Download Narcotics

Pain Management &
Opioid Analgesics
Objectives
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Determine proper opioid dosing
Differentiate between specific opioid
analgesics and be able to convert between
agents
Discuss basal and bolus doses for PCA
Discuss adverse reactions of opioids
Review the Sole Provider program
Discuss how to properly write a prescription
for a controlled substance
2
Pain

Definition
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An unpleasant sensory & emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage
Types
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Nociceptive
Somatic – bone pain, skin, soft tissue trauma
 Visceral – ab pain due to tumor invasion
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Neuropathic – post herpetic neuralgia, postmastectomy, phantom limb
3
Choosing Analgesic Therapy

What type of pain?
Nociceptive vs. neuropathic
 Acute vs. chronic
 Mild vs. severe
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What route should be used?
What agent should be used?
Type, severity of pain
 Pt characteristics – side effects, elderly, allergy,
co-morbid conditions, tolerance, previous
narcotics used
 Insurance, cost
4

WHO Ladder of Analgesics
www.anzsgm.org/vgmtp/Pain/analgesia_ladder.htm
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Non-opioid analgesics
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Aspirin
NSAIDs
Acetaminophen
Adjuvants
Antidepressants – amitriptyline, duloxetine
 Anticonvulsants – carbamazepine,
gabapentin, pregabalin
 Anesthetics – lidocaine patch (12 hours on,
12 hours off)
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Potency of Opioids
Weak Agonists
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Propoxyphene
(Darvon, Darvocet)
Codeine
Hydrocodone/APAP
(Vicodin, Lortab,
Lorcet, Norco)
Tramadol
Strong Agonists
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Morphine
Oxycodone
Hydromorphone
(Dilaudid)
Fentanyl (Duragesic,
Sublimaze)
Methadone
(Dolophine)
Meperidine (Demerol)
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Tramadol
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Synthetic analog of codeine but is NOT controlled
Weak agonist/low affinity at mu receptor and also weak
SNRI (which inhibits pain transmission in the spinal
cord)
 Use with caution in pt on TCAs, MAOIs, SSRIs as it
may lower seizure threshold
Max dose is 400 mg/day but 300 mg/day if >75yo; renal
dosing if CrCl<30
Tramadol is 5-10 times less potent than morphine and
reported to cause less respiratory depression
Approximately 50 mg tramadol = 60 mg codeine
8
Considerations in choosing
opioids

Renal impairment
Preferred oral agent: hydromorphone
 Use with caution: morphine, codeine
 Avoid meperidine
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Metabolites can accumulate and cause seizures
Other cautions with meperidine
Avoid in pts with CHF, hepatic insufficiency,
elderly
 Avoid use in pts on MAOIs (phenelzine,
selegeline, linezolid) in past 14 days
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9
Opioid
Fentanyl
Half-life
IV: 2 – 4h
Patch: 17h
Hydromorphone 2 – 3h
(Dilaudid)
Onset
Duration of
analgesic effect
IV: within minutes
Patch: 12-24h
IV: 0.5 – 1h
Patch: 72h
IV: 5 - 15 min
PO: 30 min
3 – 5h
Methadone**
8 – 59h
30 – 60 min
4 – 8h
Morphine
2 – 4h
IV:5 - 10 min
PO (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 – 6h
SR: 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 IV
1 – 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 IV
5 – 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
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dosing
Opioid
Available Doses
Fentanyl
IV: 25, 50, 100 mcg/ml
Patch: 25, 50, 75, 100 mcg
Hydromorphone (Dilaudid)
IV: 2 mg/ml; PCA: 1mg/ml & 0.2 mg/ml
PO: 2 mg
Methadone
PO: 5, 10 mg
Morphine
IV: 4 mg/ml; PCA: 1 mg/ml & 5 mg/ml
PO: IR 15, 30 mg
PO: ER (MS Contin): 15, 30, 60, 100 mg
Solution (Roxanol): 20 & 2 mg/ml
Meperidine (Demerol)
IV: 25, 50, 100 mg/ml
Codeine
PO: 30 mg
Oxycodone
PO: IR 5mg
PO: ER (OxyContin): 10, 20, 40, 80 mg
Solution (Roxicodone): 20 & 1 mg/ml
Oxycodone/APAP (Percocet)
PO: 5mg oxycodone/325 mg APAP
Hydrocodone/APAP (Norco)
PO: 5mg hydrocodone/325 mg APAP
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PCA Dosing
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Dosing considerations
 For opioid-naïve patients, use lower end of range
 Pain Assessment
 Respiratory Assessment
 Sedation Assessment
Drug
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 or
1 – 2 mg/hr
Hydromorphone (Dilaudid)
(0.1 mg/ml and 1 mg/ml)
0.2 mg
0.05-0.4 mg
5 - 15
None or
0.1 – 0.4 mg/hr
(standard concentrations)
When initiating PCA for first time (no conversion from outpatient med), the
initial demand dose is 50% of the basal rate
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PCA dosing

