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What schedule is morphine and its derivatives?
Schedule 2
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What schedule are the drugs for ADHD?
Schedule 2 (amphetamines and methylphenidate)
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What drug is the most diverted drug in the US?
hydrocodone
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What schedule is pentobarbital?
Schedule 2
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What schedule are the benzo? (diazepam, alprazolam)
Schedule 4
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What do you do if narcotics are stolen from your office?
Fill a DEA 106 form
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How long is a Schedule 2 prescription valid in CA?
6 months (it's state specific, no federal limit)
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Schedule II. Written, telephone or faxed?
Only written is acceptable (Schedule III-V can be all 3 forms)
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# of refills for a Schedule II?
NONE. can't be refilled.
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# of refills for a Schedule III-IV?
up to 5 refills max
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# of refills for a Schedule V?
not established. Up to discretion of prescriber and pharmacist
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If want to give a pt 90 day supply of a Schedule II, have to do what?
Write 3 of same Rx, dated on same date (NO post-dating!), but write "DO NOT FILL UNTIL / / "
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natural, synthetic or semisynthetic: morphine, tramadol, codeine, hydrocodone, oxymorphone, meperidine, methadone, fentanyl
- Natural: morphine and codeine
- Semi-synth; derivatives of codeine and morphine
- Synthetic: methadone, meperidine, fentanyl, tramadol
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The 2 pure opioid antagonists: names and route of administration?
- Naloxone (Narcan) =IV/IM
- naltrexone (Revia) = PO
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What's the min. suggested amount of laxative for constipation due to opioids?
Docusate 200 mg BID- TID
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What are opioid peripheral effects on biliary tract, urinary tract, cardiac,
- Biliary: increases biliary pressure
- Urinary: increases muscle tone = less output
- CV: may have bradycardia, peripheral vasodilation = hypotension. Also cerebral vasodilation = increase ICP
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Why higher dose IV compared to PO for opoiods?
High first pass effect.
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How is morphine eliminated?
- 90% = renally
- 10%= feces via bile
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What other drug interactions does morphine have that produces a synergistic effect?
CNS depressants, MAOIs, TCAs, phenothiazines (antipsychotics)
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What does heroin get metabolized to?
morphine (it's 3x as potent for pain)
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What does 10% of codeine get converted to?
morphine
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What's the difference btw Oxycontin and oxycodone?
Oxycontin is time released oxycodone.
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What are contraindications to opioids?
- lungs: brochial asthma, COPD,
- liver damage, head injuries, ETOH use, convulsive disorder, abd pain of unknown origin
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Which opioid should you never give to an opioid-naive patient?
Fentanyl and hydromorphone extended release (Exalgo)
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What is diphenoxylate + atropine?
Lomotil.
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What cardiac condition do you have to worry about w/ Methadone?
Torsades (prolonged QT)so always do EKG first.
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What else does Tramadol do besides binding to the mu receptors?
Inhibits NE and 5HT (serotonin) reuptake
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Is there cross tolerance or physical dependence for opioids w/ other CNS depressants?
no, only among themselves.
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How do you estimate tolerance?
by amt of drug needed to cause drowsiness
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What is the prototypal mixed agonist-antagonist opioid?
Pentazocine (Talwin)
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What can high doses of pentazocine cause?
cv effects (high bp,HR) dysphoria, psycho effects
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What's the difference btw anti-anxiety and sedative-hypnotic drugs?
just the dosage (higher for insomnia)
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What are effects of sedative hypnotic drugs?
sedation slurred speech, incoordination, unsteady gait, impaired attention/memory
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How are benzos metabolized?
cyp450 in liver and CYP3A4 in intestines.
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What are contraindications for benzos?
resp. disorders, severe liver/kidney dz, Hx of ETOH or drug abuse, hypersensitivity rxns
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Which benzo is most likely to cause seizures in w/drawl?
Alprazolam (xanax)
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What's the recommend tapering of benzos?
~25% q 1-2 wks over 4-16 wks.
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Which 2 benzos don't depend on the P450 system? So good for which popns?
Lorazepam (Ativan) and oxazepam (Serax) so good for elderly and those w/ liver dz. For ANXIETY
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Which benzo is ideal choice for elderly FOR insomnia?
Temazepam (Restoril)
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How long is the max recommended time for using benzos?
2-4 weeks (start losing effectiveness, and increasing chances of w/drawl sxs)
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What are some w/drawl rxns of benzos?
insomia, anxiety, deprerssion, nausea, confusion (all these more pronounced in shorter-acting drugs)
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What are some side effects from stimulants?
decreased appetite, HA, stomachache, insomnia,
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what are 3 ways you can check on pt.'s use/obtaining opoids?
urine screen, CURES website, pill counts
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What % of Schedule II need to be countersigned by a MD? in what time period
100% of the charts w/in 7 days
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What's a key phrase in the definition of addiction?
continued use despite harm
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Treat opoids at home like what?
a gun. Keep it locked up! when disposing, mix w/ coffee grounds or cat litter
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What is a better than the pain scale?
- Measure of function
- www.theacpa.org/documents/Quality _of_life_scale.pdf
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What is the conversion rate for methadone?
none exist!
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Opioids in pregnancy? what pregnancy category?
Category C
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CURES database gives you a report on what schedule drugs?
II-IV
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What are some opioids full agonists?
morphine, hydromorphone, codeine and its derivatives,methadone, and fentanyl (all have no ceiiling effect)
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How to change opioids (opioid rotation)
use equianalgesic chart and decrease by 25%
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strength of the following relative to morphine: hydromorphone, oxymorphone, oxycodone, hydrocodone, codeine, methadone, meperidine, tramadol
- hydromorphone = 4X oxymorphone = 3X oxycodone =1.5X
- hydrocodone = 1X
- codeine = 1/6
- methadone = unknown meperidine = 1/10
- tramadol =1/10
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