Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper...

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Pain Management Pain Management & Opioid & Opioid Analgesics Analgesics

Transcript of Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper...

Page 1: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Pain Management & Pain Management & Opioid AnalgesicsOpioid Analgesics

Page 2: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

ObjectivesObjectives

Determine proper opioid dosingDetermine proper opioid dosing Differentiate between specific opioid Differentiate between specific opioid

analgesics and be able to convert between analgesics and be able to convert between agentsagents

Discuss basal and bolus doses for PCADiscuss basal and bolus doses for PCA Discuss adverse reactions of opioidsDiscuss adverse reactions of opioids Review the Sole Provider programReview the Sole Provider program Discuss how to properly write a prescription Discuss how to properly write a prescription

for a controlled substancefor a controlled substance2

Page 3: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

PainPain DefinitionDefinition

An unpleasant sensory & emotional An unpleasant sensory & emotional experience associated with actual or potential experience associated with actual or potential tissue damage or described in terms of such tissue damage or described in terms of such damagedamage

TypesTypes NociceptiveNociceptive

Somatic – bone pain, skin, soft tissue traumaSomatic – bone pain, skin, soft tissue trauma Visceral – ab pain due to tumor invasionVisceral – ab pain due to tumor invasion

Neuropathic – post herpetic neuralgia, post-Neuropathic – post herpetic neuralgia, post-mastectomy, phantom limbmastectomy, phantom limb

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Page 4: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Choosing Analgesic TherapyChoosing Analgesic Therapy What type of pain?What type of pain?

Nociceptive vs. neuropathicNociceptive vs. neuropathic Acute vs. chronicAcute vs. chronic Mild vs. severeMild vs. severe

What route should be used?What route should be used? What agent should be used?What agent should be used?

Type, severity of painType, severity of pain Pt characteristics – side effects, elderly, allergy, Pt characteristics – side effects, elderly, allergy,

co-morbid conditions, tolerance, previous co-morbid conditions, tolerance, previous narcotics usednarcotics used

Insurance, costInsurance, cost 4

Page 5: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

WHO Ladder of AnalgesicsWHO Ladder of Analgesics

www.anzsgm.org/vgmtp/Pain/analgesia_ladder.htm5

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Non-opioid analgesicsNon-opioid analgesics

AspirinAspirin NSAIDsNSAIDs AcetaminophenAcetaminophen AdjuvantsAdjuvants

Antidepressants – amitriptyline, duloxetineAntidepressants – amitriptyline, duloxetine Anticonvulsants – carbamazepine, Anticonvulsants – carbamazepine,

gabapentin, pregabalingabapentin, pregabalin Anesthetics – lidocaine patch (12 hours on, Anesthetics – lidocaine patch (12 hours on,

12 hours off)12 hours off)6

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Potency of OpioidsPotency of Opioids

Weak AgonistsWeak Agonists Propoxyphene Propoxyphene

(Darvon, Darvocet)(Darvon, Darvocet) CodeineCodeine Hydrocodone/APAP Hydrocodone/APAP

(Vicodin, Lortab, (Vicodin, Lortab, Lorcet, Norco)Lorcet, Norco)

TramadolTramadol

Strong AgonistsStrong Agonists MorphineMorphine OxycodoneOxycodone Hydromorphone Hydromorphone

(Dilaudid)(Dilaudid) Fentanyl (Duragesic, Fentanyl (Duragesic,

Sublimaze)Sublimaze) Methadone Methadone

(Dolophine)(Dolophine) Meperidine (Demerol)Meperidine (Demerol)

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TramadolTramadol Synthetic analog of codeine but is NOT controlledSynthetic analog of codeine but is NOT controlled Weak agonist/low affinity at mu receptor and also weak Weak agonist/low affinity at mu receptor and also weak

