1. Pharmacology
CHAPTER 5

2. WHAT ARE AUTACOIDS?

3. OCCUR NATURALLY IN THE BODY
produced in one organ and are transported via the lymph system
All occur (made) naturally in the body.

4. Terms & Definitions Autacoids - Examples:
Prostaglandins – lipids that are synthesized locally by inflammatory stimuli –↑↑ PAIN receptors
Thromboxanes (a vasoconstrictor and a potent hypertensive agent, and facilitates platelet aggregation [clotting]).
Leukotrienes (Inflammatory molecules; precursor of prostaglandins)
“-kinins” - messengers

5. IS PAIN DIFFERENT FOR EVERYONE?

6. YES

7. PAIN Perception Reaction The Physical component of pain:
The Message that is carried from the
Injured tissue to the brain;
It is the ability to realize you are hurt
The Psychological component:
The patient’s emotional response;
Differs from person to person;
Several factors will affect reaction

8. WHAT ARE PLACEBOS?

9. ‘’FAKE’ DRUGS
For some people, pain can also be effectively treated with inactive pills (placebos)

10. WHAT ARE ANTIPYRETICS ALSO CALLED?

11. NON-OPIODS Non opioid analgesics are also called:
nonnarcotic, peripheral, mild, and
Antipyretic (agents that reduce fever)
Opioid analgesics are also called:
narcotic,
central, or
strong analgesics.

12. Classification of Analgesic Agents
Nonopioids (nonnarcotics)
Act primarily at the: peripheral nerve endings
Inhibit prostaglandin synthesis (regulating the contraction and relaxation of smooth muscle tissue)
Not effective for severe pain
3 subgroups:
Salicylates (aspirin-like group)
NSAIDs
Acetaminophen
2. Opioids (narcotics)
Act primarily within the: central nervous system
Depress the central nervous system
Effective for severe pain
Examples: Morphine, Codeine, Agents in cough suppressants
We will discuss this area more in the next chapter
Difference is in their site of action
Difference in their mode of action
LOOD AT FIGURE 5-2, PAGE 50 IN TEXTBOOK FOR REVIEW

13. WHAT CATEGORY IS ASPIRIN UNDER?

14. acetyl salicylic acid (ASA) – THE CHEMICAL NAME FOR ASPIRIN
SALICYLATES
ASPIRIN is the most useful and common salicylate to reduce pain (analgesic action)
acetyl salicylic acid (ASA) – THE CHEMICAL NAME FOR ASPIRIN

15. WHAT DOES NSAIDS STAND FOR AND WHAT DOES IT MEEAN?

16. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

17. Salicylates
Aspirin belongs to a class of medications called nonsteroidal antiinflammatory drugs (NSAIDs).
Aspirin and other NSAIDs, for example, ibuprofen (eg. Motrin, Advil) and naproxen (eg. Aleve), are widely used to treat fever (antipyretic action), pain (analgesic action), and inflammatory (anti-inflammatory action) conditions such as arthritis
Aspirin is also known for its anti-platelet action
BOX 5-2; PAGE 51

18. ASA Aspirin have: anti-inflammatory, antipyretic, analgesic, and
Salicylates:
MECHANISM OF ACTION
Aspirin have:
anti-inflammatory,
antipyretic,
analgesic, and
antiplatelet actions.
These actions are related to the ability to inhibit prostaglandin synthesis
Whereas, Acetaminophen drugs have only antipyretic & analgesic actions.
REMEMBER: Prostaglandins INCREASE pain perception at the site of infection. Therefore, in order to DECREASE pain, we need to block/inhibit prostaglandin synthesis.

