Anxiety Disorders Management
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Questions and Answers

Which of the following is a common adverse effect of barbiturates?

  • Decreased sedation
  • Increased alertness
  • Increased heart rate
  • Respiratory depression (correct)

    • What are the three classifications of barbiturates based on duration of action?

    Ultrashort-acting (thiopental), short- to intermediate-acting (secobarbital), long-acting (phenobarbital)

    Tolerance to respiratory depression caused by barbiturates can develop over time.

    True

    Barbiturates mainly bind to the GABA receptor–chloride channel __________.

    <p>complex</p> Signup and view all the answers

    What is the difference between opioids and analgesics?

    <p>Analgesics relieve pain without causing loss of consciousness, while opioids are the most effective pain relievers available.</p> Signup and view all the answers

    What is the definition of the term 'opioid'?

    <p>Any drug, natural or synthetic, that has actions similar to those of morphine.</p> Signup and view all the answers

    Pure opioid antagonists do not produce analgesia or any effects caused by opioid agonists.

    <p>True</p> Signup and view all the answers

    Opioids activate ___ receptors and can produce various effects.

    <p>mu</p> Signup and view all the answers

    What are the characteristics of Generalized Anxiety Disorder?

    <p>Uncontrollable worrying that lasts 6 months or longer</p> Signup and view all the answers

    Which drug is not a central nervous system depressant and has no abuse potential for treating Generalized Anxiety Disorder?

    <p>Buspirone [BuSpar]</p> Signup and view all the answers

    Which adverse effects may be associated with Benzodiazepines used for anxiety disorders?

    <p>All of the above</p> Signup and view all the answers

    Benzodiazepines have a lower potential for abuse compared to general CNS depressants.

    <p>True</p> Signup and view all the answers

    What are the initial symptoms of abstinence syndrome with abrupt discontinuation of morphine?

    <p>Yawning, rhinorrhea, and sweating</p> Signup and view all the answers

    Which interaction does morphine have with CNS depressants?

    <p>Increases their effects</p> Signup and view all the answers

    What drug is commonly used for the short-term management of insomnia and has side effects like daytime drowsiness and dizziness?

    <p>Zolpidem [Ambien]</p> Signup and view all the answers

    The nurse provides teaching for a patient with obsessive-compulsive disorder who has been prescribed ______ [Zoloft]. Which statement by the patient indicates that more teaching is necessary?

    <p>Sertraline</p> Signup and view all the answers

    Morphine withdrawal can be lethal.

    <p>False</p> Signup and view all the answers

    ___ is the antagonist used for treating morphine toxicity.

    <p>Naloxone</p> Signup and view all the answers

    Match the opioid with its formulation route:

    <p>Fentanyl = Transdermal Codeine = Oral Oxycodone = Controlled-release Hydrocodone = Combined with other analgesics</p> Signup and view all the answers

    Which of the following is true about Nonopioid Centrally Acting Analgesics?

    <p>They do not cause respiratory depression, physical dependence, or abuse.</p> Signup and view all the answers

    Which of the following is a mechanism of action for Tramadol?

    <p>Combination of opioid and nonopioid mechanisms</p> Signup and view all the answers

    Which drug is a selective antagonist at N-type voltage-sensitive calcium channels on neurons?

    <p>Ziconotide</p> Signup and view all the answers

    What is the primary use of Dexmedetomidine?

    <p>Short-term sedation in critically ill patients</p> Signup and view all the answers

    Which statement best describes the World Health Organization analgesic ladder?

    <p>Step 2 is for mild to moderate pain and includes NSAIDs and acetaminophen.</p> Signup and view all the answers

    What is the mechanism of action of Sumatriptan [Imitrex]?

    <p>Binds to receptors on intracranial blood vessels and causes vasoconstriction</p> Signup and view all the answers

    Which adverse effect is associated with Sumatriptan [Imitrex] use?

    <p>Chest symptoms such as 'heavy arms'</p> Signup and view all the answers

    Ergotamine is a first-line drug for stopping an ongoing migraine attack.