SNRI (which inhibits pain transmission in the spinal SNRI (which inhibits pain transmission in the spinal cord) cord) Use with caution in pt on TCAs, MAOIs, SSRIs as it Use with caution in pt on TCAs, MAOIs, SSRIs as it

may lower seizure thresholdmay lower seizure threshold Max dose is 400 mg/day but 300 mg/day if >75yo; renal Max dose is 400 mg/day but 300 mg/day if >75yo; renal

dosing if CrCl<30dosing if CrCl<30 Tramadol is 5-10 times less potent than morphine and Tramadol is 5-10 times less potent than morphine and

reported to cause less respiratory depressionreported to cause less respiratory depression Approximately 50 mg tramadol = 60 mg codeineApproximately 50 mg tramadol = 60 mg codeine

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Considerations in choosing Considerations in choosing opioidsopioids

Renal impairmentRenal impairment Preferred oral agent: hydromorphonePreferred oral agent: hydromorphone Use with caution: morphine, codeineUse with caution: morphine, codeine Avoid meperidineAvoid meperidine

Metabolites can accumulate and cause seizuresMetabolites can accumulate and cause seizures

Other cautions with meperidineOther cautions with meperidine Avoid in pts with CHF, hepatic insufficiency, Avoid in pts with CHF, hepatic insufficiency,

elderlyelderly Avoid use in pts on MAOIs (phenelzine, Avoid use in pts on MAOIs (phenelzine,

selegeline, linezolid) in past 14 daysselegeline, linezolid) in past 14 days9

Page 10: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

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Opioid Half-life Onset Duration of analgesic effect

Fentanyl IV: 2 – 4hPatch: 17h

IV: within minutesPatch: 12-24h

IV: 0.5 – 1hPatch: 72h

Hydromorphone (Dilaudid)

2 – 3h IV: 5 - 15 minPO: 30 min

3 – 5h

Methadone** 8 – 59h 30 – 60 min 4 – 8h

Morphine 2 – 4h IV:5 - 10 minPO (IR): 30 - 60 min

IR: 3 – 6h SR: 8 – 12h

Meperidine (Demerol)

3 - 5h (15-30h for

metabolite)

10 – 45 min 2 – 4h

Codeine 3 – 4h 30 – 60 min 4 – 6h

Oxycodone IR: 2 – 5h SR: 5h

15 – 60 min IR: 3 – 6hSR: 12h

Hydrocodone 3 – 4h 10 – 60 min 4 – 8h

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Opioid Usual Starting Dose Comments

Fentanyl* 25 – 100 mcg IV q1h, then 1 – 2 mcg/kg/h

Patch: NOT for acute pain & NOT for opioid-naïve pts; do not cut patch in half

Hydromorphone (Dilaudid)

0.5 – 1 mg q4h IV1 – 2 mg q4h PO

Very potent; preferred in pts with renal impairment

Methadone 5 mg q8-12h PO Monitor for QT prolongation & drug interactions

Morphine 2 – 5 mg q4h IV5 – 10 mg q4h PO (IR)15 – 30 mg q8 or 12h (SR)

MSContin: NOT for acute pain; do not split/crush tablets

Meperidine (Demerol)

50 mg q3-4h PO/IV NOT recommended for chronic use

Codeine 30 – 60 mg q4h PO Has more side effects than morphine

Oxycodone 5 mg q4h PO (IR)10 – 20 mg q12h (SR)

OxyContin: NOT for acute pain; do not split/crush tablets

Hydrocodone 5 – 10 mg q4h PO always combined with APAP or ibuprofen – which limits its dosing

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Opioid Available Doses

Fentanyl IV: 25, 50, 100 mcg/mlPatch: 25, 50, 75, 100 mcg

Hydromorphone (Dilaudid) IV: 2 mg/ml; PCA: 1mg/ml & 0.2 mg/mlPO: 2 mg

Methadone PO: 5, 10 mg

Morphine IV: 4 mg/ml; PCA: 1 mg/ml & 5 mg/mlPO: IR 15, 30 mgPO: ER (MS Contin): 15, 30, 60, 100 mgSolution (Roxanol): 20 & 2 mg/ml