62 yo patient s/p TAH has been moved to
PACU. You have been asked to start the
patient on a PCA. Which of the following is an
appropriate initial order:
Morphine PCA 1 mg/ml: LD 2 mg, 1 mg demand
dose, lock out 10 min, no basal
 Dilaudid PCA 1mg/ml: LD 2 mg, 1 mg demand
dose, lock out 10 min, no basal
 Fentanyl patch 25 mcg q72 hours
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Decreasing IV potency as you go down the table
Conversions*
Opioid
Parenteral
Oral
Fentanyl
0.1 mg
NA
Hydromorphone
(Dilaudid)
1.5 mg
7.5 mg
5 - 10 mg
2 - 20 mg***
10 mg
30 mg
75 -100 mg
300 mg
120 mg
200 mg
Oxycodone
NA
20 mg
Hydrocodone
NA
30 mg
Methadone**
Morphine
Meperidine (Demerol)
Codeine
*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
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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
Fentanyl patch
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NOT for acute pain or post-op pain
Absorbed through the skin, producing a drug
depot in the upper skin layers, then diffusing
into systemic circulation
Can have variable responses between
patients (i.e. cachetic, elderly)
Watch for drugs that inhibit its metabolism

Ketoconazole, erythromycin, diltiazem, grapefruit
juice
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Morphine:methadone
conversion
Oral morphineequivalent daily dose
(mg/day)
Initial Dose Ratio
(oral morphine:oral
methadone)
<30
2:1
30 – 99
4:1
100 – 299
300 – 499
8:1
12:1
500 – 999
15:1
>1000
20:1 or greater
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Breakthrough Dosing
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Use immediate-release opioids
Chronic oral meds
Give 10 – 20% of the total daily dose q4hprn
 Example – MS Contin 60 mg PO q12h – should
give 10 – 20 mg q4h prn of morphine immediate
release
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IV dosing (PCA dosing)
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10% of the 24 hr requirement, then:
Divide by 4 if giving every 15 minutes
 Ex: 100 mg morphine daily  2.5 mg IV q15 min
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Dose Adjustment
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Increasing the opioid dosage
For moderate to severe pain, increase by
50 – 100%
 For mild to moderate pain, increase by
25 – 50%
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Convert to oral as early as possible:
Pain is controlled
 GI function intact
 IV to oral dosage calculation
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Calculate total daily IV use
 Calculate breakthrough dose
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10-20% of total daily dose of regularly scheduled opioid
every 4 h as needed
20
Conversion problem
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Pt is taking Percocet 5/325 two tabs q6h
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What dose of oxycodone ER (OxyContin)
would you start the patient?
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What dose of morphine ER (MS Contin)?
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What dose of fentanyl patch?
21
Conversion problem
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8 tabs Percocet = 40 mg oxycodone per day
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Oxycodone ER (OxyContin) = 20mg q12h
22
Conversion Problem
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MS Contin conversion
40 mg po oxycodone =
20 mg po oxycodone
x
30 mg po morphine
 X = 60 mg po morphine daily = MS Contin 30 mg
q12h
 If you want to decrease dose to allow for decreased
cross-tolerance, decrease dose by 1/2 to 1/3 = 30 to
40 mg morphine daily = MS Contin 15 mg q12h
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Fentanyl patch
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30 – 60 mg po morphine daily = 25 mcg
fentanyl patch
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Conversion problem
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In the previous problem, your patient was
stable on MS Contin 30 mg q12h
Your attending wants to change over to the
fentanyl patch
How do you time the transition from MS
