Safe and Effective Prescribing of Analgesics · 2018-03-31 · May 2016 October 2016 June 2016 July...
Transcript of Safe and Effective Prescribing of Analgesics · 2018-03-31 · May 2016 October 2016 June 2016 July...
Mary Jo Cerepani, DNP, FNP-BC CEN
Patricia Gilliam, PhD, MEd, ANP-BC
PCNP Annual ConferenceNovember 5, 2016
Safe and Effective Prescribing of Analgesics-a component of a longitudinal project with PAFP
Primary Care Pain Management in Pennsylvania:
Optimizing Treatment, Minimizing Risk
Chronic Pain Management in Primary Care
Performance Improvement-CME Project
December, 2014 - June, 2016
Primary Care Pain Management in Pennsylvania:Optimizing Treatment, Minimizing Risk
SPONSORSHIP STATEMENT
This activity was jointly sponsored by the Pennsylvania Academy of Family Physicians
Foundation andIntegrated Learning Partners, LLC in
collaboration withPennsylvania Coalition of Nurse Practitioners.
SUPPORTER STATEMENT
This activity was supported via an educational grant
from Pfizer, Inc.
Prevalence of Pain in Pennsylvania
Significance of the Problem
Primary Care Pain Management in Pennsylvania:Optimizing Treatment, Minimizing Risk
IOM REPORT, 2011
In 2011, at least 100 million adult
Americans have common
chronic pain conditions
A direct and indirect cost of
$560-635 billion dollars per year
Approximately 40% of patients
with chronic pain do not achieve
adequate pain relief
IOM. Relieving Pain in America: A Blueprint for Transforming
Prevention, Carel Education and Research. 2011. Washington, DC.
The National Academies Press:58.
TRENDS IN PRESCRIPTION OPIOID DISPENSING IN U.S.1999 TO 2013
• The amount of
prescription opioids
dispensed in the U.S.
nearly quadrupled
• Yet there has NOT been
an overall change in the
amount of pain that
Americans report
http://www.cdc.gov/drugoverdose/epidemic/providers.html
Pennsylvania’s problems
Pennsylvania has the 14th Highest Drug Overdose
Mortality Rate in the United States
In 2013 there were 15.3 per 100,000 people suffering drug overdose fatalities
No Prescriber Education Required or Recommended
Has NO law requiring or permitting a pharmacist to require an ID prior to
dispensing a controlled substance
Lacking Support for Substance Abuse Treatment Services: Is not participating in
Medicaid Expansion, which helps expand coverage of substance abuse services
and treatment
http://healthyamericans.org/reports/drugabuse2013/release.php?stateid=PA
PENNSYLVANIA PRESCRIPTION DRUG MONITORING PROGRAM
Attorney general office 1990’s had a prescription monitoring program but only schedule 2, physician could not access the data
Pennsylvania Department of Health Injury Prevention Committee developed a committee for Unintentional Poisonings in 2005
ABC-MAP Act 191 of 2014 was developed
PA PDMP access www.doh.pa.gov/PDMP
Single County Authorities(SCAs) apps.ddap.pa.gov/GetHelpNow/CountyServices.aspx – offers assistance for your patients who need drug and alcohol treatment services
PDMP UPDATE
May 2016 October 2016June 2016 July 2016 August 2016 September 2016
May 17, 2016
National Association Board of Pharmacy (NABP) PMP InterConnect MOU
signed with PA
June 6, 2016
PA PDMP Website updated
May 3, 2016
Data Submitter's (Dispensation) Guide
May 2016 - July 2016
OAG to DOH (OTech to PMP AWARxE) data transfer –
approx. 45 million records complete
June 24, 2016
Reporting to the new PDMP system begins
August 25, 2016
New PDMP System Go-Live – Registered users began
patient searches
August 8, 2016
Online Registration opened
June 2016 - October 2016
Continuously Monitor Pharmacy Compliance
September 2016
PMP Interconnect Data Sharing with all states
CONTINUING MEDICAL EDUCATION UNITS
Partnered with Pennsylvania Medical Society (PAMED) and developed the PA PDMP CME.