19. ASA
Salicylates:
MECHANISM OF ACTION
Aspirin inhibits cyclo-oxy-genase (COX) to block production of prostaglandins
Prostaglandins can sensitize pain receptors to substances such as BRADYKININ (SEE NOTE)
A reduction in prostaglandins results in a reduction in pain
‘kinin’ acts as messengers; Bradykinins is a very powerful vasodilator and increases capillary permeability; in addition, it constricts smooth muscle and stimulates pain receptors

20. HOW LONG BEFORE ASPIRINS PEAK EFFECT?

21. REMEMBER NOT TO APPLY TOPICALLY TO ORAL MUCOSA!!!!
30 MINUTES
REMEMBER NOT TO APPLY TOPICALLY TO ORAL MUCOSA!!!!

22. ASPIRIN’S EFFECTS BY DOSE
HIGH
ASPIRIN’S EFFECTS BY DOSE
LOW
Chapter 5; page 53

23. ASA Reye’s Syndrome ADVERSE REACTIONS
Salicylates:
ASA
ADVERSE REACTIONS
Reye’s Syndrome
Associated with use of aspirin in children & adolescents who took it when they had the chickenpox or influenza
Fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver.
ACETAMINOPHEN and NSAIDs are now used for fever (antipyretic action) or pain (analgesic action) in pediatric and adolescents to reduce the chances of Reye’s Syndrome
FYI: Reye's syndrome is a potentially fatal disease that has numerous detrimental effects to many organs, especially the brain and liver, as well as causing a lower than usual level of blood sugar (hypoglycemia)The classic features are a rash, vomiting, and liver damage. The exact cause is unknown and, while it has been associated with aspirin consumption by children with viral illness, it also occurs in the absence of aspirin use.

24. WHAT DRUG SHOULD YOU NOT TAKE WITH ASPIRIN?

25. WARFARIN
A drug interaction between aspirin and Warfarin can result in significant bleeding

26. NSAIDs
A rapidly growing group with important application in dentistry
Mechanism of action and many of their pharmacologic effects and adverse reactions resemble aspirin
Many authors agree that the NSAIDs are the most useful drug group for the treatment of dental pain.
Most are available without a prescription.

27. WHEN IS THE PEAK PERIOD FOR MOST NSAIDS?

28. 1-2 hours

29. NSAIDs Most NSAIDs peak in about 1-2 hours
PHARMACOKINETICS
Most NSAIDs peak in about 1-2 hours
Well absorbed orally and food reduces the rate but not the extent of absorption
Metabolized in liver, excreted in kidneys

30. PHARMACOLOGIC EFFECTS
NSAIDs
PHARMACOLOGIC EFFECTS
have a significant anti-inflammatory effect
Similar as aspirin:
analgesic
antipyretic
anti-inflammatory
They inhibit prostaglandin synthesis

31. ARE NSAIDS ADDICTING?

32. NO!
NSAIDs are not addicting, tolerance does NOT develop, and no withdrawal syndrome can be induced.

33. NSAIDs 7. Pregnancy and Nursing Contraindicated in pregnancy;
ADVERSE REACTIONS
7. Pregnancy and Nursing
Contraindicated in pregnancy;
Like aspirin, NSAIDs given late in pregnancy can prolong gestation
IBUPROFEN is drug of choice for nursing

34. DENTAL PAIN IS BEST MANAGED BY HOW MUCH MG OF IBUPROFEN?

35. 400MG
In usual prescription doses, NSAIDs can be shown to be statistically significantly better than codeine alone, aspirin, acetaminophen, or placebo.

36. CONTRAINDICATIONS & CAUTIONS Contraindicated in pregnancy
NSAIDs
CONTRAINDICATIONS & CAUTIONS
NSAIDs should be used with caution in patients with:
asthma
cardiovascular disease
Renal diseases with fluid retention
coagulation problems
peptic ulcer disease
ulcerative colitis
Contraindicated in pregnancy
Ulcerative colitis is a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum.
peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful.

