Opioid Management

Question 1

What defines an adult with chronic pain

Answer 1

dult patients with pain have pain > 3 months or past the time of usual tissue recovery from injury

Question 2

Focus of palliative care

Answer 2

The focus in this patient population is easing suffering and generally recognizes that the illness that causes pain will likely progress over time

Question 3

What is the “dual effect” in palliative care

Answer 3

An increased risk of sedation and possibly hastening death if adequate pain control is prioritized over all other concerns

Question 4

What is total pain

Answer 4

Total pain is the term for all of the contributors that modulate pain, including psychosocial, spiritual, cultural, and other physical factors

Pain is amplified by depression, anxiety, social stressors, isolation, lack of physical activity, loss of a job, cultural inhibitions against expressing personal needs, alienation from family, existential fears about dying, sinning, or other spiritual grief, poor nutrition, and other things that humans experience

Question 5

What is unique about opioid dosing

Answer 5

there is no real dose ceiling or maximum dose other than the problems that occur (addiction risk, impaired drive to breathe) when an individual patient gets too much of a drug. We monitor the patient’s response to the drug in order to gauge response to the chosen dose, and modify the dose as necessary.

Question 6

1. When we don’t know what dose a patient will need, we start with _____

Answer 6

guideline-based starting doses

Question 7

When we don’t know what dose a patient will need, we start with _____, so we aren’t committed to a long period of fighting possible toxicity/overdose if we overshoot with our initial doses

Answer 7

short-acting medications,

Question 8

When we don’t know what dose a patient will need, we plan for _______

Answer 8

frequent reassessment and dose adjustment

Question 9

Scheduled opioids should be given at a time interval that is ________. PRN medications can be given more frequently, based on ________

Answer 9

about the same as the half-life of the medication

the time to onset of peak effect.

Question 10

Patients in active pain will progress as follows as successive doses of opioids increase:

Answer 10

Severe pain –> decreased pain–> sedation –> respiratory depression –> coma –> death.

Question 11

What is Morphine Milligram Equivalents (MME)

Answer 11

used to convert drug dosing with equianalgesic tables that convert between drugs with different potency

Question 12

_____of any drug is inversely proportional to the amount of drug needed to produce pain control.

Answer 12

Potency

More potent opioids require lower mg or even mcg doses to achieve the same effect as less potent opioids

Question 13

Bioavailability of oral opioids =

Answer 13

% of drug absorbed into the circulation and affects the oral dose needed to achieve the same effect as an IV dose of the same drug, and must be considered when switching from IV to oral medications and vice versa.

Question 14

ALL patients on scheduled opioids require a_____ to prevent opioid-induced constipation

Answer 14

bowel regimen (effective laxative treatment)

Question 15

What opioid should be avoided for pain management

Answer 15

Codeine is a dangerous drug due to its variable metabolism

Question 16

Impact of liver disease in opioid management

Answer 16

Patients with liver issues may be difficult to predict in their response. Chronic alcoholics may be relatively opioid tolerant due to alcohol-induced increase in metabolizing enzymes. Patients in frank liver failure may have an increased risk of sedation and respiratory depression, particularly with long-acting medications, due to accumulation of drug metabolism intermediates, and short-acting opiates only are the reccommendation.

Question 17

Impact of renal impairment in opioid management

Answer 17

Patients with renal impairment will accumulate active metabolites of codeine and morphine, so lower doses may need to be used and patients should be monitored closely for toxicity

Question 18

Impact of age in opioid management

Answer 18

Long-acting medications may also accumulate in elderly patients, who have decreased organ system function even without apparent organ failure.

Question 19

Impact of lung disease in opioid management

Answer 19

Patients with active lung disease do have a higher possibility for injury if respiratory depression occurs, but still need adequate pain control, so titration and monitoring should be heightened in this group.

Question 20

Can you crush up pills or combine meds?

Answer 20

Long-acting opioids, in general, cannot be crushed and put into feeding tubes or applesauce for patients that cannot take a pill.

Combination products that include acetominophen can be dangerous and cause overdose if patients are not warned to avoid other APAP-containing products

Question 21

Steps of opioid management

Answer 21

Question 22

Can you give opioids IM?

Answer 22

Never give opioids as an intramuscular shot, as this is VERY painful. If IV access is lost, give the opioid as a subcutaneous shot using the same dose and dosing interval.

Question 23

What determines dosing interval?

Answer 23

The dosing interval is determined by the medication duration of effect, which is determined by its half-life.

Question 24

Dosing intervals for short acting vs long acting opioids

Answer 24

For short acting opioids, the dosing interval should NOT be longer than 4 hours as the typical duration of effect from an oral dose is 3-4 hours.

If we start her on long-acting opioids down the road, the dosing interval is typically Q24H or Q12H.