Meperidine (Demerol) IV: 25, 50, 100 mg/ml

Codeine PO: 30 mg

Oxycodone PO: IR 5mgPO: ER (OxyContin): 10, 20, 40, 80 mgSolution (Roxicodone): 20 & 1 mg/ml

Oxycodone/APAP (Percocet) PO: 5mg oxycodone/325 mg APAP

Hydrocodone/APAP (Norco) PO: 5mg hydrocodone/325 mg APAP

Page 13: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

PCA DosingPCA Dosing Dosing considerationsDosing considerations

For opioid-naïve patients, use lower end of rangeFor opioid-naïve patients, use lower end of range Pain AssessmentPain Assessment Respiratory AssessmentRespiratory Assessment Sedation AssessmentSedation Assessment

Drug (standard concentrations)

Usual Demand

Dose

Range of Demand

Dose

Lockout Interval (min)

Usual Basal Rate

Morphine (1mg/ml and 5 mg/ml)

1.0 mg 0.5-2.5 mg 5 - 15 None or1 – 2 mg/hr

Hydromorphone (Dilaudid)(0.1 mg/ml and 1 mg/ml)

0.2 mg 0.05-0.4 mg 5 - 15 None or0.1 – 0.4 mg/hr

13When initiating PCA for first time (no conversion from outpatient med), the initial demand dose is 50% of the basal rate

Page 14: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

PCA dosingPCA dosing

62 yo patient s/p TAH has been moved to 62 yo patient s/p TAH has been moved to PACU. You have been asked to start the PACU. You have been asked to start the patient on a PCA. Which of the following is an patient on a PCA. Which of the following is an appropriate order:appropriate order: Morphine PCA 1 mg/ml: LD 2 mg, 1 mg demand Morphine PCA 1 mg/ml: LD 2 mg, 1 mg demand

dose, lock out 10 min, no basaldose, lock out 10 min, no basal Dilaudid PCA 1mg/ml: LD 2 mg, 1 mg demand Dilaudid PCA 1mg/ml: LD 2 mg, 1 mg demand

dose, lock out 10 min, no basaldose, lock out 10 min, no basal Fentanyl patch 25 mcg q72 hoursFentanyl patch 25 mcg q72 hours

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initialinitial

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Conversions*Conversions*Opioid Parenteral Oral

Fentanyl 0.1 mg NA

Hydromorphone (Dilaudid)

1.5 mg 7.5 mg

Methadone** 5 - 10 mg 2 - 20 mg***

Morphine 10 mg 30 mg

Meperidine (Demerol) 75 -100 mg 300 mg

Codeine 120 mg 200 mg

Oxycodone NA 20 mg

Hydrocodone NA 30 mg

*When switching between opioids, there is NOT a complete cross tolerance. If patient is controlled, consider decrease the dose by 1/2 to 1/3 to avoid side effects.

**conversion ratio is highly variable 15

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Page 16: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Initial Fentanyl Patch Dose Conversion

PO 24-hour morphine (mg/day) Fentanyl Patch Dose (mcg/hr)

45-134 25

135-224 50

225-314 75

315-404 100

405-494 125

495-584 150

585-674 175

675-764 200

765-854 225

855-944 250

945-1034 275

1035-1124 300

For CHRONIC pain: 25 mcg/hr fentanyl patch = oral morphine 50 mg/24h

Page 17: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Fentanyl patchFentanyl patch

NOT for acute pain or post-op painNOT for acute pain or post-op pain Absorbed through the skin, producing a drug Absorbed through the skin, producing a drug

depot in the upper skin layers, then diffusing depot in the upper skin layers, then diffusing into systemic circulationinto systemic circulation