37. WHAT IS THE MOST COMMONLY USED NSAID?

38. IBUPROFEN

39. WHAT HAS NO ANTI-INFLAMMATORY EFFECT?

40. ACETAMINOPHEN

41. Acetaminophen
Used as an analgesic and antipyretic in children and adults when aspirin is contraindicated
Has no anti-inflammatory action

42. Acetaminophen PHARMACOKINETICS
Rapidly and completely absorbed from the GI tract
Peak plasma level in 1 – 3 hours
Half life of 1 to 4 hours
Metabolized by the liver
Excreted by the kidneys in 24 hours
When large doses are ingested, an intermediate metabolite is produced that is thought to be hepatotoxic and possibly nephrotoxic. .
Hepatotoxic: Damaging or destructive to the liver
Nephrotoxic: Destructive to kidney cells

43. AN ACUTE OVERDOSE OF ACETAMINOPHEN CAN CAUSE WHAT?

44. LIVER DAMAGE

45. Acetaminophen Acetaminophen is used as an: Analgesic agent (↓ pain)
USES
Acetaminophen is used as an:
Analgesic agent (↓ pain)
Antipyretic agent (↓ fever)
FYI: chemical name is 4-hydroxyacetanalide. Its chemical formula is C 8 H 9 NO 2

46. Acetaminophen
USES
Used when hypersensitivity to aspirin or for patients experiencing aspirin-gastric induced irritation.
Used as an antipyretic instead of aspirin for young children; due to aspirin’s association with Reye’s syndrome.
Can be used in all stages of pregnancy (always ask doctor)

47. WHAT DRUGS ARE USED TO TREAT GOUT?

48. Allopurinol AND Probenecid

49. Drugs Used to Treat Gout
Allopurinol (Zyloprim)
used in PREVENTION of a gout attack.
Inhibits the synthesis of uric acid
Also used in patients receiving either chemotherapy or irradiation
If a pruritic rash should occur, the drug should be promptly discontinued
Probenecid (Benemid)
Is an uricosuric drug that increases uric acid excretion in the urine

50. CHAPTER 6

51. WHAT ARE OPIODS USED TO TREAT?

52. MODERATE TO SEVERE PAIN
At first referred to drugs that are derivatives of opium poppy
Opioid or narcotic analgesics are used to manage dental pain in patients in whom NSAIDs are contraindicated

53. CLASSIFICATION -THREE GROUPS-
Mechanism of action at the receptor site:
GROUP
SUBGROUP
EXAMPLE
OPIOID AGONISTS
morphine, codeine
MIXED OPIOIDS
AGONIST-ANTAGONISTS
PARTIAL AGONIST
pentazocine
buprenorphine
ANTAGONISTS
Naloxone

54. BOX 6-1 OPIOD ANALGESIC AGENTS BY STRUCTURE GROUP
CLASSIFICATION:
CHEMICAL STRUCTURE
BOX 6-1 OPIOD ANALGESIC AGENTS BY STRUCTURE GROUP
MORPHINE AND CODEINE
(Largest Group)
hydromorphone (Dilaudid) agonist
hydrocodone (in Vicodin) agonist
dihydrocodeine (in Synalgos-DC)
oxycodone (in Percodan, Percocet, Tylox) agonist
METHADONE
methadone (Dolophine) agonist
propoxyphene (Darvon) agonist
MORPHINAN
butorphanol (Stadol) agonist-antagonist
pentazocine (in Talwin-NX) agonist-antagonist
MEPERIDINE
meperidine (Demerol) agonist
fentanyl (Sublimaze) agonist
diphenoxylate (in Lomotil)
OTHER
buprenorphine (Buprenex, Subutex) partial agonist
Do not give any of these drugs if the patient has an allergy to morphine or codeine
Mep-pear-a-d-ene BOX 6-1 page 66 NOTE: the drug names bolded will appear on the test – they are discussed throughout the slides and key points to know for each drug are highlighted in red.

