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Opioid Selection for Acute and Chronic Pain Control J K Lilly MD MS Appalachian Pain Therapy Institute Charleston, WV 1 Objectives Identify the difference between acute and chronic pain treatment in opioid- naive verses opioid-tolerant patients. Identify medications appropriate for treatment of each type of pain. Know the Equianalgesic Doses of IV Morphine, Dilaudid and Fentanyl & convert to oral doses (enterohepatic=1.3). Know about Iatrogenic Abstinence Syndrome Realistically apply the Visual Analog Pain Score to evaluating response to opioids. Differentiate Addiction Disorder from Chronic Pain and Chronic Pain Behavior 2 Equianalgesic Dosing Pure Opioids Drug PO Dose IM Dose & 1/2 life Morphine 1 30-60 10 (=) Hydrocodone 1 30-60 n/a (=) 1.3 15-30 20 (=) 20 acute (1.3) 2-4 chronic (8-12) 10 (++) 400 mcg 0.1 (+) 2-4 2-4 (+) 4-8 1.5 (=) Oxycodone Methadone Fentanyl Levorphanol Hydromorphone “Dilaudid” 100 15 5 3 Equianalgesic Dosing Weak Opioids and Mixed Agonists Drug PO IM & ½ Life Meperidine Codiene 0.1 0.5 300 60-120 100-200 (=) 130-160 (=) Propoxyphene 0.15 450 n/a (+) Buprenorphine Nalbuphine Butorphanol Pentazocine 10 1 ~25 0.15 n/a (30) n/a n/a 325 .32-.96 (+) 10 (=) 5 (=) 30-60 (=/+) 4 Equianalgesic Dosing Consider the example of switching from Methadone 10 tid to Oxycodone-SR First, determine the Morphine equivalent dose to current drug, Then, estimate dose of new drug from the Morphine equianalgesic dose i.e. Methadone → Morphine → Oxycodone 30 mg/d x 8 = 240 mg/d x .66= 160mg/day 5 Equianalgesic Dosing Convert from Fentanyl 50 mcg/hr patch plus Percocet 10/650 up to tid for recurrent pain plus IV Demerol 25 mg up to once per shift for “bad” pain to IV Morphine infusion dose (real example) Fent 50 x24hr=1200 mcg/day x100= 120mg MS; Oxycod 30 x1.3= ~ 40mg MS; Demerol 75 = 75x.1= ~8-10mg MS => 120+~40+~10= ~180mg MS equivalent dose/day or IV-infusion hourly dose of 6.6 mg/hr 6 Acute Pain Control Plan Acute Pain: physical discomfort, short duration (hours to weeks), usually severe, usually associated with disease, birthing process or injury Opioid-Naïve (narcotic celibacy) Opioid-Tolerant (taking the equivalent of >25 mg/ day of Oxycodone or equivalent dose of any sustained release opioid preparation) Visual Analog Pain Score (0-10) only advisory! 7 Chronic Pain Control Plan Pain lasting longer than six months Persists disproportionately beyond the initial cause May not respond in the same way as acute pain to techniques and medications Cause may not be resolvable! May require combined treatment modalities Long Term Opioid Therapy (LTOT) may be the final therapeutic (last/ best) alternative Chronic Pain Syndrome and its attendant behavior ARE NOT equivalent to Addiction Disorder 8 Opioid -Naive With PCA (preferred) Continuous (controversial)- MS 2mg/hr or second line drug in equianalgesic dose (0.2 mg/ hr HM, 20 mcg/ hr Fentanyl) Demand Bolus - MS 1 mg or equianalgesic dose Lockout – 10-15 minutes Rescue – RN administered intermittent rescue ~ twice the dose of PCA bolus q 1 hr prn until reviewed Review & adjust orders q 12 hrs Continuous Oximetry 9 Opioid -Naive Without PCA (but IV) First Line: Morphine 2mg IV q 5 min prn ‘til comfortable or AE Second Line: Hydromorphone 0.2 mg IV q 5 min prn or Fentanyl 20 mcg IV q 5 min prn, (1st if creatanine >2.5) Meperidine not recommended!! Review orders q 12 hrs Continuous Oximetry Convert to Oral ASAP Avoid 3rd & 4th Line Agents 10 Opioid Tolerant (taking opioid equivalent to >25 mg Oxycodone/ 24 hrs ) With PCA (preferred) Continuous Infusion = PCA Background – baseline 24 hr opioid dose X .3 per day, (ie. MS Contin 60mg q12h = 120 x .3 = 40mg/24hrs, or 2.5mg/ hr infusion – round-up to 3mg/ hr) PCA Demand- 50-100% of hourly rate, Lockout – q10-15 min Review adjust at least q 12h, titrate systematically Continuous Oximetry 11 Opioid Tolerant (taking opioid equivalent to >25 mg Oxycodone/ 24 hrs ) Without PCA 10-20% of 24 hr dose q 1-3 hrs prn “basal dose” RN administered IV “Rescue Doses” @ 2x the “basal dose” Continuous Oximetry Adjust doses q 12h 12 Pain Taxonomy Acute Pain- tissue injury, distention or inflammation Episodic Pain- related to activity recurrent, breakthrough, incident Chronic Pain- constant and unremitting waxes & wanes but seldom subsides 13 Episodic Pain Short acting opioids indicated Oral route preferred Usually treated Schedule III (+APAP or IB) Exertion/ Activity related 14 Constant Pain Sustained Response (SR) oral agents indicated Consider Immediate Response (IR) agents for rescue doses – start at ~10% of 24 hr dose of long acting agent q4-8 hrs prn SR formulations are designed for q 12 hr dosing but mean effective dose may be shorter duration (q 8-10 hr) Use coanalagesics and anticipate adverse effects Addiction risk is 3% or less (large studies) 15 Analgesic Selection Mu (m) Opioid Receptor Agonists – most familiar to clinicians as to effects and sideeffects; best for initiating opioid therapy for moderate to severe pain (VAPS 5-10/10). Morphine, Hydromorphone, Oxycodone, Hydrocodone, Fentanyl, Codeine, Hydrocodeine, Levorphanol, Methadone, Meperidine. . 