Home' Australian Pharmacist : Australian Pharmacist November 2012 Contents Australian Pharmacist November 2012 I ©Pharmaceutical Society of Australia Ltd. 895
Continuing Professional Development
1. Serotonin toxicity:
a) usually has a gradual onset within 30
days of commencing the causative
b) is characterised by altered
mental status and autonomic and
c) is a self-limiting adverse drug reaction
that is unpleasant but never life-
d) always causes the same combination
of symptoms with the same level of
2. Which of the following is NOT
a risk factor for drug-induced
a) Male gender.
b) Older age.
c) Severe illness.
d) Low BMI.
3. Choose the INCORRECT statement
a) People using insulin therapy or oral
antihypoglycaemic agents are at
increased risk of hypoglycaemia.
b) Brain glucose deprivation can cause
changes in mental status such as
c) The plasma glucose level at which
symptoms of hypoglycaemia
frequently develop is < 8 mmol/L.
d) Possible signs and symptoms of low
plasma glucose include sweating,
tremor, and palpitations.
4. Discontinuation syndrome:
a) is more likely to occur with
antidepressants with long half-lives.
b) produces the same symptoms
regardless of the drug class.
c) can occur with irregular dosing or
d) None of the above.
5. Choose the CORRECT statement.
a) Signs of physical dependence include
craving and compulsive behaviour.
b) Experiencing withdrawal symptoms is
always indicative of addiction.
c) Opioid withdrawal symptoms include
abdominal cramping and sweating.
d) There is a high risk of addiction with
opioid therapy for chronic pain.
withdrawn from oxycodone within one
month, depending on how high the dose
was prior to initiating tapering.21
You recommend that Justin make an
appointment with his regular GP to
investigate the cause of his symptoms.
You inform Justin that his symptoms may
be the result of him stopping his pain
medications abruptly. You explain that if
people have taken opioid analgesics for
a prolonged period, they can feel unwell
if they suddenly stop taking them. You
reassure him that this doesn't mean he's
'addicted'; people need to be weaned off
these types of medications gradually to
avoid experiencing unpleasant symptoms,
which can last for up to a week.
Justin returns to the pharmacy the
following day with a new prescription
for Oxycontin 5 mg and a dose reduction
schedule written by his doctor. Justin tells
you that his doctor has calculated a starting
dose of three tablets twice a day, which he
is to reduce every three days depending
on how he feels. His doctor decided on
this dose based on the average amount of
Endone and Panadeine Forte he had been
taking each day. His doctor explained the
need to reduce his dose of oxycodone
gradually to make sure he doesn't
experience any withdrawal symptoms and
that his pain does not return.
1. Serotonin Syndrome [revised Feb 2010]. The Merck Manual
[online]. At: www.merckmanuals.com
2. Draper R. Serotonin syndrome [revised Apr 2011]. Patient.co.uk
[online]. At: www.patient.co.uk/doctor/Serotonin-Syndrome.
3. Isbister GK, Buckley NA, Whyte IM. Serotonin toxicity: a practical
approach to diagnosis and treatment. MJA. 2007;187(6):361--5.
4. Derlet RW. Influenza [revised Aug 2012]. Medscape Reference
[online]. At: http://emedicine.medscape.com/article/219557
5. Egger C, Muehlbacher M, Nickel M. A review on hyponatraemia
associated with SSRIs, reboxetine and venlafaxine. Int J Psych
Clin Prac. 2006;10(1):17--26.
6. Therapeutic Goods Administration. Medicines Safety Update
Apr 2011 [online]. At: www.tga.gov.au/hp/msu-2011-02.htm
7. Simon EE. Hyponatremia [revised Mar 2012]. Medscape
Reference [online]. At: http://emedicine.medscape.com/
8. Hamdy O. Hypoglycemia [revised Feb 2012]. Medscape
Reference [online]. At: http://emedicine.medscape.com/
9. Ng CL. Hypoglycaemia in nondiabetic patients -- an evidence
based approach. Australian Family Physician. 2010;39(6):399--
10. NHS Scotland. Stopping antidepressants -- the antidepressant
discontinuation syndrome [online]. 2005. At: www.nes.scot.
11. The British Pain Society's Opioids for persistent pain: Good
practice [online]. 2010. At: www.britishpainsociety.org/
12. eTG complete [Internet]. Melbourne: Therapeutic Guidelines;
13. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in
chronic pain: a review of opioid abuse predictors and strategies
to curb opioid abuse. Pain Physician. 2012;15:ES67--ES92.
14. McKeown NJ. Withdrawal syndromes [revised Jun 2012].
Medscape Reference [online]. At: http://emedicine.medscape.
15. Stannard C. All Party Parliamentary Group on Drug Misuse
Inquiry -- Response on behalf of the British pain Society
[online]. At: www.britishpainsociety.org/APPG_report.pdf
16. Minozzi S, Amato L, Davoli M. Development of dependence
following treatment with opioid analgesics for pain relief:
a systematic review. Addiction. 2012, doi: 10.1111/j.1360-
17. Schneider JP, Kirsh KL. Defining clinical issues around tolerance,
hyperalgesia, and addiction: a quantitative and qualitative
outcome study of long-term opioid dosing in a chronic pain
practice. Journal of Opioid Management. 2010; 6(6): 385--95.
18. Savage SR, Joranson DE, Covington EC, et al. Definitions related
to the medical use of opioids: evolution towards universal
agreement. Journal of Pain and Symptom Management.
19. Cheatle MD, O'Brien CP. Opioid therapy in patients with chronic
noncancer pain: diagnostic and clinical challenges. Chronic
Pain and Addiction. 2011;30:61--91.
20. Agency Medical Directors Group. Interagency guideline on
opioid dosing for chronic non-cancer pain [online]. 2010. At:
21. Robinson G, Wilson H, eds. Update on oxycodone -- what can
primary care do about the problem? NZ Best Practice Journal.
Key learning points
• Opioid medications do not usually
result in addiction when used
for pain management in patients
without a history of substance abuse
or co-morbid psychiatric disorder.
• Opioid withdrawal syndrome
is characterised by unpleasant
autonomic symptoms and central
neurologic arousal. The onset
and duration of symptoms can
vary depending on the half-life
of the opioid causing the
• Gradual tapering of doses can help
to minimise withdrawal symptoms
in patients who have been taking
opioids for a prolonged period.
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