Addressing Pennsylvania’s Opioid Crisis: What the Health Care Team Needs to Know
The CME program is divided into four sessions and each session consists of four, 15-minute modules. The program covers a variety of tools and resources for prescribers and dispensers to better address opioid addiction with their patients. Sessions include:
1: Opioid Prescribing Guidelines for Non-Cancer Pain
2: Naloxone
3: Referral to Treatment
4: PA PDMP Database
These are free CMEs until June 30, 2017, for all medical professionals that need to renew license this year.
Performance Improvement CME Project:
Primary Care Management of Patients with Chronic non-cancer pain
December, 2014 - May, 2016
Primary Care Pain Management in Pennsylvania:Optimizing Treatment, Minimizing Risk
PAFP & ILP PROJECT TEAM
Our Team:
Co-Leaders:
Angie Halaja-Henriques, Chief Officer of QI and Public Health Programs (PAFP)
Sherlyn Celone, President and Chief Learning Officer (ILP)
Project Team Members:
Elizabeth Shaw, Project Manager (PAFP)
Patricia Gilliam, PhD, NP Clinical Leader/Practice Coach (ILP)
Peter Gamache, PhD, MBA, MPH, RN Outcomes Specialist (ILP)
David DePalma, PhD Sr. Creative Change/Patient Engagement Specialist (ILP)
Debra Hammaker, CHTS-CP, CHTS-IS, PCMH CCE, EHR Practice Liasion for PAFP
Suzanne Hockenberry, PCMH CCE, Practice Liaison (PAFP)
Sherrie Whisler, Data/Reporting Specialist (PAFP)
PROJECT FACULTY
Mary Jo Cerepani, DNP, FNP-BC, CEN
University of Pittsburg
David DePalma, PhD
Integrated Learning Partners
Westport , CT
Patricia Gilliam, PhD, MEd, ANP-BC
Course Education Director and,PerformanceImprovement Coach
Integrated Learning Partners
Jeff Gudin, MD
Englewood Hospital and Medical Center
Englewood, NJ
Elizabeth Khan, MD
Course Medical Director
Tilghman Medical Center
Allentown, PA
Mary Lynn McPherson, PharmD, MA, BCPS, CPE
University of MD College of Pharmac
Baltimore
Lee Radosh, MD
Director, Family Medicine Residency
Reading, PA
BEST PRACTICES IN PAIN MANAGEMENT
Comprehensive Assessment
REMS
Screening for Substance Use & Abuse Potential
Controlled Substance Agreement
Comprehensive Plan of Care
Interprofessional collaboration and treatment
Community Partners and Resources
Medication Management
Patient-Provider Relationship and Communication
PROJECT METRICS
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
PQRS # 374
Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.
PQRS # 131
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Percentage of patients >12 y.o. screened for clinical depression using a standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
PQRS # 134
PROJECT METRICS: SPECIFIC TO CHRONIC PAIN
% of Controlled Substance Agreements (CSA) on file for the patients prescribed an opioid for > 6mos whose pain medications are being managed by the PCP
Will work with practices to build a field to add the executed CSA agreement
Click yes/no and attach CSA
90%
% of chronic pain patients on an opioid medication, whose pain medications are managed by the PCP, who are being screened for opioid abuse/addiction according to the practice or provider protocol
Identifying those patients with chronic pain who are currently being treated with an opioid medication who may be at risk for opioid abuse or addiction by using a validated screening tool.
90%
OTHER MARKERS OF SUCCESS
Improvements in Providers’ Knowledge, Skills and Confidence around Chronic Pain Management
Improved Patient Engagement
Communication Skills, Patient Education & Shared decision-making
Use of Comprehensive Evaluation, Planning and Treatment Guidelines
Provider Surveys, Patient Surveys
CME Pre-Post Tests
Review of Performance Improvement and PDSA Cycle Development and Implementation
Review and analysis of Comprehensive Care of Patients with Chronic Pain randomized into project database using a project developed Chronic Pain Managment Checklist
PROJECT MODELProject Components
1) InterprofessionalTraining/Coaching
2) Provider-patient Experience Study
3) Patient/Caregiver Education Resources
4) Outcomes Measures (e.g., clinical, patient satisfaction, professional development, comprehensive patient care, etc.)
