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Chapter 31: Opioid Analgesics & Antagonists

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A 63-year-old man is undergoing radiation treatment as an outpatient for metastatic bone cancer. His pain has been treated with a fixed combination of oxycodone plus acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse.

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The most appropriate oral medication for his increasing pain is

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(A) Buprenorphine

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(B) Codeine plus aspirin

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(C) Hydromorphone

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(D) Pentazocine

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(E) Tramadol

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In most situations, pain associated with metastatic carcinoma ultimately necessitates the use of an opioid analgesic that is equivalent in strength to morphine, so hydromorphone, oxymorphone, or levorphanol would be indicated. Pentazocine or the combination of codeine plus salicylate would not be as effective as the original drug combination. Propoxyphene is even less active than codeine alone. Buprenorphine, a mixed agonist-antagonist, is not usually recommended for cancer-associated pain because it has a limited maximum analgesic effect (“ceiling”) and because of possible dysphoric and psychotomimetic effects. The answer is C.

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A 63-year-old man is undergoing radiation treatment as an outpatient for metastatic bone cancer. His pain has been treated with a fixed combination of oxycodone plus acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse.

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It is possible that this patient will have to increase the dose of the analgesic as his condition progresses as a result of developing tolerance. However, tolerance will not develop to a significant extent with respect to

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(A) Biliary smooth muscle

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(B) Emesis

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(C) Pupillary constriction

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(D) Sedation

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(E) Urinary retention

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Chronic use of strong opioid analgesics leads to the development of tolerance to their analgesic, euphoric, and sedative actions. Tolerance also develops to their emetic effects and to effects on some smooth muscle, including the biliary and the urethral sphincter muscles. However, tolerance does not develop significantly to the constipating effects or the miotic actions of the opioid analgesics. The answer is C.

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You are on your way to take an examination and you suddenly get an attack of diarrhea. If you stop at a nearby drugstore for an over-the-counter opioid with antidiarrheal action, you will be asking for

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(A) Codeine

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(B) Dextromethorphan

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(C) Diphenoxylate

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(D) Loperamide

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