2 physical dependence |
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Term
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Definition
| spinal, inc respiratory depression, incx2 gi motility, antidepressant |
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Term
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Definition
| spinal, peripheral, inc respiratory depression, dysphoria/sedation, inc x2 physical dependence |
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Term
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Definition
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Term
| Opioid therapeutic effects |
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Definition
- Reduce perception of pain in the central nervous system (CNS)
• Occurs without loss of consciousness
• Provides symptomatic relief of pain
• Analgesia is dose dependent
• Therapeutic effects are best achieved through dose titration
- Cough suppression
• Codeine used more often than morphine
• Mechanism of action is mediated depression of cough reflex center of the medulla
• Suppression of cough reflex occurs at opioid doses lower than those required to produce analgesic effects or depress respiration |
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Term
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Definition
- Pupillary miosis
• Pupillary constriction occurs at therapeutic opioid doses
• A central effect of the oculomotor nerve
• Chronic users will continue to have constricted pupils
- Itching
• Secondary to histamine release
- Constipation
• Reduced GI motility
• Tolerance will NOT develop to this side effect
• Patients on long-term opiates should be on a bowel regimen
- Nausea/vomiting |
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Term
| opioid severe adverse effects: |
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Definition
- Respiratory depression
• Respiratory control centers in brain
• Occurs in a dose-dependent manner
• Potentially life threatening
- Hypotension
• Caused by histamine releaseàvasodilation
- Bradycardia
• Direct effect on cardiac pacemaker cells
- True allergy:
• Bronchospasm
• Very low blood pressure/shock
• Angioedema |
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Term
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Definition
• Opioid therapy should be considered only if expected benefits will outweigh risks
• Immediate-release opioids should be prescribed initially
• The lowest effective dose should be utilized for the shortest duration possible
• Avoid concurrent prescription of benzodiazepines, when feasible |
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Term
| Opioids: Contraindications |
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Definition
• Significant respiratory disease
• Comatose patients (unless used for palliative care for a dying patient)
• Hypersensitivity to structurally similar opioid medications |
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Term
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Definition
• Bowel obstruction
• CNS depression
• Delirium tremens
• Head trauma
• Renal impairment (for renally cleared opioids)
• Respiratory disease (COPD, cor pulmonale, etc.)
• Seizure disorders |
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Term
| Opioids: Pregnancy and Lactation |
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Definition
- Chronic use: fetus can become dependent in utero
- Neonatal withdrawal syndrome:
• Irritability
• Hyperactivity
• High-pitched cry •
Tremor
• Vomiting
• Seizure
- Lactation: excreted in breast milk |
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Term
| full agonist opioid agents |
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Definition
| fentanyl, heroin, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone |
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Term
| partial agonist opioid agents |
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Definition
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Term
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Definition
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Term
| opioid structural classes |
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Definition
phenanthrenes: morphine, codeine (natural), )synthetic: oxycodone, hydromorphone, oxymorphone, hydrocodone (also buprenorphine, butorphanol)
phenylpiperidines: meperidine, fentanyl (also alfentanil, sulfentanil)
phenylheptanes: methadone (diphenylheptane) |
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Term
| codeine metabolism and excretion |
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Definition
• Metabolism:hepatic
• Glucuronidation to codeine-6-glucuronide • CYP 2D6 to morphine (active)
• CYP 3A4 to norcodeine
- Excretion:viaurine |
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Term
| has fatal side effect for kids after tonsillectomy |
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Definition
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Term
| race with most ultra-rapid metabolizers of CYP 2D6 |
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Definition
| (codeine) north africans, ethiopians, or saudi arabians (caucasians second most) |
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Term
| elderly, renal dysfunction, hemodialysis and morphine sulfate |
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Definition
• Recommendation:monitorforADRsclosely,consider initiation of a different opioid (hydromorphone, oxycodone, fentanyl are options)
