Opioids learning module

6. Self-assessment questions

We suggest you note down the correct answers and when you’ve finished, click on each option to reveal the feedback and whether or not your response is correct

Question 1

Which of the following statements is correct?

  • Opioids are a sub-class of opiates


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    Opioids comprise products derived from the opium poppy (opiates, eg codeine and morphine) as well as synthetic agonists at the opioid receptor (eg buprenorphine, methadone, and pethidine) and endogenous opioids (endorphins and enkephalins).

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  • Diphenoxylate is a pethidine-based rapid-acting analgesic


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    Diphenoxylate is a pethidine derivative, but it does not have useful analgesic effect at usual doses. It is combined with atropine as co-phenotrope for use in the management of diarrhoea.

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  • Mixed opioid agonist–antagonist drugs such as buprenorphine are best for treating diarrhoea


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    Neither of the two mixed agonist–antagonist opioids used in the UK (buprenorphine and pentazocine) is licensed for treating diarrhoea; both have systemic effects. Opioids selected for treating diarrhoea should generally be devoid of systemic effects.

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  • Opioids can be used for a range of indications including pain, cough, and diarrhoea


    Correct

    Although opioids are most often used for managing pain, they are also used for other effects, including suppression of cough, management of diarrhoea, and management of opioid addiction. Opioids whose activity is confined primarily to the gut (eg diphenoxylate and loperamide) are chosen for controlling diarrhoea, while opioids with long half-lives (eg buprenorphine and methadone) are used for opioid substitution therapy in the management of opioid addiction.

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  • Therapeutic use of opioids should be avoided in those addicted to heroin


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    An opioid should not be withheld if it is needed to relieve pain in an opioid-dependent person. If opioid abuse is continuing the dose of opioid may need to be higher than that used for non-dependent persons, to overcome tolerance. (However, tolerance can reverse rapidly and a previously tolerated dose might prove hazardous.)

    Further, a long-acting opioid can be used for the management of heroin addiction.

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Question 2

Which one of the following statements about gastrointestinal effects of opioids is correct?

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Question 3

Which of the following central nervous system adverse effect is most likely with an opioid given by mouth for controlling acute postoperative pain? Choose the single best answer.

  • Confusion


    Correct

    Opioid use is associated with sedation, cognitive impairment and confusion. However, these effects usually diminish on long-term use of an opioid.

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  • Convulsions


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    Convulsions rarely occur with therapeutic doses of most of the opioids used for managing pain.

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  • Hyperalgesia


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    Hyperalgesia—an exaggerated response to painful stimuli—is a complication of long-term use of opioid analgesics. It does not occur with short-term use such as in postoperative pain.

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  • Insomnia


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    Short-term use of opioids is more commonly associated with sedation and drowsiness; insomnia occurs only infrequently during treatment

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  • Parkinsonian syndrome


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    Opioids do not induce parkinsonian symptoms.

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Question 4

4. Pairs of drugs are listed below. Choose a pair most likely to help in dealing with opioid-induced bradycardia and bronchoconstriction.

  • Hyoscine butylbromide tablets and ephedrine injection


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    Although the antimuscarinic effect of hyoscine could help to reverse opioid-induced bradycardia, the absorption of hyoscine butylbromide when given by mouth is inadequate for reliable systemic effect.

    As a bronchodilator, ephedrine is less safe than beta2 adrenergic agonists. In practice, drugs with much more specific effect are used to reverse opioid-induced respiratory depression or bronchoconstriction. Ephedrine was formerly used for its stimulant effect on alpha-adrenergic and beta-adrenergic receptors, to increase blood pressure or for bronchodilation; it also stimulates the respiratory centre.

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  • Verapamil injection and dexamethasone injection


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    The calcium-channel blocker verapamil is an antiarrhythmic and antianginal drug. Verapamil is not suitable for reversing opioid-induced bradycardia; it is contraindicated in hypotension and marked bradycardia as it slows conduction through the atrioventricular node.

    The management of severe or life-threatening acute asthma involves the use of a systemic corticosteroid, usually prednisolone by mouth or hydrocortisone by intravenous injection. However, a corticosteroid such as dexamethasone is not appropriate treatment for opioid-induced respiratory depression; the specific opioid antagonist naloxone is used. Opioid-induced exacerbation of bronchoconstriction should first be managed with specific treatment such as oxygen (if necessary) and a beta2 adrenergic agonist such as salbutamol given through a large-volume spacer device or by nebulisation.

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  • Labetalol injection and budesonide nebuliser solution


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    Labetalol, with its non-cardioselective beta-blocking activity and some alpha-blocking activity is used for the management of hypertension and even to induce hypotension in some surgical procedures. It is not suitable for managing the cardiovascular effects opioids.

    The corticosteroid budesonide has no role in the immediate management of opioid-induced respiratory depression. Exacerbation of bronchoconstriction induced by opioids calls for treatment with a beta2 adrenergic agonist such as salbutamol.

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  • Atropine sulphate injection and salbutamol inhaler


    Correct

    Opioid-induced bradycardia responds to treatment with the antimuscarinic drug atropine.