Provider/Patient
ExperienceStudy
(2-Surveys)
Patient Ed Group Visits
(Live)
Patient/Caregiver
Educational Tool Kit(Print & Digital)
QI CME
Workshop
(1)
CME
Webinars
(4)
PDSA
Plans
Practice
Coaching
(1-2)
Baseline Follow-UpContinuous Needs
Assessment Process
Interventions/Activities
Patricia Gilliam, PhD, MEd, ANP-BC
Clinical Education and Research ConsultantClinical Study Center of Asheville
Asheville, NC
Safe and Effective Prescribing of Analgesics-a component of a longitudinal project with PAFP
Primary Care Pain Management in Pennsylvania:
Optimizing Treatment, Minimizing Risk
LEARNING OBJECTIVES:SAFE AND EFFECTIVE PRESCRIBING OF ANALGESICS
Discuss the appropriate use of non-opioids and adjuvant drugs including basic
pharmacology, risk/benefit and safety concerns in the treatment of chronic non-
cancer pain
Discuss the appropriate use of opioids including basic pharmacology, risk/benefit
and safety concerns in the treatment of chronic non-cancer pain
Calculate conversions between equianalgesics.
Convert dose of short-acting opiate to the appropriate dose of a long-acting
opiate
COMPONENTS: SAFE AND EFFECTIVE PRESCRIBING OF ANALGESICS
Appropriate Provider Education
Comprehensive Assessment of Patients’ Pain (H&P plus)
Screening for Abuse and Addiction
Comprehensive Treatment Plan with updates (agreed upon with patient)
Contract-Controlled Substances Agreement
Network of referral sites
Physical Therapy, Mental Health, Abuse/addiction, other Community Resources
Risk Evaluation and Mitigation Strategies (REMS)
WHAT IS PAIN?
“Pain is whatever the person experiencing it says it is” (McCaffery).
An unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage (IASP).
“Total” Pain (Dame Cicely Saunders)
Physical (due to disease or treatments)
Psychological (anger, fear of suffering, depression, past experience of illness)
Social (loss of role, status, job; financial concerns, worries about
future/family, dependency)
Spiritual (anger, loss of faith, finding meaning, fear of the unknown
www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=8705
Chronic Pain Affects Many Dimensions of a Patient’s Life
Borneman T, et al. Oncol Nurs Forum. 2003;30:997-1005.
Physical Social
Anger/
Fear
• Relationships
• Ability to show affection/sexual function
• Isolation
• Function
• Activities of daily living
• Sleep/rest
Psychological
Anxiety/
Depression
NOCICEPTIVE , MIXED & NEUROPATHIC PAIN
Postoperativepain
Mechanicallow back pain
Sickle cellcrisis
ArthritisPostherpetic
neuralgia
Neuropathic low back pain
CRPS*
Pain from injuries
Central post-stroke
pain
Trigeminalneuralgia
Distalpolyneuropathy
(eg, diabetic, HIV)
1 Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice.
Philadelphia, Pa: FA Davis Company; 1996:4.