• Avoid long-acting (daily) formulations in high-risk populations |
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Term
| hydromorphone immediate release vs extended release |
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Definition
| immediate release- dilaudid, extended release- Exalgo |
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Term
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Definition
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Term
| oxycodone + acetaminophen |
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Definition
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Term
|
Definition
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Term
|
Definition
| roroxycodone (weakly active) |
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Term
|
Definition
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Term
|
Definition
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Term
| hydrocodone + acetaminophen |
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Definition
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Term
• Extremely potent, NOT for opioid naïve
• Least cardiovascular effects |
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Definition
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Term
• Analgesia
• Potent opioid μ-receptor agonist
• Blocks NMDA receptor
• Inhibits monoaminergic reuptake
• Adult dose (oral, opioid naïve): 2.5 mg every 8 hours
• Useful for detoxification and treatment of opioid abuse • Highly regulated
• Drug interactions (CYP 3A4 and 2B6)
• QTc prolongation, seizures |
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Definition
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Term
• Centrally acting synthetic analgesic
• Multiple mechanisms:
- Opioid receptor agonist
- Increased release of serotonin
- Inhibition of serotonin and norepinephrine reuptake
• Available in combination with acetaminophen (Ultracet®)
• Metabolism: hepatic
-CYP 3A4, 2B6, glucuronidation: inactive metabolites
-CYP 2D6: O-desmethyl tramadol (active)
• Excretion: via urine
• Greatest seizure potential |
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Definition
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Term
| Opioids: Pearls for Prescribing |
|
Definition
• Extended release products should never be crushed or chewed
- Abuse potential
• Dangerous drug interactions
- All: CNS depressants (alcohol, benzodiazepines, barbiturates)
- Some: CYP 3A4 inhibitors (protease inhibitors, macrolides, calcium channel blockers, azole antifungals, grapefruit juice)
- Some: CYP 2D6 inhibitors (antidepressants, ritonovir, quinidine)
• Bowel regimen
- Stimulant laxative + stool softener (senna + docusate) |
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Term
• Sublingual, transdermal patch (Butrans®), IV/IM (Buprenex®)
• Analgesic ceiling
• Reduced potential for abuse (but still possible)
• Treatment of opioid dependence
- Buprenorphine/naloxone (Suboxone®) • Highly regulated |
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Definition
| Partial Agonists: Buprenorphine (C-III) |
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Term
| What has an active metabolite that accumulates in renal impairment? |
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Definition
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Term
| Schedule I Controlled Substances |
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Definition
• No currently accepted medical use in treatment in the United States
• Lack of safety for use under medical supervision
• High potential for abuse
• Illegal to prescribe these substances in the vast majority of cases
• Examples:heroin, lysergic acid diethylamide (LSD), marijuana, methylene-dimethoxy- methamphetamine (ecstasy) |
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Term
| Schedule II Controlled Substances |
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Definition
• High potential for abuse
• Associated with severe psychological or physical dependence
• Legal to prescribe but with strict federal regulations*
• Examples: morphine,oxycodone,oxymorphone, methadone, meperidine, fentanyl, hydrocodone, cocaine, pentobarbital |
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Term
| Schedule II Prescribing Laws (Federal) |
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Definition
• No refills may be prescribed on any schedule II controlled substance.
• There is no federal time limit for the filling of a schedule II prescription (i.e., does not expire).
- However—pharmacists are encouraged to use clinical judgment.
• A signed hard copy must be presented to the pharmacy prior to dispensing of the controlled substance.
- Prescriptions may be faxed only if the hard copy is presented to the pharmacist prior to the physical dispensing of the drug.
• Only one prescription may be written per prescription blank.
• Exceptions to the requirement for hard copy prescriptions:
- In emergency situations, an emergency supply may be called into the pharmacy for only the minimum quantity required during that period.
- Prescriptions to be compounded for direct administration by parenteral, IV, IM, SubQ, or intraspinal infusion may be faxed.
- Prescriptions for residents of long-term care facilities may be faxed.
- Prescriptions for patients enrolled in a hospice care program certified and/or paid for by Medicare may be faxed.
• No refills? No problem!