55. WHAT ARE WEAKER FORMS OF OPIODS?

56. Codeine (in Tylenol#3) and Hydrocodone (in Vicodin) are some of the weakest

57. SCHEDULE FOR CONTROLLED SUBSTANCE
DRUG NAME (SOME EXAMPLES)
COMMENTS
SCHEDULE FOR CONTROLLED SUBSTANCE
STRONGEST
MORPHINE
Standard agent; prototype II
MERPERIDENE
(Demerol)
Abused by professionals
INTERMEDIATE
OXYCODONE
(in Percocet)
Popular with addicts ‘shopping’ for opioids
WEAKEST
HYDROCODONE
(in Vicodin)
III
CODEINE
(in Tylenol#3)
#2=15mg; #3-30mg; #4=60mg
SEE BOX 6-2; PAGE 66 FOR A FULL LIST

58. WHERE DO NONOPIODS ACT?

59. PERIPHERAL NERVE ENDINGS
Opioids bind to receptors in both the central nervous system (CNS) and the spinal cord, producing an altered perception of reaction to pain

60. WHAT ARE NATURAL OPIODS?

61. RELIEVE PAIN AND RELAXATION
Natural opioids (also called endogenous opioids), include:
Enkephalins
Endorphins
Dynorphins
These are the chemicals that make sure we can function during accidents, like after breaking our leg…

62. The Discovery of 3 Groups of Endogenous Substances
MECHANISM OF ACTION
The Discovery of 3 Groups of Endogenous Substances
stimulates delta() receptor
Enkephalins
Endorphins
Dynorphins
All 3 have opioid-like action and are found in the body.
They are naturally occurring peptides that possess analgesic action and addiction potential
Probably function as neurotransmitters, although their exact function has not been elucidated.
reduces pain & positively affects mood.
stimulates the kappa ()-receptor
Enkephalin - Endogenous opioid ligand; stimulates -receptor.
Endorphin - Group of chemicals produced in the brain; reduces pain and positively affects mood.
Dynorphin - Endogenous opioid ligand; stimulates the -receptor.

63. WHEN DO OPIODS START WORKING?

64. Duration – necessitates dosing every 4-6 hours
WITHIN 1 HOUR
The dosing intervals of most opioids are between 4-6 hours; the usual dose depends on the drug.
Duration – necessitates dosing every 4-6 hours

65. WHAT IS THE FIRST PASS EFFECT?

66. REDUCES THE BIOAVAILABILITY
Undergoes first pass metabolism in the liver and intestine, reducing its bioavailability.

67. PHARMACOKINETICS
Distribution:
Oral bioavailability of opioids is primarily limited by first pass metabolism.
Undergoes first pass metabolism in the liver and intestine, reducing its bioavailability.
Degree of first pass differs among individuals.
May cause respiratory depression in fetus when mother is given opioids near term.

68. Metabolized opioids and the unchanged drug are excreted in the urine.
PHARMACOKINETICS
A.D.M.E
Excretion:
Most opioids are excreted through the kidneys, but this action does not selectively affect their availability after oral administration.
Metabolized opioids and the unchanged drug are excreted in the urine.

69. severity of side effects is proportional to the efficacy (strength)?
True or false?

70. TRUE
A pharmacologic effect may also be an adverse reaction, depending on the clinical use of the agent.

71. IS MORPHINE THE STRONGEST OR WEAKEST OPIOD?

72. Morphine is the opioid agonist by which all others are measured.
THE STRONGEST
Morphine is the opioid agonist by which all others are measured.
Strongest can relieve severe pain while weaker agents mixed with non-opioids are equivalent to NSAIDs.

73. PHARMACOLOGIC EFFECTS
Analgesia
What do aspirin, acetaminophen, ibuprofen, and codeine have in common?
Aspirin (ASA) and ibuprofen (NSAID) are analgesic, antipyretic, and antiinflammatory, and they inhibit platelet aggregation.
Acetaminophen is analgesic and antipyretic.
Codeine is analgesic.