2 Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. 2000:8-9. Wright, 2015
Caused by a combination of both primary injury and secondary effects
Caused by activity in neural pathways in
response to potentially tissue-damaging stimuli1
Initiated or caused by primary lesion or dysfunction in the nervous system2
Nociceptive Pain Mixed Type Neuropathic Pain
Pancreatitis
IMPACT OF THE TYPE OF PAIN ON THE STEPWISE APPROACH TO THE PATIENT WITH PAIN
Onset
Acute or Chronic
Etiology
Neuropathic Inflammatory
Mechanical/compressive Visceral Muscular
Impacts Treatment Choices
PAIN ASSESSMENT-HISTORY
Onset of pain
Precipitating factors
Palliative factors [current and past treatments for pain]
Location, intensity and radiation pattern of pain
Characteristics of pain
Neuropathic pain (Burning, stabbing or shooting pain)
Musculoskeletal pain or Mechanical compression pain (Aching, soreness, stiffness)
Inflammatory pain (Aching, swelling, hot, red)
Grading of pain and impact on level of functioning; Define goals
Psychosocial assessment
Comorbidities
History of Substance Abuse
Chronic medical conditions
PAIN TREATMENT HISTORY
Pain management
Include treatments that worked and those that did not and WHY
Referring clinicians
Radiologic studies
Past Surgeries
Psychiatry/Mental Health Assessments and Treatments
Other
PAIN PHYSICAL EXAMINATION
General Examination: Fever, Tachycardia, Thyromegaly, Proximal Muscle Weakness, Joint inflammation, Dermatitis, Neurologic abnormalities, Hepatomegaly or Splenomegaly, Lymphadenopathy
Focus on the area of reported pain (consider that pain may be referred)
Observe patient's gait, movementd and posture
Assess for Trigger Points
Myofascial Pain Syndrome and Tender Points
Complete Musculoskeletal Exam
Shoulder, scapular, iliac crest.Muscle, facet, SI, piriformis, hip
Complete Neurologic Exam
Sensory, Motor, Reflex, CN, Cerebellar
Psychiatric
MULTIDIMENSIONAL PAIN ASSESSMENT TOOLS
Brief Pain Inventory (BPI)
7 Domains that assess the impact of pain on:
General Activity
Work
Mood
Ability to Walk
Relationships
Sleep
Enjoyment of Life
SAFE PRESCRIBING OF ANALGESICS MUST INCLUDE OPIOID RISK MANAGEMENT-----REMS
Patient Interview
Screening Tools for for Abuse/Addiction
State Prescription Drug Monitoring database (PDMP)
Urine Drug Testing
CLIA waived immunoassay
GC LC/MS
Criminal background check
National Institute of drug abusehttps://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/screening-assessment-drug-testing-resources/chart-evidence-based-screening-tools-adults
WHO Pain Relief Ladder (1996)
http://www.who.int/cancer/palliative/painladder/en/
3 •Opioid Analgesics
2 •Adjuvant Analgesics
1 •Non-opioid Analgesics
ACETAMINOPHEN
Other names – Tylenol, APAP, Paracetamol
APAP (N-acetyl-para-aminophenol)
Analgesic, antipyretic
Widely available in US
Legend prescription combinations – 228
OTC monotherapy and combinations – > 60
31,580 individual NDC codes for mono and combo prescription and OTC products
28 billion doses purchased yearly in US
Single ingredient OTC 8 billion doses
Combination OTC 9.7 billion doses
Acetaminophen / opioid combos 11 billion doses
Retrieved from National Drug Code Directory database: (http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm)
IMS Health, IMS National Sales Perspectives™, Year 2005, Extracted 9/06.
ACETAMINOPHENMECHANISM OF ACTION
Active metabolite of phenacetin
Not clearly understood; centrally active
Weak COX-1 and COX-2 inhibitor
Equivalent to ASA as an analgesic and antipyretic agent
Lacks anti-inflammatory properties
Does not affect uric acid levels
Does not inhibit platelet function
Role in therapy
Minimal role in OA of knees; no role in low back pain
Smith HS. Potential analgesic mechanisms of acetaminophen. Pain Physician; 2009;12:269-280.