Can have variable responses between Can have variable responses between patients (i.e. cachetic, elderly)patients (i.e. cachetic, elderly)

Watch for drugs that inhibit its metabolismWatch for drugs that inhibit its metabolism Ketoconazole, erythromycin, diltiazem, grapefruit Ketoconazole, erythromycin, diltiazem, grapefruit

juicejuice17

Page 18: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Morphine:methadone Morphine:methadone conversionconversion

Oral morphine-equivalent daily dose (mg/day)

Initial Dose Ratio(oral morphine:oral methadone)

<30 2:1

30 – 99 4:1

100 – 299 8:1

300 – 499 12:1

500 – 999 15:1

>1000 20:1 or greater

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Page 19: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Breakthrough DosingBreakthrough Dosing

Use immediate-release opioidsUse immediate-release opioids Chronic oral medsChronic oral meds

Give 10 – 20% of the total daily dose q4hprnGive 10 – 20% of the total daily dose q4hprn Example – MS Contin 60 mg PO q12h – should Example – MS Contin 60 mg PO q12h – should

give 10 – 20 mg q4h prn of morphine immediate give 10 – 20 mg q4h prn of morphine immediate releaserelease

IV dosing (PCA dosing)IV dosing (PCA dosing) 10% of the 24 hr requirement, then:10% of the 24 hr requirement, then:

Divide by 4 if giving every 15 minutesDivide by 4 if giving every 15 minutes Ex: 100 mg morphine daily Ex: 100 mg morphine daily 2.5 mg IV q15 min 2.5 mg IV q15 min

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Page 20: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Dose AdjustmentDose Adjustment

Increasing the opioid dosageIncreasing the opioid dosage For moderate to severe pain, increase by For moderate to severe pain, increase by

50 – 100%50 – 100% For mild to moderate pain, increase by For mild to moderate pain, increase by

25 – 50%25 – 50% Convert to oral as early as possible: Convert to oral as early as possible:

Pain is controlledPain is controlled GI function intactGI function intact IV to oral dosage calculationIV to oral dosage calculation

Calculate total daily IV useCalculate total daily IV use Calculate breakthrough doseCalculate breakthrough dose

10-20% of total daily dose of regularly scheduled opioid 10-20% of total daily dose of regularly scheduled opioid every 4 h as neededevery 4 h as needed 20

Page 21: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Conversion problemConversion problem

Pt is taking Percocet 5/325 two tabs q6hPt is taking Percocet 5/325 two tabs q6h

What dose of oxycodone ER (OxyContin) What dose of oxycodone ER (OxyContin) would you start the patient?would you start the patient?

What dose of morphine ER (MS Contin)?What dose of morphine ER (MS Contin)?

What dose of fentanyl patch?What dose of fentanyl patch?

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Page 22: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Conversion problemConversion problem

8 tabs Percocet = 40 mg oxycodone per day8 tabs Percocet = 40 mg oxycodone per day

Oxycodone ER (OxyContin) = 20mg q12hOxycodone ER (OxyContin) = 20mg q12h

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Page 23: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Conversion ProblemConversion Problem

MS Contin conversionMS Contin conversion 40 mg po oxycodone 40 mg po oxycodone = = 20 mg po oxycodone 20 mg po oxycodone

xx 30 mg po 30 mg po morphinemorphine

X = 60 mg po morphine daily = MS Contin 30 mg q12hX = 60 mg po morphine daily = MS Contin 30 mg q12h If you want to decrease dose to allow for decreased If you want to decrease dose to allow for decreased

cross-tolerance, decrease dose by 1/2 to 1/3 = 30 to cross-tolerance, decrease dose by 1/2 to 1/3 = 30 to 40 mg morphine daily = MS Contin 15 mg q12h40 mg morphine daily = MS Contin 15 mg q12h

Fentanyl patchFentanyl patch 30 – 60 mg po morphine daily = 25 mcg fentanyl 30 – 60 mg po morphine daily = 25 mcg fentanyl

patchpatch23

Page 24: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Conversion problemConversion problem

In the previous problem, your patient was In the previous problem, your patient was stable on MS Contin 30 mg q12hstable on MS Contin 30 mg q12h

Your attending wants to change over to the Your attending wants to change over to the fentanyl patchfentanyl patch

How do you time the transition from MS How do you time the transition from MS Contin to the patch?Contin to the patch?

