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Questions and Answers
Which receptor is primarily associated with the respiratory depression seen in acute opioid overdose?
Which receptor is primarily associated with the respiratory depression seen in acute opioid overdose?
What is a common clinical sign associated with acute opioid poisoning?
What is a common clinical sign associated with acute opioid poisoning?
In the context of opioid overdose, what physiological change is typically observed in skeletal muscles?
In the context of opioid overdose, what physiological change is typically observed in skeletal muscles?
What might explain decreased urinary output in an individual experiencing opioid toxicity?
What might explain decreased urinary output in an individual experiencing opioid toxicity?
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Which of the following symptoms is least likely to occur in the later stages of opioid poisoning?
Which of the following symptoms is least likely to occur in the later stages of opioid poisoning?
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What complication often occurs alongside respiratory depression in acute opioid overdose?
What complication often occurs alongside respiratory depression in acute opioid overdose?
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Which mechanism is primarily responsible for the psychogenic effects experienced during opioid use?
Which mechanism is primarily responsible for the psychogenic effects experienced during opioid use?
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Which of the following could indicate the presence of foamy pulmonary edema during opioid overdose?
Which of the following could indicate the presence of foamy pulmonary edema during opioid overdose?
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How does opioid toxicity typically affect body temperature?
How does opioid toxicity typically affect body temperature?
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What gastrointestinal effect can result from opioid toxicity?
What gastrointestinal effect can result from opioid toxicity?
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What is the primary cardiovascular effect of cocaine that may lead to complications?
What is the primary cardiovascular effect of cocaine that may lead to complications?
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Which of the following is a first-line treatment for cocaine-induced seizures?
Which of the following is a first-line treatment for cocaine-induced seizures?
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A typical characteristic of marijuana poisoning at low doses includes which of the following?
A typical characteristic of marijuana poisoning at low doses includes which of the following?
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Which symptom is most likely to occur during high doses of cocaine?
Which symptom is most likely to occur during high doses of cocaine?
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What physiological effect may occur following high doses of cocaine regarding the respiratory system?
What physiological effect may occur following high doses of cocaine regarding the respiratory system?
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At what dosage of THC may cognitive disturbances begin to appear in marijuana poisoning?
At what dosage of THC may cognitive disturbances begin to appear in marijuana poisoning?
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What treatment may be indicated for managing hypotension in a cocaine overdose situation?
What treatment may be indicated for managing hypotension in a cocaine overdose situation?
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What effect does marijuana have on sensory perception after low-dose use?
What effect does marijuana have on sensory perception after low-dose use?
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Which symptom may not typically occur at lower doses of cocaine?
Which symptom may not typically occur at lower doses of cocaine?
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What is a significant risk factor for death resulting from cocaine use?
What is a significant risk factor for death resulting from cocaine use?
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What is the key acute toxic effect of fentanyl derivatives?
What is the key acute toxic effect of fentanyl derivatives?
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Which fentanyl derivative is reported to be the most potent compared to morphine?
Which fentanyl derivative is reported to be the most potent compared to morphine?
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What unique cardiovascular response is associated with high doses of pentazocine?
What unique cardiovascular response is associated with high doses of pentazocine?
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Which characteristic is primarily associated with meperidine use?
Which characteristic is primarily associated with meperidine use?
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Which opioid is a synthetic analog of methadone that may cause potential toxicity?
Which opioid is a synthetic analog of methadone that may cause potential toxicity?
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What is a significant concern when using propoxyphene, especially in combination with another substance?
What is a significant concern when using propoxyphene, especially in combination with another substance?
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Which mode of cocaine usage is most commonly associated with fatalities?
Which mode of cocaine usage is most commonly associated with fatalities?
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Cocaine affects which neurotransmitter mechanism leading to its toxic effects?
Cocaine affects which neurotransmitter mechanism leading to its toxic effects?
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What major effect does 3-Methyl-fentanyl have that distinguishes it from other opioids?