Hepatotoxicity
Skin reactions
Drug-Drug interactions
Age-related metabolic changes
Pregnancy
Asthma
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) AGENTS
• Diclofenac*
• Indomethacin
• Sulindac
• Tolmetin
• Celecoxib **
• Meclofenamate
• Mefenamic acid
• Nambumetone
• Piroxicam
Meloxicam
Fenoprofen
Flurbiprofen
Ibuprofen ***
Ketoprofen
Naproxen
Oxaprozin
Etodolac
Ketorolac ***
*Available as topical; **COX-2 selective; ***Available as injectablewww.online.factsandcomparison.com
AnalgesicAntipyretic
Anti-inflammatoryAntiplatelet
NSAID TOXICITY
Gastrointestinal
Perforation, ulcers, bleeding
Cardiovascular/cerebrovascular
MI, heart failure, CVA
Renal adverse effects
Decreased GFR, progression of CKD
Other adverse effects
3 •Opioid Analgesics
2 •Adjuvant Analgesics
1 •Non-opioid Analgesics
Addition of an ADJUVANT ANALGESIC
http://www.who.int/cancer/palliative/painladder/en/
Adjuvant
WHAT IS AN ADJUVANT?
What is an adjuvant?
“Serving to help or assist; auxiliary.”
“Serving to aid or contribute.”
What is an adjuvant analgesic?
“Drugs with a primary indication other than pain that have analgesic properties in some painful conditions.”
“Medications whose primary indication is the treatment of a medical condition, with secondary effects of analgesia.”
Also referred to as “co-analgesics”
www.ask.com; www.merriam-webster.com; http://theoncologist.alphamedpress.org/content/9/5/571.fullAm J Hospice Pall Med 2012:29(1):70-79
ADJUVANT ANALGESICS
• Multipurpose Analgesics
• Antidepressants, NSAIDs, α-2 adrenergic agonists, neuroleptics
• Adjuvants for Neuropathic Pain
• Anticonvulsants, Na+ channel blockers, NMDA antagonists, cannabinoids
• Topical Analgesics
• Capsaicin, local anesthetics, NSAIDs
• Adjuvants for Bone Pain
• NSAIDs, calcitonin/bisphosphonates, Radiopharmaceuticals
• Other
• Adjuvants for bowel obstruction, musculoskeletal pain
Portenoy, Ahmed. http://www.futuremedicine.com/doi/abs/10.2217/ebo.11.340
ANTIDEPRESSANTS
Classpa Examples Analgesic effects
Tricyclic antepressants (TCAs) Nortriptylineamitriptyline
++++++
Selective serotonin reuptake inhibitors (SSRIs)
ParoxetineCitalpramSertraline
+++
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
DuloxetineVenlafaxineMilnacipram
+++ FDA indication:pain++++++ FDA indication:pain
Atypical agents BupropionMirtazapine
+++
Dharmshaktu, Taylor & Kaira (2102). Efficacy of antidepressants as analgesics: a review. J.
J. Clin. Pharacol, 52 (1), 6-17.
Which of the following antidepressants
is LEAST likely to provide pain relief?
A. Nortriptyline (Pamelor)
B. Duloxetine (Cymbalta)
C. Sertraline (Zoloft)
D. Venlafaxine (Effexor)
PRINCIPLES OF ADJUVANT ANALGESIC USE
General principles of adjuvant analgesic use:
Multiple pathways of pain transmission provide multiple targets of pain relief
Use specific adjuvant for specific condition
Titrate only one drug at a time
May take several days-weeks to notice improvement in pain
Adjuvants usually do not provide full pain relief
Educate patients about trial-and-error nature of adjuvant use
Select rational combinations of analgesics/adjuvant analgesicsPortenoy, Ahmed. http://www.futuremedicine.com/doi/abs/10.2217/ebo.11.340
3 •Opioid Analgesics
2 •Adjuvant Analgesics
1 •Non-opioid Analgesics
OPIOID ANALGESICS
http://www.who.int/cancer/palliative/painladder/en/
Opioids
OPIOID CATEGORIES
Category Examples
Phenanthrenes • Morphine• Codeine• Hydromorphone• Levorphanol• Oxycodone• Hydrocodone• Oxymorphone• Buprenorphine• Nalbuphine• Butorphanol
Benzomorphans • Pentazocine
Phenylpiperidines • Fentanyl, alfentanil, sufentanil• Meperidine
Diphenylheptanes • Methadone• (Propoxyphene) – off market
Pain Physician 2008;11:S133-S153.