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Page 25: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Conversion problemConversion problem

In the previous problem, your patient was In the previous problem, your patient was stable on MS Contin 30 mg q12hstable on MS Contin 30 mg q12h

Your attending wants to change over to the Your attending wants to change over to the fentanyl patchfentanyl patch

How do you time the transition from MS How do you time the transition from MS Contin to the patch?Contin to the patch? It takes about 12 hrs for onset of fentanyl patchIt takes about 12 hrs for onset of fentanyl patch Give patient one last dose of MS Contin at the Give patient one last dose of MS Contin at the

same time the patch is appliedsame time the patch is applied25

Page 26: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of conversion from Example of conversion from oral med to PCAoral med to PCA

Pt taking OxyIR 20 mg PO q4h Pt taking OxyIR 20 mg PO q4h Pt’s pain is well-controlledPt’s pain is well-controlled Want to convert to hydromorphone PCAWant to convert to hydromorphone PCA

What would be a basal dose (in mg/hr)?What would be a basal dose (in mg/hr)?

What would be the bolus/demand dose?What would be the bolus/demand dose?

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Page 27: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of conversion of Example of conversion of oral med to PCAoral med to PCA

Pt taking OxyIR 20 mg q4hPt taking OxyIR 20 mg q4h Convert total oral daily dose (120 mg oxycodone) Convert total oral daily dose (120 mg oxycodone)

to oral hydromorphone to oral hydromorphone 120 mg po oxycodone 120 mg po oxycodone = = 20 mg po oxycodone 20 mg po oxycodone

xx 7.5 mg po 7.5 mg po hydromorphonehydromorphone

X = 45 mg po hydromorphoneX = 45 mg po hydromorphone Convert to IVConvert to IV

45 mg po hydromorphone45 mg po hydromorphone = = 7.5 mg po7.5 mg po

xx 1.5 mg IV1.5 mg IV x = 9 mg IV hydromorphone dailyx = 9 mg IV hydromorphone daily

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Page 28: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of conversion to Example of conversion to PCAPCA

Basal rateBasal rate 9 mg daily total = 0.4 mg per hour9 mg daily total = 0.4 mg per hour May want to decrease basal by 1/2 to 1/3 to May want to decrease basal by 1/2 to 1/3 to

account for incomplete cross toleranceaccount for incomplete cross tolerance Basal dose of 0.2 to 0.3 mg per hourBasal dose of 0.2 to 0.3 mg per hour

Bolus/demand dose is usually 10% of the Bolus/demand dose is usually 10% of the daily dose divided by 4daily dose divided by 4 (0.10 x 9 mg) / 4 = 0.2 mg q 15 minutes(0.10 x 9 mg) / 4 = 0.2 mg q 15 minutes

Titrate based on use & pt’s responseTitrate based on use & pt’s response28

Page 29: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of PCA conversion Example of PCA conversion to oral medto oral med

Pt on post-op morphine PCA with basal of Pt on post-op morphine PCA with basal of 1 mg/hr and bolus of 1 mg q15 minutes1 mg/hr and bolus of 1 mg q15 minutes

Pt used 40 bolus injections in 24 hoursPt used 40 bolus injections in 24 hours What dose of oral morphine (basal & What dose of oral morphine (basal &

breakthrough) should be used?breakthrough) should be used?

What dose of oral oxycodone (basal & What dose of oral oxycodone (basal & breakthrough) should be used?breakthrough) should be used?

