Lecture 77 - Non-Malignant Pain Part 3 Flashcards

1
Q

Opioids

A

Uses: Acute and chronic pain
Side effects: Antitussive; Constipation; Nausea & vomiting; Itching; Orthostatic Hypotension; Urinary Retention; Sedation; Respiratory depression
Clinical pearls: Consider starting stool softener and/or stimulant laxative; Potential for tolerance, dependence and addiction; Schedule II controlled substances - Exceptions: tramadol, codeine

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2
Q

Opioids: Codeine (Tylenol #3)

A

Available formulations: Tablet; Cough syrup Clinical pearls: Schedule V, III or II controlled substance, depending on strength; Metabolized to morphine via CYP 2D6 - Poor metabolizers will get no effect from codeine, Ultra-rapid metabolizers can experience overdose resulting in respiratory depression and death, especially in children, Not recommended in breastfeeding mothers or children < 12

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3
Q

Opioids: Tramadol (Ultram- Discontinued, ConZip, Qdolo)

A

Available formulations: Capsule ER 24hr (Conzip); Tablet- IR and ER 24hr; Oral solution; Combination products with acetaminophen and celecoxib available
Clinical pearls: Risk of serotonin syndrome when used with other serotonergic medications; Renally dose adjusted; US Boxed Warning: Use of CYP 450 3A4 inducers, 3A4 inhibitors, and 2D6 inhibitors with tramadol requires careful consideration of the effects on the parent drug and metabolite; Schedule IV controlled substance

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4
Q

Opioids: Morphine

A

Available formulations: Capsule ER 24 hr; Tablet - IR and 12 hr ER (MS Contin®); Oral solution; Solution for injection (IM, IV, subQ); Suppository; Abuse-deterrent tablet - DISCONTINUED
Clinical pearls: Itching more prominent compared to other opioids; Morphine and its metabolites are renally excreted and accumulate in renal dysfunction - Avoid in patients with end stage renal disease or acute kidney injury; US Boxed Warning: Avoid alcohol while taking ER capsules- leads to increased morphine plasma levels and potentially fatal overdose.

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5
Q

Opioids: Hydromorphone (Dilaudid)

A

Available formulations: IR and ER tablets; Oral solution; Solution for injection; Suppository
Clinical pearls: US Boxed Warning about dosing errors when prescribing, dispensing an administering: Oral solution- do not confuse mg and mL, IV solution- do not confuse high potency solution (10mg/mL) with other solutions (1, 2 or 4mg/mL)

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6
Q

Opioids: Hydrocodone +/- Acetaminophen (Combination products are all generic- discontinued brands are Norco, Lortab, Vicodin)

A

Available formulations: Oral solution; ER tablet (Hysingla); Tablet - Norco 5/325mg, 7.5/325mg, 10/325mg
Clinical pearls: Counsel patients on acetaminophen use; US Boxed Warning: Use with CYP 3A4 inhibitors may increase hydrocodone plasma concentrations

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7
Q

Opioids: Oxycodone (Oxycontin, Xtampza) Oxycodone and Acetaminophen (Percocet)

A

Available formulations: Tablet (IR and ER 12 hr); Capsule (IR and ER 12 hr); Oral solution
Clinical pearls: Counsel patients on acetaminophen use with combination product
- Percocet 2.5/325mg, 5/325mg, 7.5/325mg, 10/325mg; ER capsule/tablets are abuse-deterrent; US Boxed Warning: Use with CYP 3A4 inhibitors may increase oxycodone plasma concentrations

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8
Q

Opioids: Fentanyl

A

Available formulations: Buccal tablet; Sublingual liquid; Lozenge; Injectable solution; Patch
Clinical pearls: US Boxed Warning: Monitor patients receiving CYP3A4 inhibitors or inducers; Can use in renal impairment; Less hypotension than morphine or hydromorphone at similar doses; Non-injectable forms are ONLY indicated for patients who are opioid tolerant - Opioid tolerant is defined as taking morphine 60mg per day (or equivalent) for at least 1 week, Doses are NOT converted from one fentanyl product to another on a mcg-per-mcg basis

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9
Q

Fentanyl (Duragesic) Patch Counselling

A

Apply one patch every 72 hours (3 days)
Apply the patch to the chest, back, flank, or
upper arm
Do not cut the patches or use a patch that is torn or damaged - This could cause an overdose
Do not use the patch over broken skin
Do not let the patch get too warm while wearing
- Avoid using heating pad, electric blanket, sauna, hot tub, heated waterbed, sunlight, or hot weather; Your body will absorb too much medication

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10
Q

Opioids: Methadone (Methadose)

A

Uses: Last line treatment of chronic pain; Opioid detoxification
Available formulations: Oral solution; Injectable solution; Tablet
Clinical pearls: US Boxed Warning: QTc prolongation - Check baseline ECG prior to initiation; US Boxed Warning: Monitor patients receiving CYP 3A4 inhibitors or inducers; Long half life (8-59 hours)

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11
Q

Opioids: Meperidine (Demerol)

A

Available formulations: Injectable solution; Oral solution; Tablet
Clinical pearls: Avoid in the elderly, avoid in renal impairment, caution use in hepatic impairment; US Boxed Warning: Monitor patients receiving CYP 3A4 inhibitors or inducers; US Boxed Warning: Do not use within 14 days of monoamine oxidase inhibitors (MAOI’s); Metabolized by the liver into an active metabolite - Accumulation of active metabolite can cause
delirium and seizures; Not commonly used due to adverse effects

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12
Q

Potential Side Effects

A

Several of the opioids have serotonergic activity and have potential to:
1. Lower seizure threshold
2. Cause serotonin syndrome when used with other agents with serotonergic activity
especially tramadol

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13
Q

Allergic Cross Reaction - natural opiates

A

Morphine, Codeine
Yes: Avoid in patients with allergy to other natural opiates and semi synthetic opioids

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14
Q

Allergic Cross Reaction - semi synthetic opioids

A

Hydromorphone, Oxycodone, Oxymorphone, Hydrocodone, Buprenorphine
Yes: Avoid in patients with allergy to other semi synthetic opioids and natural opiates

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15
Q

Allergic Cross Reaction - synthetic opioids

A

Fentanyl, Methadone, Meperidine, Tramadol
No: Can be used if patient has an allergy to another synthetic opioid, semi synthetic opioid or natural opiate

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16
Q

Switching Between Opioids

A

Calculate: Calculate daily consumption for each opioid
Convert: Convert each opioid to oral morphine
Add: Add morphine doses together to get total daily oral morphine dose
Reduce: Due to cross-tolerance, reduce the equal analgesic dose by 25-50%
Split: Split total daily dose into appropriate dosing interval based on opioid selected (duration of action)