ATYPICAL OPIOIDS
Tramadol and Tapentadol
Indicated for the management of moderate to severe acute or
chronic pain
Tramadol: Weak mu opioid agonist, increases serotonin and
norepinephrine levels
Tapentadol: Mu opioid agonist and primarily inhibits reuptake of
norepinephrine
OPIOID INDICATIONS AND USES
Analgesia for Moderate to Severe pain
Anesthesia
Cough
Detoxification
Diarrhea
Dyspnea
OPIOIDS IN CHRONIC NON-
CANCER PAIN?
Until latter part of the 1990’s, long-term opioid therapy for CNCP was prohibited in most US states.
Data on long-term safety emerged; advocacy groups lobbied to lift the relative prohibition on opioid use in CNCP
Franklin GM. AAN; Neurology 2014; 83(14):1277-1284.
OPIOIDS IN CHRONIC NON-
CANCER PAIN?
Data on efficacy for opioid use in CNCP lacking
Increasing mortality from accidental poisoning, concomitant with dramatically increasing average daily morphine equivalent doses developed quickly
Franklin GM. AAN; Neurology, 2014; 83(14):1277-1284.
AHQR, 2014
The Effectiveness and Risks of Long-Term
Opioid Treatment of Chronic Pain
“Evidence on long-term opioid therapy for chronic pain
is very limited but suggests an increased risk of serious
harms that appears to be dose-dependent. More
research is needed to understand long-term benefits,
risk of abuse and related outcomes, and effectiveness of
different opioid prescribing methods and risk mitigation
strategies.”
http://www.ahrq.gov/research/findings/evidence-based-reports/opoidstp.html
OPIOID RESPONSIVENESS
Pseudo-resistant
Dose too low, patient not absorbing opioid, genetic variation
Semi-opioid resistant pain
Bone metastases, some neuropathic pain, activity-related (some musculoskeletal pain)
Skin ulceration, bladder and rectal tenesmus
Opioid-resistant pain
Some neuropathic pain, muscle spasm
Chronic visceral or central pain syndromes
Abdominal or pelvic pain; pancreatic pain
Fibromyalgia
Headaches
Chronic low back pain
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_215.htm; Am Fam Phys 2012;86(3):252-258.
AMERICAN ACADEMY OF NEUROLOGY, 2014
Opioids for chronic noncancer pain: A position paper
of the American Academy of Neurology
Franklin GM. Neurology 2014; 83(14):1277-1284.
Opioids are not recommended for treating:
Tension-type headaches
Fibromyalgia
Chronic low back pain
FIRST LINE OPIOIDS
Morphine
Oxycodone
Hydromorphone
Methadone
Buprenorphine
Fentanyl
Pain Pract 2008;8:287-313.
MORPHINE
Agonist at mu and kappa opioid receptors
Metabolized in the liver to morphine-3-glucuronide (M3G, 55%) and morphine-6-glucuronide (M6G, 10%). 10% eliminated unchanged.