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Page 30: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of PCA conversion Example of PCA conversion to oral medto oral med

Total daily use of IV morphineTotal daily use of IV morphine 1 mg/h x 24 h + 40 bolus = 64 mg/24 hour1 mg/h x 24 h + 40 bolus = 64 mg/24 hour

Convert to oral morphineConvert to oral morphine 64 mg IV morphine 64 mg IV morphine = = 1 mg IV morphine1 mg IV morphine

xx 3 mg po morphine3 mg po morphine X = 192 mg po morphine X = 192 mg po morphine

MS Contin 100 mg q12h (basal)MS Contin 100 mg q12h (basal) Morphine IR 30 mg q4h prn for breakthroughMorphine IR 30 mg q4h prn for breakthrough

10 – 20% of daily dose q4h (10 – 20% of 200 mg is 20 10 – 20% of daily dose q4h (10 – 20% of 200 mg is 20 to 40 mg)to 40 mg)

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Page 31: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Example of PCA conversion Example of PCA conversion to oral medto oral med

Converting to po oxycodoneConverting to po oxycodone 192 mg po morphine 192 mg po morphine = = 30 mg po morphine30 mg po morphine

xx 20 mg po oxycodone20 mg po oxycodone X = 128 mg po oxycodoneX = 128 mg po oxycodone

Decrease daily dose by 1/2 or 1/3 to allow for incomplete Decrease daily dose by 1/2 or 1/3 to allow for incomplete cross tolerancecross tolerance

Total daily dose of oxycodone = 64 to 85 mgTotal daily dose of oxycodone = 64 to 85 mg

OxyContin dose (basal): 60 mg q12h or can use OxyContin dose (basal): 60 mg q12h or can use 30 to 40 mg q12h if want to account for 30 to 40 mg q12h if want to account for incomplete cross toleranceincomplete cross tolerance

Oxycodone IR (breakthrough): 5-10 mg q4h prnOxycodone IR (breakthrough): 5-10 mg q4h prn31

Page 32: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Side EffectsSide Effects

Constipation – worsens with dose increasesConstipation – worsens with dose increases Sedation, fatigue – wears off within 1 weekSedation, fatigue – wears off within 1 week Dizziness – wears off, may require slower Dizziness – wears off, may require slower

titrationtitration Nausea – usually wears off; switching products Nausea – usually wears off; switching products

may helpmay help Hallucinations – more common at higher dosesHallucinations – more common at higher doses Itching - anti-histamine; rotate narcoticsItching - anti-histamine; rotate narcotics Respiratory depression – rare side effect with Respiratory depression – rare side effect with

chronic dosing; more common with IV, epiduralchronic dosing; more common with IV, epidural32

Page 33: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Respiratory DepressionRespiratory Depression

0.2 – 2 mg naloxone IV, IM, SC0.2 – 2 mg naloxone IV, IM, SC Repeat doses every 2 to 3 min prnRepeat doses every 2 to 3 min prn Total dose up to 10 mgTotal dose up to 10 mg After reversal, may need to readminister dose After reversal, may need to readminister dose

at a later interval (20 to 60 minutes) at a later interval (20 to 60 minutes) depending on the type/duration of opioiddepending on the type/duration of opioid

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Page 34: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Assessment ScalesAssessment Scales

RespiratoryRespiratory Should be counted for at Should be counted for at

least 30 secondsleast 30 seconds If RR <12/min, then count If RR <12/min, then count

for full minutefor full minute If RR <10/min, stop PCAIf RR <10/min, stop PCA If RR <4/min, give If RR <4/min, give

naloxonenaloxone

SedationSedation 1 = agitated, restless1 = agitated, restless 2 = cooperative, oriented2 = cooperative, oriented 3 = asleep, easily 3 = asleep, easily

arousablearousable 4 = asleep, arouses to 4 = asleep, arouses to

voicevoice 5 = no response to verbal 5 = no response to verbal

stimulistimuli 6 = no response to pain6 = no response to pain Stop PCA & give naloxone Stop PCA & give naloxone

for score 5 & 6for score 5 & 6 34

Page 35: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

ConstipationConstipation

Need a stool softenerNeed a stool softener Docusate 100 mg: 1 to 2 caps po twice dailyDocusate 100 mg: 1 to 2 caps po twice daily