16 Analgesic Selection Agonist/ Antagonists & Partial Agonists – Primarily activate the Kappa (k) receptor and antagonize or partially occupy the Mu receptor (m antagonists), analgesic ceiling effect, risk iatrogenic abstinence syndrome when given with m agonist tolerant patients, watch out in ER! no proven advantage in avoiding abuse. Pentazocine, Butorphanol, Nalbuphine and the “partial agonists” Buprenorphine and Dezocine (VAPS 4-7/10) 17 3rd & 4th Line Analgesic Agents Limited Proven Analgesic Efficacy Adverse Effects Drug-to-Drug Interaction Toxic Metabolites Organ-limited Elimination 18 3rd & 4th Line Analgesic Agents Propoxyphene equianalgesic to Extra Strength Tylenol in blind studies (VAPS 1-3/10 = mild) norpropoxyphene-cardio & neurotoxic Tramadol weak m agonist but primarily active on spinal adrenergic receptors similar to tricyclics (VAPS 4-5/10 = moderate) Meperidine short acting (450-90 mins), metabolites accumulate within 48 hrs, side-effects common normeperidine- cardio & neurotoxic Codiene effective pain relief but many side-effects at analgesic doses Hydrocodiene isn’t routinely monitored on UDS NSAIDs, APAP and AEDs, TCAD are “co-analgesics” 19 Dosing for Relief Around-The-Clock (ATC) dosing is associated with more consistent relief PRN-dosing is associated with more unpredictability and side-effects Optimal analgesic dosing varies widely among patients; review regularly; titrate systematically Anticipate side effects; most subside with time For some, NO dose of opioid will sufficiently relieve ALL of their pain...aim for TOLERABLE pain levels (VPA3-4/10), improved functionality and controlled side effect Transition quickly from IV to PO (enterohepatic) 20 Opioids and Addiction Physical Dependence Physiologic occurrence usually within 3 days of initiating therapy; Pharmacological property characterized by withdrawal syndrome after abrupt discontinuation; Abstinence symptoms usually lacking or attenuated with “wean to discontinue” orders NOT synonymous with tolerance or addiction! 21 Opioids and Addiction Tolerance Spectrum of acquired physiologic responses to therapy Pharmacological property of the class drug; With chronic use, larger dose may be needed for same effect Countered with drug rotations, furloughs, tolerance inhibitors, prescriptive boundaries NOT synonymous with physical dependence or addiction! 22 Opioids and Addiction Pseudo-addiction Usually attributable to provider practice pattern, ergo iatrogenic Unrealistic expectation by prescriber Misconceived safety concern by providers Patient motivation: ”relief, not rush” NOT synonymous with physical dependence, tolerance or addiction! 23 Opioids and Addiction Addiction Psychological and physiologic state (<3 & >0.3% of chronic pain suffers) characterized by obsessive pursuit of access to medication- regardless of consequences, for psychological effects Not a pharmacological property of a given drug NOT synonymous with tolerance or physical dependence! 24 Plan if Addiction is Recognized -Be Humane - Intervene and Wean to withdrawal -Evaluation, treatment and extended recovery care by addiction professionals is optimal -Know community and regional resources for treatment & extended recovery care when initiating LTOT -Prescribing opioids to treat addiction (Methadone Clinics) is advisable only for specially certified addiction medicine and psychiatry physicians -Buprenorphine Addiction Treatment (Subtex) requires additional training and additional DEA certification…too new to assess. 25 Opioid Therapy Current Clinical Guidelines Pain relief is defined as a primary care (PCP) function Remain reasonable, rational, responsible and available Examine thoroughly and review regularly Utilize LTOT Informed Consent to Treat and Opiate Access Agreement Document & define providers & pharmacy Require patient to notify all providers of Opiate Access Agreement participation Monitor compliance (pill counts, UDS, etc.) and response to therapy (functional assessments, charts, diaries, surveys, etc.), Review OAA violation consequences regularly Match the tool to the problem-SR opioid for continual pain, IR for recurrent pain; pick analgesics sensibly 26 Opioid Therapy Current Clinical Guidelines (cont.) Consult and co-manage appropriately, require formal behavioral assessment periodically Stipulate that verified non-clinical information may be considered when deciding whether to continue LTOT Beware of 90 day prescription “Prescription Drug Benefit Requirements” -cost saving scheme that may be technically illegal for opioids; i.e.. unmonitored and unlicensed warehousing of Class II & III medications in homes not supported by law or regulation Recognize that LTOT may be the therapy of last resort 27 Opioid Options on the Near Horizon Lipid-Based Sustained Release Opioid & Local Anesthetic Vehicles Vanilloid and Cannabinoid Receptor Agonists New Spinally-infused Drugs Abuse-resistant Opioid Preparations Co-analgesic Use of Anti-seizure Drugs Deep-Brain and Motor Cortex Stimulation 28 Thanks! I Enjoyed your attention! 29 Opioid Selection for Acute and Chronic Pain Control Thanks for you’re your questions!! It’s time to head home. 30