PTCB Quiz Prep

PTCB Guide to Opioids

Also called opioid analgesics (narcotic analgesics) · suffix no single suffix · updated

Quick answer

  • Mechanism: opioids are agonists at mu opioid receptors in the central nervous system, which blunts pain signaling and produces analgesia along with sedation and euphoria.
  • Top side effects: respiratory depression (the most dangerous and the usual cause of overdose death), constipation, sedation, and physical dependence with long-term use.
  • Key point: the strong opioids (morphine, oxycodone, hydrocodone, fentanyl, hydromorphone, methadone) are Schedule II, and naloxone (Narcan) reverses an overdose.

What gets tested

  • Matching brand to generic (OxyContin is oxycodone, Dilaudid is hydromorphone, Ultram is tramadol)
  • The mu receptor agonist mechanism and that opioids treat moderate to severe pain
  • DEA controlled substance schedules, especially which opioids are Schedule II
  • Recognizing naloxone (Narcan) as the opioid overdose reversal agent
  • The FDA boxed warning on combining opioids with benzodiazepines, and the separate boxed warning that restricts codeine and tramadol in children
  • Common combination products (Percocet, Norco, Vicodin) and their acetaminophen content
  • Common strengths, dosage forms, and routes: immediate-release versus extended-release tablets, transdermal patches, oral solutions, and injections

What is not tested

You do not need to memorize equianalgesic milligram conversions, receptor binding affinities, or opioid rotation calculations, since those are prescriber-level decisions. The PTCE does expect you to recognize common strengths, dosage forms, routes of administration, and how long a therapy typically runs, so do not skip the product details: Percocet 5 mg with 325 mg of acetaminophen, fentanyl as a 72-hour transdermal patch, and the acetaminophen ceiling in combination products are all fair game. What stays out of scope is selecting or adjusting a regimen for a patient.

Why opioids matter

Opioids appear across the Medications, Federal Requirements, and Patient Safety areas of the PTCE. They are among the most tightly regulated prescription drugs a technician handles, so knowing their schedules, combination products, and the naloxone reversal point is high-yield for both the exam and the pharmacy.

Opioids at a glance

GenericBrandPrimary indication
morphineMS Contin (Kadian)moderate to severe pain (Schedule II)
oxycodoneOxyContin (Roxicodone)moderate to severe pain (Schedule II)
oxycodone with acetaminophenPercocetmoderate to severe pain (Schedule II)
hydrocodone with acetaminophenNorco (Vicodin, Lortab)moderate to severe pain (Schedule II)
hydromorphoneDilaudidmoderate to severe pain (Schedule II)
fentanylDuragesic (Sublimaze)severe or chronic pain, transdermal patch (Schedule II)
codeineoften combined, as in Tylenol with Codeinemild to moderate pain and cough (single-entity codeine is Schedule II; combinations of not more than 90 mg per dosage unit, such as Tylenol with Codeine, are Schedule III; cough preparations of not more than 200 mg per 100 mL are Schedule V)
tramadolUltram (ConZip)moderate to moderately severe pain (Schedule IV)
methadoneDolophine (Methadose)pain and opioid use disorder maintenance (Schedule II)
buprenorphineButrans (Belbuca); Suboxone is buprenorphine with naloxonepain and opioid use disorder (Schedule III)

Mechanism of action

Opioids act as agonists at opioid receptors, mainly the mu receptor, in the central and peripheral nervous systems and the gastrointestinal tract. There are three main receptors: mu, kappa, and delta. Mu receptor activation mediates most of the effects of opioids: analgesia, sedation, euphoria, constipation, and respiratory depression. Binding activates inhibitory G proteins and inhibits adenylyl cyclase. The G protein subunits also close presynaptic calcium channels and open postsynaptic potassium channels, which reduces neuronal excitability and blunts the transmission of pain signals. A few agents behave differently: tramadol is a weak mu agonist that also inhibits reuptake of serotonin and norepinephrine, and buprenorphine is a partial mu agonist. Across the class the result is relief of moderate to severe pain along with the characteristic central nervous system and respiratory effects.