    <p>False</p> Signup and view all the answers

    Which drug is mentioned as a preventive therapy for migraines besides beta blockers and antiepileptic drugs?

    <p>Tricyclic antidepressants</p> Signup and view all the answers

    What is a possible key driver of increased patient satisfaction and successful opioid tapering with medical cannabis?

    <p>Better sleep</p> Signup and view all the answers

    According to the findings, what role does medical cannabis potentially play in a subset of patients?

    <p>Support</p> Signup and view all the answers

    What is the typical cost range per month for low-dose naltrexone at US compounding pharmacies?

    <p>$25 to $65</p> Signup and view all the answers

    What is the key difference between nociceptive pain and neuropathic pain in terms of responsiveness to anti-inflammatory agents and opiates?

    <p>Nociceptive pain is responsive, while neuropathic pain is poorly responsive.</p> Signup and view all the answers

    What type of pain is primarily postoperative and posttraumatic?

    <p>Nociceptive</p> Signup and view all the answers

    Neuropathic pain may become hardwired into the nervous system due to consequences of central nervous system _______ changes.

    <p>plasticity</p> Signup and view all the answers

    Neuropathic pain is often responsive to anti-inflammatory agents and opiates.

    <p>False</p> Signup and view all the answers

    Match the pain components with the corresponding example: herniated disc patient.

    <p>Somatic nociceptive pain = Disruption of the disc Neuropathic pain = Compression and inflammation of the nerve root</p> Signup and view all the answers

    A patient with cancer complains of bone pain that he rates an 8 on a scale of 0 to 10. Which medication should the nurse administer?

    <p>Hydromorphone [Dilaudid]</p> Signup and view all the answers

    When caring for a patient with moderate to severe cancer pain, what is the pharmacist’s priority?

    <p>Adequate pain relief with opioid medications</p> Signup and view all the answers

    A patient with cancer is being discharged with a prescription for opioids. Which statement by the patient indicates that teaching has been effective?

    <p>If the drug no longer works, the dose can be increased.</p> Signup and view all the answers

    The nurse is caring for a patient with bone cancer who is an opioid abuser. The patient has bone pain rating an 8 on a scale of 1 to 10. Which ordered medication would be most effective for treating this patient?

    <p>Adequate doses of opioids</p> Signup and view all the answers

    Study Notes

    Here are the study notes:

    Sedative-Hypnotic Drugs and Anxiety

    • Sedative-hypnotic drugs, including benzodiazepines (e.g., Ativan, Xanax, Valium, Klonopin) and "z-drugs" (e.g., Ambien, Lunesta), are widely prescribed for insomnia and anxiety.
    • Long-term use of these drugs by older people has caused concern among researchers due to potential risks.

    Risks Associated with Sedative-Hypnotic Drugs

    • Higher rates of falls and fractures
    • Increased auto accidents
    • Cognitive problems
    • Increased emergency room visits and hospital admissions

    American Geriatrics Society's Choosing Wisely List

    • Sedative-hypnotic drugs are included in the list of treatments that doctors and patients should question.

    Study on Benzodiazepine Use and Alzheimer's Disease

    • Researchers from France and Canada conducted a study on the link between benzodiazepine use and Alzheimer's disease.
    • The study reviewed medical records of almost 1,800 older people diagnosed with Alzheimer's and compared them with nearly 7,200 control subjects.
    • Results:
      • Benzodiazepine users had a 51% increase in the odds of a subsequent Alzheimer's diagnosis.
      • The association strengthened with greater exposure to the drugs (i.e., longer duration of use).
      • Short-term use (≤ 90 days) did not increase the risk of Alzheimer's disease.