74. WHAT IS AN ANTITUSSIVE?

75. SUPRESSES A COUGH
dextromethorphan

76. Gastrointestinal Effects
PHARMACOLOGIC EFFECTS
Opioid analgesics ↑ smooth muscle tone and ↓ propulsive contractions and motility (some opioids have constipation as a side effect).
Useful for treating diarrhea.
Example: diphenoxylate (in Lomotil)
Opioids are not used for depression, infections, or hypertension

77. ADVERSE REACTIONS TRUE or FALSE
Combining an opioid with a nonopioid analgesic produces an additive analgesic effect with fewer adverse reactions.
TRUE
These agents work at two different levels on pain and produce an additive analgesic effect. In combination products, lower doses of each analgesic may be used, and a potential exists for a reduction in adverse reactions.

78. DO OPIODS INCREASE OR DEPRESS THE RESPIRATORY CENTRE?

79. DEPRESS THE RESPIRATORY CENTER IN A DOSE RELATED MANNER
The rate and depth of breathing are reduced.
The depression is related to a decrease in the sensitivity of the brainstem to carbon dioxide.

80. Respiratory Depression (RP)
ADVERSE REACTIONS
RP is usually the cause of death with an overdose
Not a problem with usual doses in normal patients

81. ADVERSE REACTIONS
Nausea and Emesis
Analgesic doses of opioids often produce nausea and vomiting.
Result of their direct stimulation of the chemoreceptor trigger zone (CTZ) located in the medulla.
Repeated administration of regular doses can prevent vomiting at the vomiting center (VC).
M-E-sis

82. WHAT IS A VERY COMMON SIDE EFFECT OF OPIOD USE?

83. Their duration outlasts their analgesic effect
CONSTIPATION
Their duration outlasts their analgesic effect

84. WHAT IS A SIGN IN RECOGNIZING AN OPIOD ADDICT?

85. MIOSIS – ‘PINPOINT PUPILS’. RESPIRATORY DEPRESSION

86. HOW DO YOU TREAT AN OVERDOSE TO OPIODS?

87. such as naloxone (in Narcan)
AN ANTAGONIST
an antagonist
such as naloxone (in Narcan)

88. Biliary Tract Constriction
ADVERSE REACTIONS
Biliary Tract Constriction
Opioids may constrict the biliary duct, causing biliary colic (bile duct obstruction leading to gall stones).
Importance in patients passing gallstones who are being treated with opioids.
BIB-LEE-AIR-E

89. A MOTHER ON OPIODS – WHAT CAN HAPPEN TO THE BABY?

90. THE INFANT MAY HAVE DEPRESSED RESPIRATION AND WITHDRAWL SYMPTOMS
Not teratogenic, but may prolong labor or depress fetal respiration if given near term. .
Not usually a problem with mother’s milk with therapeutic doses.

91. Use of opioids is NOT contraindicated in hypertensive
patients.
Page 69 Table 6-4 FOR TESTING PURPOSE: KNOW THE CONDITIONS THAT ARE CONTRAINDICATED/CAUTION FOR THE USE OF OPIOIDS

92. Addiction ADVERSE REACTIONS
The degree of addiction potential is proportional to analgesic strength.
An addict will develop tolerance to the effects of opioids, EXCEPT for miosis and constipation.
Addiction - Dependence on a substance (e.g., alcohol, other drugs) or an activity to the point that stopping is very difficult and causes severe physical and mental reactions.
Tolerance: ability of the body to alter its response (to adapt) to drug effects so that the effects are minimized over time.

93. AN ADVANTAGE OF NSAIDs OVER OPIOIDS:
ADVERSE REACTIONS
Addiction
Since the duration of use in dentistry is usually short – addiction for dentistry does not pose a problem
NSAIDs should be used to control dental pain in the addict.
AN ADVANTAGE OF NSAIDs OVER OPIOIDS:
NSAIDs are not addictive, tolerance does not develop, and no withdrawal syndrome can be induced.