Common and important side effects

  • Respiratory depression is the most dangerous effect and the usual cause of overdose death
  • Constipation, which does not fade over time and often needs a scheduled bowel regimen
  • Sedation, drowsiness, and dizziness
  • Nausea and vomiting, especially when first starting therapy
  • Miosis (pinpoint pupils), a classic sign of opioid overdose
  • Tolerance, physical dependence, and risk of misuse or opioid use disorder

Key interactions

  • Benzodiazepines and other central nervous system depressants (alcohol, sedatives, muscle relaxants, sleep aids) add to sedation and respiratory depression: the FDA requires a boxed warning against combining opioids with benzodiazepines
  • Serotonergic drugs (SSRIs, SNRIs, MAO inhibitors, triptans) raise the risk of serotonin syndrome with tramadol, and tramadol can also lower the seizure threshold
  • CYP3A4 inhibitors and inducers can change levels of oxycodone, fentanyl, and methadone, and methadone can prolong the QT interval
  • Other opioid agonists combined with a partial agonist or antagonist (such as buprenorphine, or naloxone in combination products) can trigger withdrawal or reduced pain relief

Patient counseling notes

  • Do not drink alcohol or take benzodiazepines or other sedatives with an opioid unless the prescriber approves, because of the risk of slowed breathing
  • Opioids cause drowsiness: avoid driving or operating machinery until you know how the medicine affects you
  • Expect constipation and ask about a stool softener or laxative, and increase fluids and fiber
  • Do not cut, crush, or chew extended-release tablets or fentanyl patches, since this can release a fatal dose all at once
  • Codeine and tramadol are not for children under 12, are not used for pain after tonsil or adenoid surgery in anyone under 18, and are not recommended while breastfeeding, because some people convert them to morphine very quickly
  • Ask about a naloxone (Narcan) kit, especially with high doses or when other sedatives are also used
  • Store opioids locked and away from children and others, do not share them, and return unused doses to a take-back program

Practice questions

Then test the whole class in context with the drug class identification quiz and the brand and generic quiz.

1. A prescription is written for OxyContin. Which generic drug should the technician expect to dispense?

  1. A. Hydromorphone
  2. B. Oxycodone ✓
  3. C. Hydrocodone
  4. D. Tramadol

Answer: B. OxyContin is the extended-release brand name for oxycodone, a Schedule II opioid. The distractors are other opioids with their own generic names.

2. Morphine, oxycodone, hydrocodone, and fentanyl are all classified under which DEA controlled substance schedule?

  1. A. Schedule I
  2. B. Schedule II ✓
  3. C. Schedule III
  4. D. Schedule IV

Answer: B. These full mu agonists have a high potential for abuse but an accepted medical use, which places them in Schedule II. Schedule I drugs have no accepted medical use.

3. Which medication is used to reverse an opioid overdose?

  1. A. Flumazenil
  2. B. Naloxone ✓
  3. C. Acetylcysteine
  4. D. Naltrexone

Answer: B. Naloxone (Narcan) is an opioid antagonist that rapidly reverses the respiratory depression of an opioid overdose. Flumazenil reverses benzodiazepines, and acetylcysteine treats acetaminophen overdose. Naltrexone is also an opioid antagonist, but it is long acting and used to maintain abstinence in opioid or alcohol use disorder, not to reverse an acute overdose.

4. Combining an opioid with which drug class carries an FDA boxed warning because of the risk of fatal respiratory depression?

  1. A. Statins
  2. B. Benzodiazepines ✓
  3. C. Proton pump inhibitors
  4. D. Antihistamines

Answer: B. The FDA requires a boxed warning against combining opioids with benzodiazepines, because both depress the central nervous system and together can cause severe respiratory depression, coma, and death.

5. Norco and Percocet both combine an opioid with which nonopioid ingredient?

  1. A. Ibuprofen
  2. B. Acetaminophen ✓
  3. C. Aspirin
  4. D. Caffeine

Answer: B. Norco is hydrocodone with acetaminophen and Percocet is oxycodone with acetaminophen. Both are Schedule II, and the acetaminophen sets a daily limit to avoid liver toxicity.

Cheat sheet

  • Class: opioid analgesics (mu receptor agonists)
  • Use: moderate to severe pain (some also for cough or opioid use disorder)
  • Schedule II: morphine, oxycodone, hydrocodone, fentanyl, hydromorphone, methadone, codeine as a single agent
  • Schedule III: buprenorphine (Butrans, Belbuca; Suboxone is buprenorphine with naloxone), Tylenol with Codeine (not more than 90 mg codeine per dosage unit)
  • Schedule IV: tramadol (Ultram); Schedule V: codeine cough preparations with not more than 200 mg codeine per 100 mL (Robitussin AC)
  • Combos: Percocet = oxycodone + acetaminophen, Norco and Vicodin = hydrocodone + acetaminophen (all C-II; hydrocodone combinations moved from C-III to C-II in October 2014)
  • Watch: respiratory depression, constipation, sedation, dependence
  • Reversal: naloxone (Narcan); boxed warning: do not combine with benzodiazepines

Related drug-class guides

BenzodiazepinesNSAIDsAll drug classes

Official sources

PTCB Quiz Prep is an independent study resource, not affiliated with the Pharmacy Technician Certification Board. This guide is for exam preparation, not medical advice. See our editorial standards. Part of the PTCB Medications domain.