    Conclusion

    • Long-term use of benzodiazepines is linked to a higher risk of Alzheimer's disease, particularly with prolonged exposure.### Benzodiazepines and Alzheimer's Disease
    • Taking benzodiazepines for a longer period increases the risk of developing Alzheimer's disease
      • 32% increased risk for patients who took daily doses for 91-180 days
      • 84% increased risk for patients who took daily doses for more than 180 days
    • The association between benzodiazepines and Alzheimer's disease persists despite controlling for health and demographic factors
    • The link is stronger for longer-acting forms of benzodiazepines, such as Valium, compared to formulations that leave the body more quickly, such as Ativan and Xanax

    Opioids and Pain Relief

    • Analgesics are drugs that relieve pain without causing loss of consciousness
    • Opioids are the most effective pain relievers available
    • Endogenous opioid peptides, such as enkephalins, endorphins, and dynorphins, are naturally produced by the body
    • Opioid receptors, including mu, kappa, and delta receptors, are responsible for the effects of opioids

    Morphine

    • Morphine is a strong opioid agonist that activates mu and kappa receptors
    • It is used to relieve pain, particularly in cancer patients, and has a range of effects, including:
      • Analgesia
      • Drowsiness
      • Mental clouding
      • Anxiety reduction
      • Sense of well-being
      • Respiratory depression
      • Constipation
      • Urinary retention
      • Orthostatic hypotension
      • Emesis
      • Miosis
      • Cough suppression
      • Biliary colic
    • Tolerance to morphine can develop, leading to the need for higher doses
    • Physical dependence on morphine can occur, leading to withdrawal symptoms when the drug is discontinued

    Other Opioid Agonists

    • Fentanyl is a strong opioid agonist that is 100 times more potent than morphine
    • It is available in various formulations, including patches, lozenges, and buccal tablets
    • Other strong opioid agonists include alfentanil, sufentanil, remifentanil, meperidine, and methadone
    • Each of these drugs has its own unique characteristics, benefits, and risks

    Important Considerations

    • Opioid agonists should be used with caution and under close medical supervision
    • They can be habit-forming and may lead to physical dependence and addiction
    • Patients should be monitored for signs of respiratory depression, and dosage should be adjusted accordingly
    • Opioid agonists should not be used in combination with other CNS depressants, as this can increase the risk of respiratory depression and death### Moderate to Strong Opioid Agonists
    • Similar to morphine in most respects
    • Produce analgesia, sedation, and euphoria
    • Can cause:
      • Respiratory depression
      • Constipation
      • Urinary retention
      • Cough suppression
      • Miosis
    • Can be reversed with naloxone
    • Different from morphine:
      • Produce less analgesia and respiratory depression
      • Somewhat lower potential for abuse

    Codeine

    • Actions and uses:
      • 10% converts to morphine in liver
      • Pain and cough suppression
    • Preparations, dosage, and administration:
      • Usually oral (formulated alone or with aspirin or acetaminophen)
      • 30 mg produces same effect as 325 mg of acetaminophen

    Oxycodone

    • Analgesic actions equivalent to those of codeine
    • Long-acting analgesics:
      • Immediate-release
      • Controlled-release (OxyContin)
      • Abuse: Crushes and snorts or injects medication
      • 2010 OP formulation much harder to crush and does not dissolve into an injectable solution to decrease risk of abuse

    Hydrocodone

    • Most widely prescribed drug in the United States
    • Combined with aspirin, acetaminophen, or ibuprofen

    Tapentadol

    • Analgesic effects equivalent to oxycodone
    • Causes less constipation than traditional medications

    Agonist-Antagonist Opioids

    • Pentazocine
    • Nalbuphine
    • Butorphanol
    • Buprenorphine
      • 7-day patch: Butrans
      • Sublingual film: Suboxone

    Clinical Use of Opioids

    • Pain assessment:
      • Essential component of management
      • Based on patient's description
      • Evaluate:
        • Pain location, characteristics, and duration
        • Things that improve or worsen pain
        • Status before taking drug and 1 hour after
    • Dosing guidelines:
      • Assessment of pain
        • Pain status should be evaluated before opioid administration and about 1 hour after
      • Dosage determination
        • Opioid analgesics must be adjusted to accommodate individual variation
      • Dosing schedule
        • As a rule, opioids should be administered on a fixed schedule
      • Avoiding withdrawal
    • Physical dependence:
      • State in which an abstinence syndrome will occur if the dependence-producing drug is abruptly withdrawn
      • NOT equated with addiction
    • Abuse:
      • Drug use that is inconsistent with medical or social norms
    • Addiction:
      • Behavior pattern characterized by continued use of a psychoactive substance despite physical, psychologic, or social harm