94. IF A CLIENT CLAIMS ALLERGIES TO NSAIDS, WHAT COULD THIS MEAN?

95. TERMED ‘SHOPPERS’ THE CLIENT IS LOOKING FOR A SPECIFIC OPIOD.
OPIOD ADDICT
TERMED ‘SHOPPERS’ THE CLIENT IS LOOKING FOR A SPECIFIC OPIOD.
KEEP IN MIND – THIS ISNT ALWAYS THE CASE…LOOK FOR OTHER SIGNS NOT JUST ONE

96. Identification of an Addict
ADVERSE REACTIONS
Addiction:
Identification of an Addict
The “shoppers” - What to look for:
Asks for the opioid analgesic by name and says that this is the only drug that works for them.
Claims allergies to NSAIDs .
Cancels dental appointment but still requests the opioid analgesic even though they will be “out of town on business”.
Experiences pain for days after scaling and root planing
Moves from office to office because “others don’t understand”.
Claims a “low pain threshold”.
Needs refills several days after a procedure without complications.
Calls with a request for an opioid analgesic just as the office is closing or after hours.

97. WHAT IS METHADONE?

98. USED TO TREAT OPIOD ADDICTION AND WITHDRAWL
Maintaining patients on high doses of methadone (methadone maintenance).

99. Addiction: 4 Treatment Options
ADVERSE REACTIONS
Addiction: Treatment Options
Addiction, overdose, and withdrawal can be treated with opioid antagonists
Substituting addict with oral opioid (methadone).
Going cold turkey and using medication such as phenothiazines, clonidine or benzodiazepines (to alleviate symptoms of withdrawal).
Maintaining patients on high doses of methadone (methadone maintenance).
Administering an orally effective, long-acting antagonist Naltrexone (Trexan).
NAL-TREX-IN

100. Addiction: Treatment Options Example: The Heroin Addict
ADVERSE REACTIONS
Addiction: Treatment Options
Example: The Heroin Addict
The following drugs can be used to treat heroin addiction
METHADONE, is used by substituting methadone for heroin and then tapering off or maintaining the addict on oral methadone.
FYI: Naltrexone is basically used for people suffering from alcoholism and opioid dependence. This drug is an receptor antagonist, the drug simply blocks the normal reaction of the part of the brain that produces the feeling of pleasure when opioids are taken.
Methadone: (also known as Symoron, Dolophine, Amidone, Methadose, Physeptone, Heptadon and many other names) is a synthetic opioid. It is used as a pain (mostly for severe) reliever and as part of drug addiction detoxification and maintenance programs.
NALTREXONE, a long-acting opioid antagonist, is used to block the action of usual doses of opioid administered illegally

101. IS TRUE OPIOD ALLERGY COMMON?

102. NO
Most common types of true allergic reactions to opioids is dermatologic in nature.
Due to the histamine-releasing properties of opioid analgesics.
Includes skin rashes and urticaria.
GI side effects are often reported.

103. Because they are all members of the same morphine and codeine group.
This includes:
oxycodone
hydromorphone,
hydrocodone, and
dihydrocodone
Because they are all members of the same morphine and codeine group.
A patient with a true allergy to codeine should NOT be given an analgesic in that group
SEE BOX 6-1 PAGE 66

104. FIGURE 6-3; PAGE 71

105. WHAT IS THE PROTOTYPE OPIOD AGONIST WHICH OTHER OPIODS ARE MEASURED?

106. MORPHINE

107. The prototype opioid agonist which other opioids are measured
SPECIFIC OPIODS
Agonists: Morphine
The prototype opioid agonist which other opioids are measured
Parenterally: used to control postoperative pain
Orally: used primarily in the treatment of cancer

108. SPECIFIC OPIODS
Agonists: Oxycodone
Used alone or combined with aspirin (in Percodan) or acetaminophen (in Percocet, Tylox) with fewer adverse reactions.
For moderate to severe pain.
It is located in the middle of the chart for strength value.