Need a stimulant laxativeNeed a stimulant laxative Senna: usual dose is 1 tab at bedtime or twice Senna: usual dose is 1 tab at bedtime or twice

daily but can titrate up to 4 tabs three times daily but can titrate up to 4 tabs three times daily prndaily prn

Bisacodyl 5 mg: 1 to 2 tabs twice daily prnBisacodyl 5 mg: 1 to 2 tabs twice daily prn

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Page 36: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

ConstipationConstipationMedication Dose

Polyethylene Glycol (Miralax)

17 g in 8oz water daily to twice daily

Milk of Magnesia 30 – 60 ml daily to twice daily

Lactulose 20 – 60 ml twice to four times daily

Magnesium Citrate** 8oz daily

Bisacodyl suppositories

Daily to twice daily

Fleet enemas Daily to twice daily

36www.toonpool.com

Page 37: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Opioid “Allergy”Opioid “Allergy”

““Pseudoallergy” caused by histamine Pseudoallergy” caused by histamine release – most commonly seen with release – most commonly seen with codeine, morphine, meperidinecodeine, morphine, meperidine Pt c/o flushing, itching, hives, sweatingPt c/o flushing, itching, hives, sweating Mild hypotensionMild hypotension Use H2RAUse H2RA Decrease doseDecrease dose Switch to a more potent opioid (i.e. fentanyl, Switch to a more potent opioid (i.e. fentanyl,

hydromorphone)hydromorphone)

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Opioid “Allergy”Opioid “Allergy” Pts with “true” allergyPts with “true” allergy

Breathing, speaking, swallowing difficultiesBreathing, speaking, swallowing difficulties Swelling of face, lips, mouth, tongue, pharnyx, or Swelling of face, lips, mouth, tongue, pharnyx, or

larynxlarynx Severe hypotensionSevere hypotension

Switch to a different classSwitch to a different class Phenylpiperidines: meperidine, fentanylPhenylpiperidines: meperidine, fentanyl Diphenylheptanes: methadone, propoxypheneDiphenylheptanes: methadone, propoxyphene Morphine group: morphine, codeine, hydrocodone, Morphine group: morphine, codeine, hydrocodone,

oxycodone, hydromorphone, nalbuphine, oxycodone, hydromorphone, nalbuphine, butorphanolbutorphanol

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Page 39: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Sole Provider ProgramSole Provider Program PurposePurpose

To monitor patients exhibiting signs of drug-seeking behavior, To monitor patients exhibiting signs of drug-seeking behavior, insufficient analgesia, evidence of non-optimization in care insufficient analgesia, evidence of non-optimization in care options, psychosocial issues, or other complex options, psychosocial issues, or other complex pharmaceutical care issuespharmaceutical care issues

Narcotic prescriptions onlyNarcotic prescriptions only

The primary care provider can be the Sole Provider The primary care provider can be the Sole Provider or choose to refer a patient to a Sole Provideror choose to refer a patient to a Sole Provider

Opioid “contract” signed between patient and Sole Opioid “contract” signed between patient and Sole Provider physicianProvider physician

Pharmacy informed and note put in CHCSPharmacy informed and note put in CHCS Sole Provider committee will monitor for violationsSole Provider committee will monitor for violations

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Sole Provider ProgramSole Provider Program

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1. NNMC Intranet

2. Site Map3. Pharmacy

Page 41: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Sole Provider ProgramSole Provider Program

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Page 42: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