    REMS

    • Risk Evaluation and Mitigation Strategy (REMS)
    • Developed by the U.S. Food and Drug Administration
    • Designed to reduce opioid-related injuries and deaths

    Opioid Antagonists

    • Principal uses:
      • Treatment of opioid overdose and relief of opioid-induced constipation
      • Reversal of postoperative opioid effects
      • Reversal of neonatal respiratory depression
      • Management of opioid addiction

    Pure Opioid Antagonists

    • Naloxone (Narcan)
    • Methylnaltrexone (Relistor)
    • Alvimopan (Entereg)
    • Naltrexone (ReVia, Vivitrol)

    Naloxone

    • Mechanism of action:
      • Competitive antagonist
    • Pharmacologic effects:
      • Reversal of opioid effects
    • Pharmacokinetics:
      • Distributed through the body
      • Eliminated through metabolism
    • Therapeutic uses:
      • Reversal of opioid overdose
      • Reversal of postoperative opioid effects
      • Reversal of neonatal respiratory depression

    Nonopioid Centrally Acting Analgesics

    • Relieve pain by mechanisms largely or completely unrelated to opioid receptors
    • Do not cause respiratory depression, physical dependence, or abuse
    • Not regulated under the Controlled Substances Act

    Tramadol

    • Mechanism of action:
      • Combination of opioid and nonopioid mechanisms
    • Therapeutic use:
      • Pain relief
    • Adverse effects and interactions:
      • CNS depression
      • Seizure risk
    • Drug interactions:
      • CNS depressants
    • Abuse liability:
      • Suicide risk
    • Preparations, dosage, and administration:
      • Immediate-release and extended-release

    Clonidine

    • Treatment of hypertension and relief of severe pain
    • Mechanism of pain relief:
      • Alpha2-adrenergic agonist
    • Analgesic use:
      • Used in combination with opioid analgesics
    • Adverse effects:
      • Cardiovascular: Severe hypotension, rebound hypertension, and bradycardia
    • Contraindications:
      • Pregnancy and lactation

    Ziconotide

    • Mechanism of action:
      • Selective antagonist at N-type voltage-sensitive calcium channels on neurons
      • Blocks calcium channels on primary nociceptive afferent neurons in dorsal horn of the spinal cord
    • Pharmacokinetics:
      • Distributed through cerebrospinal fluid and then transported to systemic circulation
    • Adverse effects:
      • CNS and muscle injury
    • Drug interactions:
      • Formal studies not done
    • Preparations, dosage, and administration:
      • Intrathecal administration

    Dexmedetomidine

    • Selective alpha2-adrenergic agonist
    • Acts in the CNS to cause sedation and analgesia
    • Uses:
      • Short-term sedation in critically ill patients who are initially intubated and undergoing mechanical ventilation
      • Sedation for nonintubated patients before or during surgical and other procedures
    • Adverse effects:
      • Hypotension
      • Bradycardia
    • Drug interactions:
      • No specific interactions
    • Preparations, dosage, and administration:
      • IV administration

    Pain Management in Patients with Cancer

    • Barriers to treating cancer pain:
      • Patient concerns
      • Healthcare system
      • Healthcare professionals
      • Patients
    • Pathophysiology of pain:
      • Neurophysiologic basis of painful sensations
      • Nociceptive pain versus neuropathic pain
    • Assessment and ongoing evaluation:
      • Comprehensive initial assessment
      • Ongoing evaluation
      • Barriers to assessment
    • Drug therapy:
      • Nonopioid analgesics
      • Opioid analgesics
      • Adjuvant analgesics
    • Principles of drug therapy for cancer pain:
      • Comprehensive pretreatment assessment
      • Individualize the treatment plan
      • Use the World Health Organization analgesic ladder and the National Comprehensive Cancer Network guidelines
      • Avoid intramuscular injections
      • Provide a fixed schedule of around-the-clock treatment
      • Evaluate the patient frequently for pain relief and drug side effects

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