Contin to the patch?
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Conversion problem
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In the previous problem, your patient was
stable on MS Contin 30 mg q12h
Your attending wants to change over to the
fentanyl patch
How do you time the transition from MS
Contin to the patch?
It takes about 12 hrs for onset of fentanyl patch
 Give patient one last dose of MS Contin at the
same time the patch is applied
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Example of conversion from
oral med to PCA
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Pt taking OxyIR 20 mg PO q4h
Pt’s pain is well-controlled
Want to convert to hydromorphone PCA
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What would be a basal dose (in mg/hr)?
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What would be the bolus/demand dose?
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Example of conversion of
oral med to PCA
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Pt taking OxyIR 20 mg q4h
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Convert total oral daily dose (120 mg oxycodone)
to oral hydromorphone
120 mg po oxycodone = 20 mg po oxycodone
x
7.5 mg po hydromorphone
 X = 45 mg po hydromorphone
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Convert to IV
45 mg po hydromorphone =
7.5 mg po
x
1.5 mg IV
 x = 9 mg IV hydromorphone daily
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Example of conversion to
PCA
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Basal rate
9 mg daily total = 0.4 mg per hour
 May want to decrease basal by 1/2 to 1/3 to
account for incomplete cross tolerance
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Bolus/demand dose is usually 10% of the
daily dose divided by 4
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Basal dose of 0.2 to 0.3 mg per hour
(0.10 x 9 mg) / 4 = 0.2 mg q 15 minutes
Titrate based on use & pt’s response
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Example of PCA conversion
to oral med
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Pt on post-op morphine PCA with basal of
1 mg/hr and bolus of 1 mg q15 minutes
Pt used 40 bolus injections in 24 hours
What dose of oral morphine (basal &
breakthrough) should be used?
What dose of oral oxycodone (basal &
breakthrough) should be used?
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Example of PCA conversion
to oral med
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Total daily use of IV morphine
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1 mg/h x 24 h + 40 bolus = 64 mg/24 hour
Convert to oral morphine
64 mg IV morphine =
1 mg IV morphine
x
3 mg po morphine
 X = 192 mg po morphine
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MS Contin 100 mg q12h (basal)
 Morphine IR 30 mg q4h prn for breakthrough
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10 – 20% of daily dose q4h (10 – 20% of 200 mg is 20
to 40 mg)
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Example of PCA conversion
to oral med
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Converting to po oxycodone
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192 mg po morphine =
x
X = 128 mg po oxycodone
30 mg po morphine
20 mg po oxycodone
Decrease daily dose by 1/2 or 1/3 to allow for incomplete
cross tolerance
 Total daily dose of oxycodone = 64 to 85 mg
OxyContin dose (basal): 60 mg q12h or can use
30 to 40 mg q12h if want to account for
incomplete cross tolerance
Oxycodone IR (breakthrough): 5-10 mg q4h prn
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Side Effects
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Constipation – worsens with dose increases
Sedation, fatigue – wears off within 1 week
Dizziness – wears off, may require slower
titration
Nausea – usually wears off; switching products
may help
Hallucinations – more common at higher doses
Itching - anti-histamine; rotate narcotics
Respiratory depression – rare side effect with
chronic dosing; more common with IV, epidural
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Respiratory Depression