Both pharmacologically active
M6G analgesic; both can cause toxicity
Accumulated in renal impairment and may cause toxicity
Reduce dose/avoid in renal impairment
Use cautiously with hepatic impairment
Oral morphine may become more bioavailable
May require increase in dosing interval
Available as:
SA tablets, capsules, oral solution, oral intensol
LA tablets, capsules; Rectal suppositories; Injectable formulation
OXYCODONEPLUS ACETAMINOPHEN=VICODIN, PERCOCET
Agonist at the mu opioid receptor
Metabolized in the liver to noroxycodone
Threefold greater affinity for mu receptor than oxycodone but poorly penetrates CNS
Ten percent of oxycodone excreted unchanged
Parent drug and active metabolites accumulate with renal impairment
Use with caution and at lower doses
• Consider SA formulations in hepatic impairment
• Available as SA tablets, capsules, oral solution, oral intensol, long-acting tablet
Frequently given in combination with acetaminophen (e.g., Percocet), and to a lesser extent with aspirin (e.g., Percodan)
HYDROMORPHONE- DILAUDID
Agonist at the mu and kappa opioid receptors
Metabolized in the liver to hydromorphone-3-glucuronide, which is pharmacologically active
Moderate to severe renal failure increases hydromorphone area under the curve and half-life of elimination 2-4 fold, respectively
Reduce dose or avoid in renal impairment
Use cautiously with hepatic impairment
Oral hydromorphone may become more bioavailable with severe hepatic impairment
May require longer dosing interval
Available as oral tablets, long-acting tablets, oral solution, injectable formulation and rectal suppository
FENTANYL - SUBLIMAZE, DUROGESIC
Agonist at the mu opioid receptor
Metabolized by the liver to inactive metabolites; little parent drug excreted unchanged
Bolus doses require no dosage adjustment
Continuous infusion and transdermal fentanyl (TDF) doses should be reduced in severe renal impairment
Avoid TDF in severe hepatic disease, fever, cachexia
Available as injectable, transmucosal, intranasal and transdermal formulations
All but injectable may ONLY be used in opioid-tolerant patients
Oral morphine > 60 mg/day for > 7 days or equivalent opioid
Fentanyl is approximately 100 times more potent than morphine
BUPRENORPHINE -SUBOXONE
Partial agonist at the mu opioid receptor, antagonist at the kappa opioid receptor
Metabolized to norbuprenorphine (weak mu agonist) and buprenorphine-3-glucuronide
No dosage adjustment needed in renal impairment/failure or mild to moderate hepatic impairment (Not evaluated in severe hepatic impairment)
Available as sublingual tablets and injection
SL tablets with and without naloxone
Available as transdermal formulation
5 mcg/hour, 7.5 mcg/hour, 10 mcg/hour, 15 mcg/hour, 20 mcg/hour
May be started in opioid-naïve patients
METHADONE
Agonist at the mu receptor, antagonist at the N-methyl-D-aspartate receptor (NMDA)
Metabolized to inactive metabolites
No dosage adjustment is needed in renal impairment but use caution with end-stage renal disease
Half-life may be prolonged with hepatic impairment; allow extra time to achieve steady-stage and dose with caution
Available as oral tablets, oral solution, concentrated oral solution and injectable formulation
Caution when switching from other opioids to methadone
Allow 4-7 days or longer to achieve steady state; do not adjust dose before
PATIENT-RELATED VARIABLES
Age, ethnicity, body habitus
Opioid-use history (naïve, tolerant?)
Ability to use/manipulate dosage formulation
Renal and hepatic function
History of opioid responsiveness in past (therapeutic or toxic; allergic)
Patient’s lifestyle and dosing interval considerations
Patient health care beliefs, cognitive status
Patient febrile, pregnant, breast-feeding
History of substance abuse, medical conditions worsened by opioid
adverse effects
OPIOID-INDUCED ADVERSE EFFECTS
Gastrointestinal adverse effects
Nausea and vomiting
Constipation
CNS adverse effects
Sedation, mental clouding, impaired psychomotor function
Cardiorespiratory
Cardiac effects of opioids (methadone, buprenorphine)
Respiratory depression
Other adverse effects (pruritus, immunologic effects, hormonal change, hyperalgesia, bladder dysfunction)
Benyamin R et al. Pain Physician 2008;11:S105-S120. Swegle JM et al. Am Fam Physician 2006;74:1347-1354
REASONS FOR CHANGING OPIOIDS
Lack of therapeutic response
Development of adverse effects
Change in patient status
Other considerations
Opioid/formulation availability
Formulary issues
Patient/family health care beliefs
Opioid rotation, substitution, switching
PUTTING IT ALL TOGETHER…
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MORPHINE, GABAPENTIN, OR BOTH
41 patients with neuropathic pain randomized to four groups (x 5 weeks)
SR morphine
Gabapentin
SR morphine + gabapentin
Placebo (lorazepam)
Group Pain Rating (0-10)
Baseline 5.72
Placebo 4.49
SR morphine 4.15
Gabapentin 4.15
MS + Gabapentin 3.06
• Morphine + gabapentin doses were lower than the morphine or gabapentin arms, with better pain relief.
