Step two: Moderate pain Tramadol Opioid combinations Acetaminophen or aspirin with Codeine...

Step two:Moderate pain

Step two:Moderate pain

Tramadol

Opioid combinations

Acetaminophen or aspirin with

•Codeine•Hydrocodone•Oxycodone

Plus/minus adjuvants

Dose limiting toxicity

Tramadol

Opioid combinations

Acetaminophen or aspirin with

•Codeine•Hydrocodone•Oxycodone

Plus/minus adjuvants

Dose limiting toxicity

AdjuvantsAdjuvants

Primarily for neuropathic pain

Antidepressants

Tricyclics

Venlafaxine, Duloxitene

Anticonvulsants

Gabapentin, pregabalin, carbamazepine

Antiarrhythmics

Lidocaine, mexilitene

Primarily for neuropathic pain

Antidepressants

Tricyclics

Venlafaxine, Duloxitene

Anticonvulsants

Gabapentin, pregabalin, carbamazepine

Antiarrhythmics

Lidocaine, mexilitene

Step 3:Severe pain

Step 3:Severe pain

Pure opioids•Morphine•Hydromorphone•Oxycodone•Fentanyl•Oxymorphone•Methadone

No ceiling effect

Variable toxicity at very high dose

Plus/minus adjuvants, non-opioids, steroids

Pure opioids•Morphine•Hydromorphone•Oxycodone•Fentanyl•Oxymorphone•Methadone

No ceiling effect

Variable toxicity at very high dose

Plus/minus adjuvants, non-opioids, steroids

OpioidsOpioids

OpioidsOpioids

Short acting oral agents

Long acting oral agents

Equianalgesic dose conversions

Opioid infusions

PRN dosing and dose escalation

Methadone

Short acting oral agents

Long acting oral agents

Equianalgesic dose conversions

Opioid infusions

PRN dosing and dose escalation

Methadone

Short acting oral agentsShort acting oral agents

Peak analgesic effect 60-90 minutes

Expected duration of 3-4 hours

Typical prescribed interval is Q 4-6 hours

AHCPR recommends dosing interval of 3-4 hours

Peak analgesic effect 60-90 minutes

Expected duration of 3-4 hours

Typical prescribed interval is Q 4-6 hours

AHCPR recommends dosing interval of 3-4 hours

Short acting pure opioidsoral dosing

Short acting pure opioidsoral dosing

Routine (not prn) schedule important for continuous pain relief

PRN dose should be 10-15% of total daily dose

Every 1 hour administration of single agent is safe if pain not controlled

Routine (not prn) schedule important for continuous pain relief

PRN dose should be 10-15% of total daily dose

Every 1 hour administration of single agent is safe if pain not controlled

Example 1prn dosingExample 1prn dosing

Oxycodone 30 mg q 4 hours

180 mg daily dose

10-15 % = 18-24 mg

Oxycodone 15-30 mg Q 3 hour prn

May give 30 mg in 1 hour if needed


180 mg daily dose

10-15 % = 18-24 mg

Oxycodone 15-30 mg Q 3 hour prn

May give 30 mg in 1 hour if needed

Example 2Pseudo-prn dosing

Example 2Pseudo-prn dosing

Oxycodone 30 mg q 4 hour

Oxycodone 30 mg q 4 hours prn

Patient uses all prn doses consistently

Total daily dose 360 mg

New schedule:


Oxycodone 30-60 mg q 4 hour prn

Oxycodone 30 mg q 4 hour

Oxycodone 30 mg q 4 hours prn

Patient uses all prn doses consistently

Total daily dose 360 mg

New schedule:


Oxycodone 30-60 mg q 4 hour prn

Long acting oral agentsLong acting oral agents

Morphine

Morphine ER

Kadian, Avinza

Oxycontin

Hydromorphone (Exalgo)

Oxymorphone (Opana/ER)

Methadone

Should be prescribed along with short acting agent for breakthrough pain

Morphine

Morphine ER

Kadian, Avinza

Oxycontin

Hydromorphone (Exalgo)

Oxymorphone (Opana/ER)

Methadone

Should be prescribed along with short acting agent for breakthrough pain

~$40/mo~$40/mo~$680-770/mo~$680-770/mo

~$600/mo~$600/mo

~$3200/mo~$3200/mo

~$550/mo~$550/mo

Cost relative to MS 200 mg/day Cost relative to MS 200 mg/day

~$20/mo~$20/mo

EquianalgesicDosing

EquianalgesicDosing

Fred is a 58 y.o. man with pancreatic cancer diagnosed 9 months ago.