109. Agonists: Hydrocodone
SPECIFIC OPIODS
Agonists: Hydrocodone
Weak opioid analgesic with fewer adverse reactions.
Less potential for abuse.
Combination of Hydrocodone (5mg) with acetaminophen (500mg) is recommended for the majority of dental patients with pain
In Vicodin, it has been reported as being safe to use when breastfeeding

110. WHAT IS THE MOST COMMON OPIOD IN DENTISTRY?

111. CODEINE
Most commonly used opioid in dentistry and is often combined with acetaminophen (Tylenol #3) for oral administration

112. SPECIFIC OPIODS
Agonists: Meperidine
Favorite drug of abuse for medical personnel; 100mg meperidine=10mg morphine.
For acute management of moderate to severe pain.
Poor choice for oral use because it has a high first pass effect; short duration of action.
Less constipating, and without miosis or cough suppression.
EXAMPLE: meperidine HCl (Demerol)

113. WHAT IS HYDROMORPHINE USED FOR?

114. MANAGEMENT OF SEVERE PAIN, MORE POTENT THEN MORPHINE

115. Agonists: Hydromorphone
SPECIFIC OPIODS
Agonists: Hydromorphone
An orally effective opioid, reserved for management of severe pain.
More potent than morphine
Similar adverse reactions to morphine.
Favourite of the addicts because of its high strength; requires careful monitoring.
EXAMPLE: Dilaudid

116. Agonists: Methadone Used primarily to treat any opioid addicts
SPECIFIC OPIODS
Agonists: Methadone
Slower onset and longer duration of action.
Similar to morphine.
Methadone is used either to withdraw the patient gradually or for methadone maintenance. Because it has a longer duration of action, withdrawal from methadone is easier than from heroin. Because it is an opioid analgesic, however, the risk for dependence still exists.
EXAMPLE: Dolophine
Used primarily to treat any opioid addicts
(eg. Heroin addicts)

117. Antagonists naloxone (Narcan)
SPECIFIC OPIODS
naloxone (Narcan)
Naloxone will block the therapeutic and toxic actions of opioids
Methadone is an opioid used in treatment of addiction, but will exacerbate symptoms of an opioid overdose.
An pure opioid antagonist that is active parenterally.
Drug of choice for treating agonist or mixed opioid overdoses.
Naloxone, used if overdose occurs, is effective parenterally but not orally because it is inactivated

118. WHAT IS TRAMADOL?

119. An orally administered non-opioid with weak analgesic activity
(ULTRAM)
An orally administered non-opioid with weak analgesic activity

120. SPECIFIC OPIODS Tramadol (Ultram)
Few studies have confirmed its efficacy:
Binds with mu (μ) opioid receptors; inhibits reuptake of serotonin and norepinephrine, and modifies ascending pain pathways.
Its analgesic efficacy is equivalent to that of codeine.
Side effects can include: miosis and CNS effects, such as dizziness, headache and stimulation and GI tract effects include nausea, diarrhea, constipation and vomiting.
Is moving up the top 200 most prescribed drugs.

121. DENTAL USE OF OPIODS Most dental pain can be managed with NSAIDs.
If NSAIDs are contraindicated - the DDS has a wide variety of opioids to choose from.
Eg. Beginning with codeine or hydrocodone combinations, and progressing to oxycodone combinations.
Only in rare cases and for short periods of time (approx. 1-2 days) should stronger opioids be prescribed for outpatient dental pain.

122. ARE OPIODS USED FOR CHRONIC OR ACUTE PAIN?

123. ACUTE IS PREFERRED* BUT CAN BE USED FOR CHRONIC PAIN

124. REVIEW: USE OF OPIODS Opioids are considered first-line therapy for:
Pain associated with procedures (bone marrow biopsy)
Pain due to trauma or cancer (burns)
Visceral pain (appendicitis)
Majority used to relieve acute or chronic pain.
Few, such as fentanyl (Sublimaze, Duragesic), alfentanil (Alfenta), and sufentanil (Sufenta), are primarily indicated for preoperative sedation to reduce patient apprehension.
Also used to suppress cough and treat diarrhea
A BRIEF SUMMARY - FOUND THROUGHOUT THE SLIDES

125. Some of the Opioids found in the TOP 200
#1. Hydrocodone
#32. Tramadol
#105. Oxycodone
#133. OxyContin
#156. Fentanyl transdermal
#175. Methadone HCl noninjectable