- Federal law allows for issuance of multiple prescriptions for up to a 90-day supply.
- Each prescription must contain all the required elements of a schedule II prescription.
- Each prescription must have clear instructions indicating the earliest date on which a pharmacy may fill them.
• This practice is not recommended for all patients.
- It is at the discretion of the provider to ensure this does not create undue risk of diversion or abuse.
- Provider must assess on a patient-by-patient basis. |
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Term
| Schedule II Prescribing Laws (Connecticut) |
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Definition
• Original and continuing orders placed in a hospital, infirmary, or clinic are limited to a maximum of 7 days from order entry.
• Prescribers may extend the order for 7 days at a time. |
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Term
|
Definition
• High potential for abuse, but less than that of a schedule I or II substance
• Examples: ketamine, dronabinol, codeine (> 90 mg per dosage unit) |
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Term
|
Definition
• Lower potential for abuse relative to schedule III
• Examples: benzodiazepines (alprazolam, lorazepam, etc.) |
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Term
|
Definition
• Lower potential for abuse relative to schedule IV
• Examples: codeine (< 200 mg/100 mL or 100 g) |
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Term
| Schedule III–V Prescribing Laws (Federal) |
|
Definition
• Permitted modes of transmission:
- Telephone, written, fax
- All required elements for a valid controlled substance prescription must be provided regardless of method used
• Refills:
- Maximum of five refills may be prescribed
• Expiration:
- Prescriptions expire six months after the date of issue |
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Term
| Schedule III–V Prescribing Laws (Connecticut) |
|
Definition
• Original and continuing orders placed in a hospital, infirmary, or clinic are limited to a maximum of 30 days from order entry.
• Faxed prescriptions are only valid if they contain the statement: “This prescription is valid only if transmitted by means of a facsimile machine.” |
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Term
| General Controlled Substance Prescribing Laws (Connecticut) |
|
Definition
• Public Act No. 16-43
• When issuing a prescription for an opioid drug to an adult for the first time for outpatient use, the prescriber shall not issue greater than a 7-day supply.
• Prescribers shall not issue a prescription for greater than a 7-day supply of opioid drug to a minor at any time.
• If, in the professional medical judgment of the prescriber, more than a 7-day supply of an opioid is required to treat a patient’s acute medical condition, or is necessary for treatment of chronic pain, then the prescriber may issue a prescription for the quantity required to treat the condition.
- This condition must be documented in the patient’s medical record, and the prescriber must document that an alternative drug was not appropriate to address the medical condition. |
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Term
|
Definition
• Uniquetoeachproviderortoeachhospital
• Containstwolettersandsixnumbers
• Hospital DEA registration numbers must be followed by a three-digit physician’s hospital code number
• Used to verify the authority of the prescribing practitioner |
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Term
| General Safeguard Recommendations |
|
Definition
• Keep prescription blanks hidden in a safe place, and try to utilize as few as possible at any given time.
• Write the word indicating the amount prescribed next to the number
• ex: 30 (thirty)
• Never pre-sign prescription blanks.
• Assist pharmacists when they contact you to clarify any information.
• Report any suspicious activity to the nearest DEA field office.
• Utilize tamper-resistant prescription pads. |
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Term
| Who May Issue Prescriptions for Controlled Substances? |
|
Definition
• Law varies by state
- Physician assistants in Connecticut are permitted to prescribe, dispense, administer, and procure controlled substances
- The DEA has a publically posted list of laws by practitioner level and by state here: https://www.deadiversion.usdoj.gov/drugreg/practioners/ml p_by_state.pdf
• Prescriber must be registered with the DEA or be exempt from registration
- Exempt: Public Health Service, Federal Bureau of Prisons, and military practitioners
• Prescribers must be acting within their scope of practice |
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Term
| Required Elements on Controlled Substance Prescriptions |
|
Definition
• Drug name
• Strength
• Dosage form
• Quantity prescribed
• Directions for use
• Number of refills (if any) authorized
• Date issued
• Patient’s full name and address
• Practitioner’s full name and address
• Practitioner’s DEA number
• Prescriptions must be written in ink, indelible pencil, or typewritten.
