Opioid Management Flashcards
naturally occurring substances with morphine like properties
opiate
includes synthetic substances that have affinity for opioid receptors
opioid
natural opioids include
morphine, codeine
semisynhetic opioids include
hydromorphone, oxycodone, hydrocodone, heroin
synthetic opioids include
buprenorphine, diphenoxylate, fentanyl, loperamide, meperidine, methadone, pentazocine, tapentadol, tramadol
opioid MOAs
Opioid inhibits inhibitory GABAergic neuron acting on pain inhibitory neuron at spinal cord (medulla)
are full or partial agonists of μ, δ, к receptors
the conversion from PO to IV doses are usually
2x higher for PO dose
how to approach opioid initiation
define goals before start
individualize opioid selection, dosing
short acting opioids may be safer
start low, go slow
Around the clock or basal dose for opioids is usually are
regularly scheduled IR or CR/SR release
breakthrough PRN dose for opioids is usually ____ of the total daily dose in IR formulation
10-15%
when to adjust Short acting IV/ SQ or IR given PRN only
dose by dose
when to adjust Short acting IV/SQ or IR given ATC
q24h
when to adjust CR/SR dose
48-72hrs
when to adjust fentanyl patch dose
q3-6 days
how to calculate new dose if pt is using lots of breakthrough doses
total up all regular and breakthrough doses in last 24hrs, divide by 3 for new regular doses, times by 10-15% for new breakthrough doses
it is recommended to restrict prescribed LT opioid dose for chronic noncancer pain to ____ morphine equivalents daily
90mg
list 3 RF for opioid abuse/ misuse/ addiction
poorly defined pain condition, personal and family hx of alcohol or drug abuse, presence of psychiatric illness, cigarette use, hx of preadolescent sexual abuse, prior hx of aberrant drug related behaviours, =<45yrs, hx of legal problems, associates with others who abuse drugs
which of the following AEs do opioid users not build tolerance to? (pick 2)
1. respiratory depression
2. constipation
3. N/V
4. cognitive effects
5. neuroendocrine and sleep effects
2, 5
how to treat opioid respiratory deprsesion
naloxone
how to treat opioid induced constipation
laxatives and methylnaltrexone
how to treat N/V from opioids
dose reduction or rotation
switch to other routes of admin
dopamine antagonists
anticholinergics
ondansetron
treat constipation
how to treat pruritius from opioids
antihistamines, opioid rotation, naloxone in refractory cases
how to treat cognitive effects from opioids
stimulants or refrain from certain tasks
how to treat neuroendocrine effects from opioids
testosterone in men
how to treat sleep disturbances from opioids
appropriate sleep hygeine
T or F: tolerance to opioid induced sleep disturbances can be build
F
T or F: most opioid allergies are AEs and should not have cross sensitivity with different structural classes
T
if there is a true allergy to morphine or codeine, what can be done?
try a synthetic or semisynthetic opioid
opioid tolerance mechanisms
receptor desensitization
superactivation of cAMP pathway
opioid tolerance management
increase dose
use longer acting opioids
add nonopioid analgesics
add drugs that prevent/ delay tolerance
opioid induced hyperalgesia MOAs
sensitization of primary afferent neurons
activation of dynorphin and central glutamatergic systems
opioid induced hyperalgesia management
taper dose
add NMDA agent
try longer acting opioids
rotate opioids
worsening pain state MOA if the patient is on opioids (3 points)
disease progression
neuropathic pain mechs
enhanced opioid metabolism
worsening pain state AE management strategies
increase dose
add nonopioid analgesics
treat for neuropathic pain/ other pain mechs
opioid rotation may be useful for ________________
balancing analgesia and AEs if AEs are believed to be due to accum of opioid metabolites
what is the codeine conversion factor to morphine
0.15
what is the oxycodone conversion factor to morphine
1.5
what si the hydromorphone conversion factor to morphine
5
after getting a MEDD, what should you do to get new dose
reduce dose for incomplete cross tolerance
how much should be reduced for incomplete cross tolerance if previous dose was 91MEDD and there were SEs
lower by 50%
how much should be reduced for incomplete cross tolerance if previous dose was 50MEDD? give a range
25-40%
4 times to stop an opioid
pain resolved
AEs > benefits
risks > benefits
opioid ineffective
should you d/c an opioid if it did little to control pain but did well in controlling anxiety
yes- is considered ineffective
a rapid taper includes decreasing the dose by _____% q___d and is often completed in ____
10-20%
q1-3d
in 1-2wks
a slow and gradual taper is decreasing the dose by ____% q___wksand is often completed in ____
5-10%
q2-4wks
in 1-6mths
in a slow and gradual taper, once 1/3 of dose is reached, what can improve success?
slowing down taper to decrease of 5% q4-8wks
a rapid taper is more for those who are
severe AEs
highly motivated
on low doses
opioid agonist therapy may be useful for
tapering/ switching pts with opioid use disorder
concurrent psych conditions
LT opioid use (>5yrs)
pregnant
opioid drug interactions include
CNS depressants like ethanol and BZs
serotonergic agents
those that interfere with CYP3A4 and 2D6
which opioids have serotonergic components
tramadol, methadone
