Lecture 4.4 - Pain Management (Opioids)

Question 1

CDC Guidelines for Opioid Prescribing

Answer 1

suggest only 3-7 day supply in many cases

careful to not exceed >50mg/day MME for chronic pain

Give naloxone w/ opioids

Question 2

General Dosing guide opioids

Answer 2

Start minimal dose and alter based on pain response/ SE

Question 3

Avoid or careful dosing opioids in….

Answer 3

Renal, hepatic dysfunction
Elderly > 65
Pregnant
Meds w/ additive CNS adverse effects
Other disease ie Severe COPD, sleep apnea

Question 4

Oral Onset + Duration

Answer 4

Onset ~ 30-45min

Duration: IR = 4-6hrs, SR = 8-12hrs

Question 5

IR Oral Onset, Peak, Duration

Answer 5

30min
1-2hrs
4-5hrs

Question 6

SR oral Onset, Peak, Duration

Answer 6

30-45min
3.5hrs
8-12hrs

Question 7

Rectal Onset, Peak, Duration

Answer 7

30min
1-2hrs
4-5hrs

Question 8

SC Onset, Peak, Duration

Answer 8

10-30min
50-90min
4-5hrs

Question 9

IM Onset, Peak, Duration

Answer 9

10-30min
30-60min
4-5hrs

Question 10

IV bolus Onset, Peak, Duration

Answer 10

5min
20min
2-4hrs

Question 11

When are IR tabs used?

Answer 11

Used as needed

usually for short duration (post-surgical, post-trauma)

Used prn to control breakout pain

Dispense amount should be limited to duration expected to have pain severe enough to require opioids

Question 12

When not to use IR tabs?

Answer 12

do not use on scheduled basis for chronic pain

increased risk for abuse & pill burden

Question 13

ER preparations used for…

Answer 13

Severe chronic pain
Usually start on IR, then convert to ER
** Dosing is q12hrs **

Question 14

Usual Fentanyl Patch dosing?

Answer 14

Q 3 days

Question 15

Switching from IR to ER dosing

Answer 15

Use same med if possible

1. calc total daily dose in 24hrs for IR
2. divide total dose into appropriate intervals of ER (q12hrs)
3. monitor and reassess for effectiveness and tolerability

Question 16

Morphine IV to oral equivalent

Answer 16

10mg = 30mg

Question 17

Dilaudid IV to oral equivalent

Answer 17

1.5mg = 7.5mg

Question 18

Codeine IV to oral equivalent

Answer 18

130mg = 200mg

Question 19

Oxycodone IV to oral equivalent

Answer 19

NA = 20mg (so 20mg is equivalent to other opioids)

Question 20

Hydrocone IV to oral equivalent

Answer 20

NA = 30mg ( so 30mg is equivalent to other opioids)

Question 21

Switching 1 opioid to another

Answer 21

1. calculate 24hrs total
2. use analogies conversion table
3. reduce by 50% to help offset incomplete cross tolerance
4. divide daily dose based on duration of actions of drug/dosage form

Question 22

Opioid Patient counseling

Answer 22

1. follow instructions, don’t increase w/o calling Dr.
2. explain what “AS NEEDED” means
3. don’t drive
4. don’t use alc or take sedatives unless approved
5. Discuss switching from 1 to another
6. Potential SE
7. Dispose left overs

Question 23

Most common opioid SE

Answer 23

Constipation
Nausea/vomiting
Pruritis (itchy)
Sedation

Other:
Respiratory depression
Drug interactions
Accumulation
urinary retention

Question 24

Tolerance

Answer 24

larger doses needed for same effect

Question 25

Dependence

Answer 25

Withdrawal sx will happen if DC abruptly

Question 26

Addiction

Answer 26

behavioral pattern characterized as loss of control over drug use, compulsive drug use, and continued use of a drug despite harm

Question 27

Opioid OD treatment

Answer 27

naloxone

Question 28

Morphine info

Answer 28

gold standard, effective and 1st cjce for severe acute and chronic pain management

Question 29

Oxycodone info

Answer 29

similar to morphine, not more effective than others tho

high potential for abuse

Question 30

Hydromorphone info

Answer 30

more potent than morphine

similar to morphine, no advantage over morphine

Question 31

Codeine info

Answer 31

less potent than morphine
used in moderate pain
many pts have GI upset

Question 32

Codeine contraindications

Answer 32

due to pro drug, metabolized to morphine by CYP2D6

Kids < 12yrs old
Kids < 18 after tonsillectomy or adenoidectomy
Dont use in kids 12-18 who are obese or sleep apnea
Avoid in breastfeeding women

Question 33

Methadone info

Answer 33

used for opioid dependence

used as analgesic (chronic pain and 4th line Neuropathic pain)

Long Hal-life = why used in OUD

Question 34

Methadone risks

Answer 34

can increase QT interval

Has bunch of drug interactions

Question 35

Meperidine info

Answer 35

Short acting

usually used in anesthesia cocktails

Question 36

Fentanyl info

Answer 36

comes in IM, IV, Patch, and transmucosal

Patch used for ppl on chronic opioids

Question 37

Converting opioids to patch

Answer 37

add up opioids pt is taking

use conversion table

table only goes left to right, not reverse

most likely keep breakthrough dose just incase

Question 38

Tramadol info

Answer 38

effective for mild to moderate nociceptive pain
effective for treatment of neuropathic pain

SE: tend to be less than opioids
Efficacy similar to Tylenol #3

also CYP2D6 prodrug, same CI as codeine

Question 39

Tramadol risks

Answer 39

Serotonin syndrome risk

Lower seizure threshold, avoid in at risk patients (history of seizures, or on drugs that also lower threshold)

Question 40

Tramadol CI

Answer 40

Kids < 12yrs old
Kids < 18 after tonsillectomy or adenoidectomay
Kids 12-18 who have sleep apnea
Dont use in breastfeeding women