What major effect does 3-Methyl-fentanyl have that distinguishes it from other opioids?
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What psychological effects can pentazocine induce?
What psychological effects can pentazocine induce?
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What is the primary treatment objective for victims of opioid overdoses?
What is the primary treatment objective for victims of opioid overdoses?
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What is naloxone primarily used for in opioid intoxication cases?
What is naloxone primarily used for in opioid intoxication cases?
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What characteristic symptoms can arise from acute toxic ingestions of codeine?
What characteristic symptoms can arise from acute toxic ingestions of codeine?
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What class of opioids does diphenoxylate belong to?
What class of opioids does diphenoxylate belong to?
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Which of the following is the most significant risk factor associated with pulmonary edema in opioid intoxication?
Which of the following is the most significant risk factor associated with pulmonary edema in opioid intoxication?
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Which properties does codeine possess?
Which properties does codeine possess?
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How long should patients be monitored after naloxone administration for opioid overdose?
How long should patients be monitored after naloxone administration for opioid overdose?
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What effect do anticholinergic symptoms in children from diphenoxylate ingestion include?
What effect do anticholinergic symptoms in children from diphenoxylate ingestion include?
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What is the consequence of using an opioid antagonist like naloxone in overdose cases?
What is the consequence of using an opioid antagonist like naloxone in overdose cases?
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Which opioids have uncertain efficacy but are recommended as supportive therapy?
Which opioids have uncertain efficacy but are recommended as supportive therapy?
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Study Notes
Clinical Toxicology - Opioids
- Opioids (narcotics), and heroin (diacetylmorphine) are frequently implicated in overdoses.
- The association between opioid overdose and low socioeconomic status is inaccurate. Victims can be of any age and social/economic background.
- Opioids can be obtained illegally or legally via prescription.
Mechanisms of Opioid Toxicity
- Opioid derivatives cause severe toxicity, severity dependent on dose and route of administration.
- Analgesia, euphoria, respiratory depression, and miosis are linked to µ-receptor occupation.
- Different types of analgesia result from K-receptor involvement.
- Dysphoria, delusions, and hallucinations are effects of opioid action on δ-receptors.
- Acute overdose significantly depresses respiration to 2-4 breaths per minute.
- Cyanosis and foamy pulmonary edema are common symptoms.
- Respiratory arrest is the primary cause of death from opioid overdose.
- Bradycardia and hypotension can further complicate respiratory depression in acute overdoses.
- Hypotension often arises in later stages due to hypoxia.
Signs of Narcotic Poisoning
- Pinpoint pupils (miosis) are a classic sign.
- Body temperature decreases, skin feels cold and clammy, due to hypothalamic heat-regulation suppression.
- Skeletal muscles become flaccid, and jaw relaxation is possible.
- Tongue may fail to block the airway.
- Decreased urinary output is related to antidiuretic hormone (ADH) release.
- Gastric motility and tone in the small and large intestines may decrease, leading to constipation.
- Death in addicts may be due to respiratory failure, complicated by conditions like pneumonia, shock, or pulmonary edema.
Management of Opioid Toxicity
- Maintaining vital functions (respiration and cardiovascular) is the primary treatment goal.
- Adequate respiratory and cardiovascular support is crucial.
- Opioid overdoses are treated using direct antagonists.
- Antagonists (e.g., naloxone) rapidly reverse CNS depression, analgesic effects, convulsions, and psychotogenic/dysphoric actions.
- Naloxone is the first-line treatment for opioid intoxications.
- Dramatic improvement in respiration is seen within minutes of naloxone administration.
- Comatose patients require swift awakening.
- Ongoing hypoxia requires prompt and adequate tissue oxygenation.
- Supportive therapy (e.g., diuretics, digitalis, steroids, antihistamines) for pulmonary edema is often considered, but efficacy is uncertain.
- Extended monitoring for naloxone effect is crucial.