• Prescriptions must be manually signed by the practitioner on the date issued.
• Prescriptions may be prepared by another individual (secretary or nurse) but must be reviewed and signed by the authorizing practitioner. |
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Term
| Ethical Considerations for cxontrolled substances |
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Definition
• Prescriptions must be issued for a legitimate medical purpose.
• Prescribers of controlled substances may only prescribe within their scope of practice.
• i.e., dentists should not be prescribing ADHD medications, etc.
• Prescribers and pharmacists share corresponding responsibility for all controlled substances filled.
• Prescriptions may NOT be issued for a practitioner to obtain controlled substances in order to dispense to patients. |
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Term
| How many refills may be prescribed for a Schedule IV controlled substance? |
|
Definition
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Term
| Scale of Opioid Addiction |
|
Definition
• Number of prescribed opioids has nearly quadrupled since 1999
• Deaths from opioid overdose have more than quadrupled in that time frame
• Addition - chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences |
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Term
|
Definition
repeated dosing has reduced effect
• 2–3 weeks
• Develops to analgesic, sedating, respiratory, cardiovascular, and emetic effects
• Does NOT develop to constipation or miosis
• Cross-tolerance possible |
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Term
| Opioids: Dependence and Withdrawal |
|
Definition
• Dependence:discontinuationleadsto withdrawal
• μ-agonismindirectlyincreasesdopaminein mesolimbic regionè“reward”
• Opioidwithdrawal
- Rhinorrhea, lacrimation, yawning, chills, goosebumps, hyperventilation, mydriasis, muscular aches, diarrhea, anxiety, hostility
- Onset depends on half-life
- Naloxone can precipitate withdrawal |
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Term
|
Definition
• Aggressively complaining about need for a drug
• Asking for specific drugs by name or brand name
• Requesting to have the dose increased
• Claiming multiple allergies to alternative drugs
• Anger or irritability when questioned about pain symptoms
• Visiting multiple doctors for controlled substances
• Frequent requests for early refills
• More concern about the drug than a medical problem |
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Term
|
Definition
• Respiratory depression (decreased tidal volume, respiratory rate, hypercarbia)
• Especially seen with concomitant CNS depressants
• Potentially fatal |
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Term
| Risk Factors for Opioid Overdose |
|
Definition
• History of opioid dependence or abuse
• Patients who use opioids using non-oral (injection or insufflating/snorting) routes
• High daily dose opioid (> 50 morphine milligram equivalents per day)
• Prolonged use (> 90 days) of opioids for nonmalignant pain
• Comorbidities (respiratory disease, renal/hepatic dysfunction, depression, older age, dementia)
• Concomitant ingestions (alcohol, benzodiazepines) |
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Term
| Symptoms of Opioid Overdose |
|
Definition
• Respiratory depression (slow breathing or apnea, cyanosis)
• Hypotension, bradycardia
• Depressed mental status
• Miosis (pinpoint pupils)
• Hyporeflexia |
|
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Term
| Opioids: Overdose: Naloxone (Narcan®) mechanism |
|
Definition
| competitively inhibits binding of opioids to their receptors |
|
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Term
| Naloxone: Opioid Withdrawal |
|
Definition
• Blocking opioids from binding to receptors will precipitate withdrawal in opioid-dependent patients.
• If this occurs, allow symptoms of withdrawal to diminish.
• If necessary ,provider can administer additional lower doses of naloxone.
• Caution: significant nausea/vomiting may occur.
- Risk of aspiration
- Consider pretreatment with an antiemetic |
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Term
| Opioid Withdrawal Symptoms |
|
Definition
• Diaphoresis
• Rhinorrhea
• Irritability
• Anxiety
• Diarrhea
• Tremor
• Anorexia
• Nausea
• Vomiting
• Muscle spasms |
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Term
| Opioids: Preventing Addiction |
|
Definition
• Establish goals before initiating therapy
• Use lowest effective dose
• Use non-opioid adjunctive agents
• Maintain close relationship with patient and ensure follow up is possible
• Regularly re-evaluate need for therapy |
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Term
|
Definition
Example
• Dr. ______ has explained the risks and benefits of chronic opioid therapy for my chronic pain.