Writing PrescriptionsWriting Prescriptions

Link on Pharmacy Website Write legiblyWrite legibly Write out your DEA numberWrite out your DEA number Spell out the quantity to be dispensedSpell out the quantity to be dispensed C-IIs are not refilled (new Rx required) & C-IIs are not refilled (new Rx required) &

require separate prescriptionsrequire separate prescriptions Use DoD Form 1289 for controlled Use DoD Form 1289 for controlled

substancessubstances

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Page 43: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

DEA numbersDEA numbers Retail and mail-order pharmacies are no Retail and mail-order pharmacies are no

longer accepting the NNMC DEA numberlonger accepting the NNMC DEA number Must apply for own practitioner DEA numberMust apply for own practitioner DEA number Active military physicians (MD, DO, DDS, Active military physicians (MD, DO, DDS,

DMD, and DPM) are fee exempt and may be DMD, and DPM) are fee exempt and may be licensed in any state to obtain a DEA licensed in any state to obtain a DEA registrationregistration

DEA number is to be used solely for DoD DEA number is to be used solely for DoD beneficiaries prescriptions and may not be beneficiaries prescriptions and may not be used for off-duty employmentused for off-duty employment

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Page 44: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

DEA numbersDEA numbers

To apply for DEA number:To apply for DEA number: Contact the Credentialing Office to complete Contact the Credentialing Office to complete

the correct paperworkthe correct paperwork Contact person: Rebekah Byrd at 319-4157Contact person: Rebekah Byrd at 319-4157

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Med Errors to AvoidMed Errors to Avoid

Roxanol v Roxicodone oral solutionsRoxanol v Roxicodone oral solutions Roxanol (morphine) v Roxicodone (oxycodone)Roxanol (morphine) v Roxicodone (oxycodone) Correct strengthsCorrect strengths

PCA strengthPCA strength Morphine: 1 mg/ml and 5 mg/mlMorphine: 1 mg/ml and 5 mg/ml Hydromorphone: 1 mg/ml and 0.2 mg/mlHydromorphone: 1 mg/ml and 0.2 mg/ml

Fentanyl patchFentanyl patch For inpatients, double check if patient has patch For inpatients, double check if patient has patch

on from homeon from home45

Page 46: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

ReferencesReferences Pharmacotherapy: A Pathophysiologic Pharmacotherapy: A Pathophysiologic

Approach. 6Approach. 6thth edition: Chapter 58. edition: Chapter 58. End of Life/Palliative Education Resource CenterEnd of Life/Palliative Education Resource Center MicromedexMicromedex Drug Facts and ComparisonsDrug Facts and Comparisons Equianalgesic Dosing of Opioids for Pain Equianalgesic Dosing of Opioids for Pain

Management. Pharmacist’s Letter 2004.Management. Pharmacist’s Letter 2004. Opioid Intolerance Decision Algorithm. Opioid Intolerance Decision Algorithm.

Pharmacist’s Letter 2006.Pharmacist’s Letter 2006. Clinical PharmacologyClinical Pharmacology

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Page 47: Pain Management & Opioid Analgesics. Objectives Determine proper opioid dosing Determine proper opioid dosing Differentiate between specific opioid analgesics.

ReferencesReferences

Principles of Analgesic Use in the Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Treatment of Acute Pain and Cancer Pain, American Pain Society, 5American Pain Society, 5thth Ed. 2003 Ed. 2003

Grammaitoni AR et al. Clinical Application Grammaitoni AR et al. Clinical Application of Opioid Equianalgesic Data. of Opioid Equianalgesic Data. Clin J Pain Clin J Pain 2003; 19(5): 286-297.2003; 19(5): 286-297.

McPherson M.L. Demystifying Opioid McPherson M.L. Demystifying Opioid Conversion Calculations: A Guide for Conversion Calculations: A Guide for Effective Dosing. 2010.Effective Dosing. 2010.

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QUESTIONS?QUESTIONS?

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