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Transcript
Safe Opioid Prescribing
The National Patient Safety Agency (NPSA) has recommended that the guidance below should be applied when the following opioid medicines are prescribed:
buprenorphine, diamorphine, fentanyl, meptazinol, methadone, morphine and pethidine (these are all in the L&D Formulary).
(The NPSA guidance also applies to the following non-formulary opioid medicines: dipipanone, hydromorphone, oxycodone and papaveretum).
In anything other than acute emergencies, the healthcare practitioner concerned or their clinical supervisor should:
Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient
This can be done through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records
Ensure where a dose increase is intended, that the calculated dose is safe for the patient
(E.g. for oral morphine in adult patients – not normally more than 50% higher than the previous dose)
Ensure patients are familiar with the following characteristics and formulations of their medicines:
usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects
While dose increments should be in line with this guidance, it is recognised that in palliative care higher than normal doses may be required. In these cases, please contact:
Mon to Fri, 8am to 4pm, extn 7522 or bleep 269 / 492. Out-of-hours: 0808 1807788
The Pain Team will also, on occasion, manage a patient outside of these parameters. Their recommendations will be documented in the medical notes for the specific
individual.
To contact the Pain Team for advice or involvement – bleep 288
Analgesic Ladder
Please prescribe by pain score and not by weight
Regular paracetamol +
Regular strong opioid:
Tramadol 100mg qds or
Morphine Sulphate tablets MR (MST) *
Plus PRN: Oramorph 10mg / 5ml
Plus or minus: adjuvants
Regular paracetamol +
Regular weak opioid:
Codeine phosphate 60mg qds or
Meptazinol 200mg qds or
Tramadol 50mg qds
Plus PRN: Oramorph 10mg / 5ml
Plus or minus: adjuvants
Regular non opioid: such
as paracetamol
Plus or minus: adjuvants
Approximate single dose equivalence of oral opioid analgesics
These equivalences are intended only as an approximate guide: patients should be
carefully monitored after any change in medication and dose titration may be required
Step 3
Pain scores 7-10
Step 2
Pain scores 4-6
Step 1
Pain scores 1-3
* Use morphine first line. If not tolerated – oxycodone can be used second line
Adjuvants
NSAIDs
- add these if not contra-indicated (i.e. in patients with
duodenal ulcers, renal failure, aspirin sensitive asthmatics).
Laxatives
- prescribe regularly with all opioids (not with anastomosis
patients): senna is the drug of choice – 2 tablets at night.
Anti-emetic
- cyclizine 50mg 8 hourly prn is first line; ondansetron 4 to 8mg
8 hourly prn is second line.
(prescribe regularly if ongoing problem)
Anticonvulsant
Oral
Dose
approx
equivalent
to 10mg
morphine
Dose and
maximum 24hr
dose
Formulation
Opioid
analgesic
Codeine phosphate
100mg
30 to 60mg 4 hourly
Max 240mg
Tablets (30mg)
Linctus (15mg in 5ml)
Tramadol
50mg
50 to 100mg 4 hourly
Capsules (50mg)
Morphine sulphate
modified release
(MR) tablets (eg.
MST®)
10mg
Always 12 hourly
regularly
No maximum dose
Tablets (5mg, 10mg, 15mg,
30mg, 60mg and 100mg)
Morphine sulphate
immediate release
solution / tablets
(eg. Oramorph®
solution
or Sevredol®
tablets)
10mg
Usually PRN –
calculated to the nearest
one 6th of total MST per
day given
2 to 4 hourly
No maximum dose
Solution (10mg in 5ml)
Concentrated solution
(100mg in 5ml)
Tablets (10mg and 20mg)
Oxycodone
modified release
(MR) tablets
(eg. Oxycontin®
tablets)
5mg
Always 12 hourly
regularly
No maximum dose
Tablets (5mg, 10mg, 20mg,
40mg, 80mg)
Oxycodone
immediate release
capsules / liquid
(eg. Oxynorm®
capsules or liquid)
5mg
Usually PRN –
calculated to the nearest
one 6th of total
Oxycontin per day
No maximum dose
Capsules (5mg, 10mg, 20mg)
Liquid (5mg in 5ml)
Buprenorphine
100mcg
200 to 400mcg 6-8
hourly
Max 1600mcg daily
Sublingual tablets (200mcg
and 400mcg)
25mcg / hr
= 90mg
morphine
daily
Replace every 72 hours
Self adhesive patches
(12mcg, 25mcg, 50mcg,
75mcg and 100mcg / hour for
72 hours)
Topical
Fentanyl
transdermal patch
(Durogesic®)
- for neuropathic pain (described as ‘shooting’, ‘pins and
needles’). Gabapentin is first line, pregabalin is second line.
Antidepressant - for neuropathic pain. (eg. amitriptyline 10mg at night)
NB. Please use the oral route whenever possible
Need help prescribing a Controlled Drug on a TTA?
Dose
Frequency
Morphine Sulphate MR 10mg tablets
Medicines
10mg
BD
Oral
Supply 28 tablets
(Twenty eight tablets)
Morphine Sulphate Solution
10mg / 5ml
10mg
2 to 4 hourly PRN
Oral
Supply 100ml
(One Hundred millilitres)
Topical
Supply 4 (four) patches
Fentanyl patch 25micrograms / hour
1 patch
 Information needed on the prescription:
72 hourly
Route
Quantity
Medicine name
Strength
Form (e.g. tablet / SR tablet / capsule / patch / solution)
Dose
Total quantity (in words and figures)
 If still unsure - please contact Ward Pharmacist or Technician BEFORE sending the TTA letter to the dispensary (otherwise the discharge process will be DELAYED)
For further information on pain management, look on the Intranet:
Documents – Local Clinical Guidance – Pain Management
Prepared by: Lynn Grigg (Senior Nurse Specialist for Pain Management), Julie Phillips, Karen Scott and Bernadette Fultang (Pharmacy) March 2009 (To be reviewed – March 2011)