Naturally Occurring Opioids - Codeine
- Codeine (or methylmorphine) possesses analgesic and antitussive properties.
- Codeine is less potent than morphine.
- Codeine alone rarely causes toxic reactions leading to death.
- Acute codeine ingestion typically elicits the same side effects seen in morphine poisoning (coma, meiosis, respiratory depression).
Synthetic Opioids - Diphenoxylate, Fentanyl, Meperidine, Pentazocine, Propoxyphene
- Diphenoxylate, a meperidine congener, is used in combination with atropine.
- Diphenoxylate has a narrow therapeutic index; it's important to understand the correct dose to avoid toxicity.
- Acute diphenoxylate intoxications, particularly in children, display anticholinergic effects (hyperpyrexia, flushing, lethargy, hallucinations, urinary retention, tachycardia).
- This anticholinergic presentation is followed by opioid-related miosis, respiratory depression, and coma.
- Alpha-methyl fentanyl is highly potent (200x morphine), showing a minimum lethal dose around 125 µg.
- 3-Methyl fentanyl exhibits even greater potency (7000x morphine).
- Fentanyl derivatives primarily cause dose-dependent respiratory depression, with effects lasting up to 30 minutes.
- Fentanyl toxicity also includes bradycardia, hypotension, chest wall rigidity, nausea, vomiting, hypothermia, and seizures.
- Meperidine hydrochloride is a pure opioid agonist, often used in post-operative or chronic pain.
- Cumulative meperidine doses can pose problems due to its pharmacokinetic properties.
- Pentazocine affects the CNS and smooth muscle, resulting in analgesia, sedation, and respiratory depression.
- High doses of pentazocine can cause cardiovascular effects like increased blood pressure, heart rate, flushing, chills, and sweating
- Propoxyphene is a synthetic opioid analog of methadone and is similar to methadone, it is often used for minor pain, however, people often underestimate its toxicity, especially during overdose. Patients with acetaminophen are a special concern.
Cocaine
- Central stimulation is a key pharmacological and toxic action of cocaine.
- Intranasal insufflation or inhalation of freebase cocaine (crack) is a common method of use.
- A survey found prevalence of cocaine use through intranasal route, smoking, injecting (intravenous).
- Most cocaine fatalities are caused by intravenous use.
- Cocaine use has been linked to body packing.
- Cocaine blocks the reuptake of norepinephrine, dopamine, and serotonin at nerve endings.
- Euphoria or dysphoria may accompany use.
- Motor coordination is generally preserved with lower doses.
- Larger doses lead to stimulation of lower motor centers, cord reflexes, and muscular twitching that can be followed by tonic–clonic convulsions.
- Respiratory failure resulting from medullary depression is the cause of death in high-dose cases.
Marijuana
- Tetrahydrocannabinol (THC) is rapidly absorbed into the blood after inhalation.
- THC subjective effects last for 2-3 hours, or longer after oral intake.
- Low doses of THC typically induce relaxation, mild euphoria, and enhanced sensory perception.
- High doses can lead to depersonalization, disorientation, paranoia, and severe sensory distortion.
- Cardiovascular effects, including dose-related tachycardia, are often observed, but blood pressure is not typically affected significantly.
- Impaired pulmonary function (bronchitis, pharyngitis, cough, asthma-like symptoms) can result.
- Marijuana smoking is implicated in cancer due to its high tar content.
- Management of marijuana-related reactions is primarily supportive.
- Removal of the ingested material from the stomach (e.g., emesis, lavage, activated charcoal) and/or prolonged calming measures (talk therapy) in cases of disorientation or panic reactions are appropriate,
- Acute, pure marijuana toxicity is rare.
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Description
This quiz delves into the clinical toxicology of opioids, including heroin. It covers the mechanisms of opioid toxicity, the effects on different opioid receptors, and the critical symptoms of overdose. Test your knowledge on this important topic in medicine related to narcotics and their effects.
