Lecture 3-4 Flashcards
Opioid Management
Name natural opioids ?
Morphine
Codeine
Name semi-synthetic opioids?
hydromorphone, oxycodone, hydrocodone ( heroin)
Name synthetic opioids .
fentanyl, methadone, buprenorphine, meperidine,
tramadol, pentazocine, diphenoxylate, loperamide
Are all opioids analgesics ?
Not all are analgesics
Can be agonist or antagonist
What is the MOA of opioids Analgesics ?
Agonist or partial agonist to mu, delta and kappa receptors in the whole PNS/CNS
Which receptors PURE agonist like to bind ?
mu
What is the INITIAL ADULT DOSE for morphine ?
5-20 mg
What is the INITIAL ADULT DOSE for oxycodone ?
5-15mg
What is the INITIAL ADULT DOSE for hydromorphone ?
1-4 mg
What are the tools for opioid risk assessment ?
CAGE and opiod risk tools
What is ATC or basal dose ?
regular schedule IR / CR / SR opioids
** depends on the nature of the pain
What are the steps for titration of opioid ?
Repeat pain assessment
Total 24hrs dose → new TTD
Divide the new TDD in regular dose + BTB dose ( 10-15% of ATC)
What is the RECOMMENDED dose of morphine equivalent for long term noncancer chronic patients ?
< 90 mg
What are the different examples of ADR of opioids ?
N/V, constipation, tolerance, overdose, sedation, respiratory depression, hyperalgesia → leading to neurotoxicity
What is the solution to respiratory depression ?
Naloxone
What are the solutions for N/V from opioid ?
Dose reduction
Rotation
Dopamine antagonist
Anticholinergics
Ondansetron
Which of the ADR is NOT tolerance developed ?
Constipation
neuroendocrine effects
sleep disturbance
If you are “allergic” to an opioid , can you switch to another ?
YES, unlikely to have cross-sensitivity
but is allergies to the PURE opioids, careful to switch
Why would want to add a NMDA antagonist ?
Opioid Induced hyperalgesia
what are the various solutions to opioid induced hyperplasia ?
Increase/ Decrease the dose
Rotation → fentanyl, buprenorphine, methadone
Add NMDA antagonist, antidepressant, anticonvulsants and NSAIDs
Non-pharm
What are the steps of opioid rotation ?
Assessment
Opioid total daily dose TDD
Morphine Equi Daily Dose (MEDD)
Convert to new agent
Reduce for incomplete cross-tolerance
>= 90 MEDD = ⬇50%
<90 MEDD = ⬇25-40%
Choose the appropriate regimen
What are the dose equivalence with the common 3 opioids ?
Morphine - 30 mg
Oxycodone - 20 mg
Hydromorphone - 6 mg
When would you STOP opioid tx ?
Pain has resolved / risks > benefits / AD > benefits
/ opioid ineffective
How to discontinue opioid if a patient takes > 1 weeks ?
Include non-opiod
Takes 1-3 weeks
⬇TDD <=25% q2-3d
What are the withdrawal symptoms for opioid ?
drug craving anxiety, insomnia, abdominal pain, vomiting, diarrhea, tremors
What is a rapid taper ?
High ADR risk
⬇ dose 10-20% q1-3 days (1-2wk)
What is a SLOW taper ?
⬇dose 5-10% q2-4wks ( 1-6 months)
Change formulation
Which opiods should i double check for DDI ? ( serotonogenic effect
methadone and tramadol
what are the PK for opiods ( DDI) ?
CYP 3A4 and 2D6