Opioid regimen:

Norco 10/325, 4-8 tabs per day

Oxycodone extended release120 mg twice daily

4 mg dilaudid 1-2 tabs per hour for “breakthrough pain”

How do you convert him to a parenteral hydromorphone infusion?

Fred is a 58 y.o. man with pancreatic cancer diagnosed 9 months ago.

Opioid regimen:

Norco 10/325, 4-8 tabs per day

Oxycodone extended release120 mg twice daily

4 mg dilaudid 1-2 tabs per hour for “breakthrough pain”

How do you convert him to a parenteral hydromorphone infusion?

EquianalgesicDosing

EquianalgesicDosing

Equianalgesic dosingEquianalgesic dosing

Step 1: Calculate total daily oral morphine equivalent (OME) for each medication using equianalgesic ratios.

Step 1: Calculate total daily oral morphine equivalent (OME) for each medication using equianalgesic ratios.

Calculate OME of each medication


Oxycodone ER 240 mg/day

Oxy: MS ratio = 2:3

OME is 360 mg

Oxycodone ER 240 mg/day

Oxy: MS ratio = 2:3

OME is 360 mg



Hydrocodone 10 mg, 2 tabs QID = 80 mg

Hydrocodone: MS ratio = 1:1

OME = 80 mg

Hydrocodone 10 mg, 2 tabs QID = 80 mg

Hydrocodone: MS ratio = 1:1

OME = 80 mg



Hydromorphone 4 mg ~ 20 tabs per day

Hydromorphone 80 mg/day

Hydromorphone: MS ratio = 1:4

OME is 320 mg

Hydromorphone 4 mg ~ 20 tabs per day

Hydromorphone 80 mg/day

Hydromorphone: MS ratio = 1:4

OME is 320 mg

Calculate total daily OME

Calculate total daily OME

Oxycodone 360 mg

Hydrocodone 80 mg

Hydromorphone 320 mg

Total OME 760 mg

Oxycodone 360 mg

Hydrocodone 80 mg

Hydromorphone 320 mg

Total OME 760 mg


Equianalgesic tables and calculators vary

Individual variation and incomplete cross tolerance between opioids exists

Tables and calculators are only guidelines

30-50% decrease in calculated dose is prudent

Equianalgesic tables and calculators vary

Individual variation and incomplete cross tolerance between opioids exists

Tables and calculators are only guidelines

30-50% decrease in calculated dose is prudent


Step 2: Reduce calculated dose by 1/3 to 1/2 based on patient variability

760 mg x 2/3 ≈ 500 mg po morphine

Step 2: Reduce calculated dose by 1/3 to 1/2 based on patient variability

760 mg x 2/3 ≈ 500 mg po morphine

500 mg po morphine * 1/3 ≈ 167 mg iv morphine

167 mg iv morphine per day/24 hours ≈ 7 mg iv morphine/hour

Step 3: Convert to equivalent parenteral morphine dose

7 mg iv morphine/hour*1.5/10 ≈ 1 mg iv hydromorphone/hour

Step 4: Calculate equianalgesic dose of i.v. hydromorphone

Or use a calculatorOr use a calculator

You order dilaudid 1 mg iv per hour continuous

2 hours later the nurse calls to tell you is pain is no better.

What happened?

What do you do?

You order dilaudid 1 mg iv per hour continuous

2 hours later the nurse calls to tell you is pain is no better.

What happened?

What do you do?

Time to steady state takes 3-5 half livesor 12-20 hours for most opioid infusions

Step 5: Add loading dose equal to 1-2 times the hourly dose

Opioid infusionsPRN dosing

Opioid infusionsPRN dosing

Fred is given 2 mg iv hydromorphone followed by 1 mg/hour continuous infusion

What is the appropriate PRN dose?

PRN should be 50-150% hourly rate

1 mg hydromorphone PRN

How often?

PRN dosing interval is based on time to Cmax

Fred is given 2 mg iv hydromorphone followed by 1 mg/hour continuous infusion

What is the appropriate PRN dose?

PRN should be 50-150% hourly rate

1 mg hydromorphone PRN

How often?

PRN dosing interval is based on time to Cmax

Step two: Moderate pain Tramadol Opioid combinations Acetaminophen or aspirin with Codeine...

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