• I, ____________, understand that I must abide by the rules of this contract or I will not be given opioids.
• I will only fill my prescription at one pharmacy (pharmacy name: _______)
• I will take this medication exactly as prescribed.
I understand that this medication will be prescribed at the minimum dose for the minimum amount of time necessary to treat my pain. |
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Term
| Drug Addiction Treatment Act |
|
Definition
• Allows maintenance treatment of addiction or detoxification in combination with counseling under qualified clinician supervision
• Qualified clinician:
- Certified in addiction medicine
- Received eight hours in training provided by approved organization
- Participated in clinical trials
• Limited number of patients allowed per qualified clinician or group |
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Term
| Opioid Addiction Treatment Programs |
|
Definition
• Separate DEA registration is required to prescribe methadone (schedule II) for purposes of opiate addiction.
- This registration is NOT required when prescribing methadone for pain
- Must notate “for pain” on prescriptions for methadone to be filled in retail pharmacies
• A waiver is required for prescribing of schedule III–V drugs approved for addiction treatment (i.e., buprenorphine).
- These practitioners will receive a Unique Identification Number
• The nation is making efforts to expand access to addition treatment in the U.S.
• As of November 17, 2016, nurse practitioners and physician assistants are allowed to prescribe buprenorphine for treatment of opioid addiction.
- Must undergo 24 hours of required training
- May prescribe for up to 30 patients
• Nurse practitioners and physician assistants who have completed the training may apply for the DEA waiver beginning early 2017. |
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Term
| Connecticut Law on Opiate Overdose |
|
Definition
• Public Act No. 16-43
• Licensed health care professionals may administer an opioid antagonist to any person to treat or prevent opioid-related overdose.
- Such provider shall not be held liable for any damages in a civil action or subject to criminal prosecution for administration of an opioid antagonist.
• All emergency medical services must be trained to use and be equipped with an opioid antagonist (including state troopers). |
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Term
|
Definition
• Health Assistance InterVention Education Network for Connecticut Health Professionals (HAVEN)
• Enables the establishment of a confidential assistance program for health care professionals suffering from physical or mental illness, emotional disorder, or chemical dependency
• Can refer yourself of a colleague: 860-276-9196
• Does not engage in the practice of medicine or mental health care
- Education and prevention
- Early identification and intervention
- Provides referral for evaluation and treatment |
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Term
| Resources for Prescribers |
|
Definition
- CT Prescription Monitoring Program
• Central database of schedule II–V drugs
• Pharmacies in and out of state submit data once per week
• More information: 860-713-6073 or
DCP.prescriptions@ct.gov
• www.ctpmp.com
- White House Opioid Overdose Toolkit |
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|
Term
| Prescription Monitoring Program (PMP) |
|
Definition
• PMP is an online database which records prescription data for controlled substances for use by health care providers in patient care.
• Its purpose is for provider overview of patient’s controlled substance use, improve quality of care, and combat prescription abuse, addiction, and overdose.
• As of May 2016, all states with the exception of Missouri have an operational PMP.
- In many states, it is required by law that both prescribers and dispensers register with and utilize the PMP.
• Not all states have PMPs which communicate with other states.
- Therefore, some information may still be missing, depending on the state in which a prescription is filled
• PublicAct15-198:Effective10/1/2015
- Prior to prescribing > 72-hour supply of any controlled substance (schedule II–V) to any patient, prescribers are required to review the patient’s records in the Connecticut Prescription Monitoring and Reporting System (CPMRS).
- Whenever prescribing controlled substances for the continuous or prolonged treatment of any patient, the prescriber must review, not less than once every 90 days, the patient’s records in CPMRS. |
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Term
| antidote for an opioid overdose |
|
Definition
|
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