    Whereas salbutamol does not reverse opioid-induced respiratory depression (a feature of excessive opioid dosage, requiring naloxone), it is effective for the management of bronchoconstriction, which is often provoked by the release of histamine caused by an opioid.

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  • Adrenaline injection and naltrexone tablets


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    Adrenaline is a sympathomimetic substance with a range of physiological and dose-related pharmacological effects, including increasing the rate and force of contraction of the heart chambers and relaxation of the bronchioles. However, for the reversal of opioid effects, more specific drugs are preferred.

    Naltrexone is not licensed for the management of opioid-induced respiratory depression. Compared to intravenous administration of naloxone, naltrexone by mouth has a longer duration of action and slower onset of effect; therefore, it is not suitable for the treatment of opioid-induced acute respiratory depression.

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Question 5

Three days ago, Dr MA, a 78-year-old retired physicist was started on morphine sulfate tablets 5 mg every 4 hours for severe pain. His pain is now well controlled but he is drowsy and gets a headrush when he sits or stands up. He is especially troubled by opioid-induced pruritus. Which of the following might help relieve the itching?

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Question 6

Sets of withdrawal symptoms are described below. Study each set carefully and select the set most likely to be associated with opioid withdrawal.

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Question 7

Which one or more of the following actions help to reduce the risk of opioid dependence?

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Question 8

Which one of the following is likely to increase the risk of constipation when given with an opioid?

  • Cefradine


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    Cefradine is a cephalosporin antibiotic. It can cause diarrhoea and is unlikely to increase the risk of constipation when given with an opioid.

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  • Ranitidine


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    Ranitidine is a H2 receptor antagonist which reduces secretion of gastric acid and promotes healing of gastric and duodenal ulcers. Ranitidine is not expected to interact with an opioid.

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  • Cetirizine


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    Cetirizine is a non-sedating antihistamine which blocks the H1 receptor; it is relatively free of antimuscarinic (anticholinergic) activity. Cetirizine is not likely to affect the risk of constipation when taken with an opioid.

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  • Lamotrigine


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    Lamotrigine is an antiepileptic drug; it is also used for managing bipolar disorders. Lamotrigine can cause diarrhoea; it is not expected to interact with opioids to increase the risk of constipation.

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  • Solifenacin


    Correct

    Solifenacin is an antimuscarinic (anticholinergic) urinary antispasmodic; it is used for managing urge incontinence and urinary frequency. Antimuscarinic drugs can increase the risk of opioid-induced constipation and urine retention. Constipation is a common side effect of solifenacin.

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Question 9

Which of the following features is suggestive of an opioid overdose?

  • Hypertension


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    Opioids depress the central nervous system. Opioid overdose is more likely to cause low blood pressure.

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  • Gooseflesh


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    Gooseflesh (or goose-bumps) and shivering are features of opioid withdrawal, not opioid overdose.

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  • Dilated pupils


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    Pupils may be dilated in patients undergoing opioid withdrawal. It is not a feature of opioid overdose.

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  • High temperature


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    Raised body temperature is not a typical feature of opioid overdose. Patients who have taken an excessive dose of opioid are more likely to have a low body temperature.

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  • Pinpoint pupils


    Correct

    Constriction of the pupils is a characteristic feature of opioid overdose. Other important features include respiratory depression and sedation leading to coma.

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Question 10

Ms ZH, aged 26 years, was brought in a comatose state to the accident and emergency department by her companions. Her blood pressure was low and her breathing was slow and shallow. Close questioning of her companions established that she had been abusing opioids for some months and had taken ‘a handful’ of capsules containing oxycodone 3–4 hours ago. Which of the following statements is correct? Choose the single best answer.

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Question 11

Tramadol accounts for over a third of opioid prescriptions dispensed in the community. Which one or more of the following are likely adverse effects of tramadol:

  • Sweating


    Correct

    Increased perspiration is a well known adverse effect of opioids and is a common effect of tramadol.

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  • Nausea


    Correct

    Nausea is a very common adverse effect of tramadol; it is a troublesome short-term side effect of opioids.

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  • Interaction with SSRI antidepressant


    Correct

    In addition to opioid agonist properties, tramadol also has serotonergic (and noradrenergic) effects. Excessive serotonergic activity when tramadol is combined with an SSRI antidepressant can be dangerous since the combination can, rarely, provoke serotonin syndrome.

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  • Interaction with cimetidine


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    Cimetidine is a liver enzyme inhibitor, but concomitant administration of cimetidine and tramadol does not result in clinically relevant interaction.

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  • Duodenal ulceration


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    Duodenal ulceration is not a feature of tramadol adverse effects. This side effect is more likely with prostaglandin inhibitors such as aspirin and other NSAIDs.

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Question 12

Following day surgery to repair a nasal injury, Mr JK, a minicab driver has been prescribed a three-day course of co-codamol 30/500 tablets. You are asked to advise him about his medicine. Which of the following is suitable advice?

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Page last modified: 17 February 2015