• Combination treatment had more constipation and dry mouth.NEJM 2005;352:1324-1334
USING OPIOIDS SAFELY IN CNCP
Opioid Responsive Pain / Minimize Use
Minimize Dose / Combination Therapy
Stay Safe (Corresponding Responsibility)
Show Functional Improvement
Exit Strategy
POINTS TO TAKE HOME…
Evaluate the utility of non-opioids (risks and benefits; acetaminophen and
NSAIDs)
Maximize the use of lifestyle modification for chronic non-cancer pain
Maximize the use of adjuvant analgesics and other non-pharmacologic
interventions
Carefully consider the appropriateness of starting or continuing an
opioid
Monitor pain ratings, and more importantly, functional status
Begin any pain management regimen with the end in mind (develop an
exit strategy).
EQUIANALGESIC OPIOID DOSING
Equianalgesic Doses (mg)
Drug Parenteral Oral
Morphine 10 30
Buprenorphine 0.3 0.4 (sl)
Codeine 100 200
Fentanyl 0.2-0.3 NA
Hydrocodone NA 30
Hydromorphone 1.5 7.5
Meperidine 100 300
Oxycodone 10* 20
Oxymorphone 1 10
Tramadol 100* 120*Not available in the USAdapted from: McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For Effective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010. Copyright ASHP, 2010. Used with permission.NOTE: Learner is STRONGLY encouraged to access original work to review all caveats and explanations pertaining to this chart.
5-STEP OCC PROCESS
1. Globally assess pain complaint (PQRSTU)
2. Determine TDD current opioid (LA and SA)
3. Decide which opioid analgesic will be used for the new
agent and consult established conversion tables to
determine new dose
4. Individualize dosage based on assessment information
gathered in Step 1
5. Patient follow-up and continual reassessment (7-14 days)
Gammaitoni AR, et al. Clinical J Pain 2003;19:286-297
USE A SIMPLE CONVERSION TO FIGURE OUT MATH
12 inches = 1 foot Problem- How many inches in 2 feet?
“x” inches = equivalents 12 inches
2 feet equivalents 1 foot
(x)(1) = (2)(12)
1X = 24
X= 24 = 24
1
NEED TO SWITCH DRUGS DUE TO S/E
Patient it currently taking 135 mg oral morphine daily. He is experiencing increasing pruritis and undesirable drowsiness.
The decision is made between the patient and the provider to switch to oxycodone.
How many mg of oxycodone should be prescribed?
SETTING UP THE CONVERSION EQUATION
“x” mg new opioid = equivalent mg new opioid
mg of current opioid equivalent mg current opioid
“x” mg oral oxycodone = 20 mg oral oxycodone
135 mg oral morphine 30 mg oral morphine
(x)(30) = (20)(135)
30X = 2700
X= 2700 = 90 mg oxycodone (reduce by 25-50% for safety)= 45-70 mg
30
Dose based on available dosage strengths and dosing frequency (SA or LA)
RESOURCES
Chronic Pain Initiative Toolkit: Primary Care Providers. (2012)
http://www.p4communitycare.org/media/related-downloads/cpi-toolkit-pcps.pdf
http://www.p4communitycare.org/media/related-downloads/cpi-toolkit-pcps.pdf
Institute for Clinical Systems Improvement. Health Care Guideline: Assessment and Management of Chronic Pain. Updated 2013.
https://www.icsi.org/_asset/bw798b/ChronicPain.pdf
https://www.icsi.org/_asset/bw798b/ChronicPain.pdf
An Annotated Bibliography of Patient and Provdier Resources
Included in PCNP meeting handouts
Questions