0.2 – 2 mg naloxone IV, IM, SC
Repeat doses every 2 to 3 min prn
 Total dose up to 10 mg
 After reversal, may need to readminister dose
at a later interval (20 to 60 minutes)
depending on the type/duration of opioid
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Assessment Scales
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Respiratory
Should be counted for at
least 30 seconds
If RR <12/min, then count
for full minute
If RR <10/min, stop PCA
If RR <4/min, give
naloxone
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Sedation
1 = agitated, restless
2 = cooperative, oriented
3 = asleep, easily
arousable
4 = asleep, arouses to
voice
5 = no response to verbal
stimuli
6 = no response to pain
Stop PCA & give naloxone
for score 5 & 6
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Constipation
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Need a stool softener
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Docusate 100 mg: 1 to 2 caps po twice daily
Need a stimulant laxative
Senna: usual dose is 1 tab at bedtime or twice
daily but can titrate up to 4 tabs three times
daily prn
 Bisacodyl 5 mg: 1 to 2 tabs twice daily prn
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35
Constipation
Medication
www.toonpool.com
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
36
Opioid “Allergy”

“Pseudoallergy” caused by histamine
release – most commonly seen with
codeine, morphine, meperidine
Pt c/o flushing, itching, hives, sweating
 Mild hypotension
 Use H2RA
 Decrease dose
 Switch to a more potent opioid (i.e. fentanyl,
hydromorphone)
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37
Opioid “Allergy”

Pts with “true” allergy
Breathing, speaking, swallowing difficulties
 Swelling of face, lips, mouth, tongue, pharnyx, or
larynx
 Severe hypotension


Switch to a different class
Phenylpiperidines: meperidine, fentanyl
 Diphenylheptanes: methadone, propoxyphene
 Morphine group: morphine, codeine,
hydrocodone, oxycodone, hydromorphone,
nalbuphine, butorphanol
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Sole Provider Program

Purpose
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
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To monitor patients exhibiting signs of drug-seeking behavior,
insufficient analgesia, evidence of non-optimization in care
options, psychosocial issues, or other complex
pharmaceutical care issues
Narcotic prescriptions only
The primary care provider can be the Sole Provider
or choose to refer a patient to a Sole Provider
Opioid “contract” signed between patient and Sole
Provider physician
Pharmacy informed and note put in CHCS
Sole Provider committee will monitor for violations
39
Sole Provider Program
1. NNMC
Intranet
2. Site Map
3. Pharmacy
40
Sole Provider Program
41
Writing Prescriptions
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Link on Pharmacy Website
Write legibly
Write out your DEA number
Spell out the quantity to be dispensed
C-IIs are not refilled (new Rx required) &
require separate prescriptions
Use DoD Form 1289 for controlled
substances
42
DEA numbers
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


Retail and mail-order pharmacies are no
longer accepting the NNMC DEA number
Must apply for own practitioner DEA number
Active military physicians (MD, DO, DDS,
DMD, and DPM) are fee exempt and may be
licensed in any state to obtain a DEA
registration
DEA number is to be used solely for DoD
beneficiaries prescriptions and may not be
used for off-duty employment
43
DEA numbers

To apply for DEA number:
Contact the Credentialing Office to complete
the correct paperwork
 Contact person: Rebekah Byrd at 319-4157

44
Med Errors to Avoid

Roxanol v Roxicodone oral solutions
Roxanol (morphine) v Roxicodone (oxycodone)
 Correct strengths


PCA strength
Morphine: 1 mg/ml and 5 mg/ml
 Hydromorphone: 1 mg/ml and 0.2 mg/ml


Fentanyl patch

For inpatients, double check if patient has patch
on from home
45
References
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
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Pharmacotherapy: A Pathophysiologic
Approach. 6th edition: Chapter 58.
End of Life/Palliative Education Resource Center
Micromedex
Drug Facts and Comparisons
Equianalgesic Dosing of Opioids for Pain
Management. Pharmacist’s Letter 2004.
Opioid Intolerance Decision Algorithm.
Pharmacist’s Letter 2006.
Clinical Pharmacology
46
References



Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain,
American Pain Society, 5th Ed. 2003
Grammaitoni AR et al. Clinical Application
of Opioid Equianalgesic Data. Clin J Pain
2003; 19(5): 286-297.
McPherson M.L. Demystifying Opioid
Conversion Calculations: A Guide for
Effective Dosing. 2010.
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QUESTIONS?
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