Question 25

PRN dosing strategy

Answer 25

The PRN dosing interval is **determined by the medication peak effect time.** For IV medications, PRN doses could be given as often as every 10 minutes (as in a pain crisis/emergency). Your PRN dose should be between 5-15% of the estimated total daily dose. NOTE: **Only short-acting medications are given as PRN doses.** If the patient is on a long-acting opioid, he will need a different medication for the PRN dose. In order to avoid polypharmacy, **try to give the same drug (in short-acting formulation) for the PRN doses.** NOTE: Long-acting medications are given as scheduled medications only- NEVER as PRN doses. NOTE: When prescribing a prn dose, p**ick a time and a dose and stick with it**. "1-2 pills" or "every 4-6 hours" is not correct and can lead to misunderstanding and accidental overdose.

Question 26

Guidelines for starting an opioid

Answer 26

1. Nonpharmacologic therapy and nonopioid drug therapy are preferred for chronic pain, should be combined with nondrug/nonopioid tx 2. Opioids are not first-line or routine therapy for chronic pain. **Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risk to patient safety**

Question 27

What us the PEG assessment scale

Answer 27

**P**ain average (0-10) Interference with **E**njoyment of life (0-10) Interference with **G**eneral activity (0-10) 30% improvement is significant

Question 28

Role of drug screens

Answer 28

When prescribing opioids for chronic pain, clinicians should use **urine drug testing before starting opioid** therapy and consider urine drug testing **at least annually** to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. Don't test for substances that wouldn't affect patient management. **Do not dismiss patients from care based on a urine drug test result.**

Question 29

How to modify dose if pain is stable but additional doses were given

Answer 29

**adjust the scheduled dose by including the amount of "prn" medication that was used** Calculate how much opioid the patient has had in the past 24H (Morphine Medication Equivalents (MME); also referred to as morphine equivalent daily dose or MEDD). Divide the MME by the dosing interval to get the new dose

Question 30

How to modify dose if pain is not stable

Answer 30

We are able to increase the total daily dose by a percentage depending on the severity of the patient's pain: by 25-50% if mild pain by 50-75% if moderate pain by 50-100% if severe pain

Question 31

Common side effects of morphine/codeine

Answer 31

nausea, vomiting, rash

Question 32

What is Incomplete Cross-Tolerance

Answer 32

Patients will develop tolerance to an opioid they have been taking for some time. **If a new opioid is started, the differences in the molecular structure will change the interaction in the opioid receptors in the liver, and the drug will not be metabolized as quickly.** Therefore there may be a greater degree of pain relief from an equianalgesic dose of a new drug. ## Footnote **Start with 50-75% of the equianalgesic dose of the new drug**

Question 33

When starting therapy, use:

Answer 33

Immediate-release opioids It does make sense to do this usually, as long-acting opioids take longer to titrate and thus the effectiveness of their use can take longer to evaluate.

Question 34

Who should prescribe methadone?

Answer 34

Only providers familiar with methadone's unique risk and who are prepared to educate and closely monitor their patients should consider prescribing it for pain. Pain specialists

Question 35

Who should not use transdermal fentanyl patch?

Answer 35

Transdermal fentanyl (fentanyl patch) can only be titrated every few days and is a **poor choice for patients who are undergoing dose titration or whose pain may change rapidly**. It is generally for stable patients who have a contraindication to taking oral long-acting pain meds, ie patients who are tube fed or cannot swallow.

Question 36

Max suggested MME daily

Answer 36

Clinicians should use caution when prescribing opioids at any dosage, s**hould carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day,** and should **avoid increasing dosage to ≥90 MME/day** or carefully justify a decision to titrate dosage to \>90 MME/day. ## Footnote **Start with lowest effective dosage and increase by the smallest practical amount.**

Question 37

Dosing guidelines for acute pain

Answer 37

Long-term opioid use often begins with treatment of acute pain. **When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.** **3 days or less will often be sufficient;** more than 7 days will rarely be needed.

Question 38

Frequency to Re-evaluate patients:

Answer 38

within 1-4 weeks of starting long-term therapy or of dosage increase at least every 3 months or more frequently.

Question 39

Dose adjustment to taper off opioids

Answer 39

Taper slowly enough to minimize opioid withdrawal A decrease of 10% per week is a reasonable starting point

Question 40

Consider offering naloxone when patients:

Answer 40

have a history of overdose have a history of substance use disorder are taking central nervous system depressants with opioids are on higher dosages of opioids (\> 50 MME/day).

Question 41

Benzodiazapenes and opioids dosing

Answer 41

The risk of death from overdose or respiratory depression is sharply increased when patients on opioids are also taking bezodiazepines. **Every effort should be made to taper off the benzodiazepines when starting opioids,** and the real risk of harm or death even at lower doses discussed with the patient.