Poine Flashcards
Types of Poine
Noceceptive – Somatic and Visceral
Somatic – aching, intense, sharp, stabbing
Visceral – squeezing, deep, cramping
Neuropathic
Burning, lancinating, pareshesias
WHO
Cancer Pain Ladder
Cancer Pain Ladder
Recipere
Poine
First Line (Non-Opoid)
RECIPERE]
P/Poine(NSAIDS)]
Acetaminopen (Tylenol) 325-650mg PO/PR q4-6h, max dose 4g day or 2g day if significant liver disease
NSAIDS
Ibuprofen (Motrin, Advil) 200-800mg PO q6-8h
Naproxen (Aleve, Naprosyn) 250-500mg PO BID
Ketorolac (Toradol) 15-30mg IV/IM q6h
** NSAIDS contraindicated in gastrointestinal, renal, or cardiovascular disease. NSAIDS can relieve mild to moderate pain particulary of somatic origin.
** If NSAIDS perscribed for more than one week a proton pump inhibitor (PPI) should also be perscribed.
PPI
Pantoprazole (Pantoloc, Tecta) 40mg PO OD
Omeprazole (Losec, Prilosec) 20mg PO OD
Rabeprazole (Pariet) 20mg PO OD
Recipere
Poine
Second Line (Weak Opioids)
RECIPERE]
P/Poine(Weak Opioid)]
Codeine 0.5-1mg/kg up to 15-60mg PO/IM/IV/SQ q4-6h (15mg, 30mg, 60mg)
Tylenol with Codeine (1,2,3,4) 1-2 tabs PO q4h, (7.5/300, 15/300, 30/300, 60/300)
Percocet (Oxycet, oxycodone+acetaminophen) 1-2tabs PO q4-6h PRN (2.5/300, 5/300, 7.5/300, 10/300)
Percodan (Oxycodan, oxydodone+acetylsalicylic acid)
1 tab PO q6h PRN (4.88/325)
Recipere
Poine
Second Line (Strong Opioid)
RECIPERE]
P/Poine (Strong Opioid)]
Morpine (MS Contin, controlled release)
Start at 30mg PO q8-12h PRN and titrate up (15, 30, 60, 100, 200)
Oxycodone (Oxycontin, OxyNEO) 5mg IR PO q4-6h PRN, 10-40mg CR PO q12h PRN
Oxymorphone (IR - Immediate Release, ER - extended release) 10-20mg IR PO q4-6h, 5mg ER PO q12h and titrate up, ER (5, 10, 20, 30, 40)
Hydromorphone (Dilauded) 2-4mg PO q4-6h PRN, 0.5-2mg IM/SC or slow IV q4-6h
Fentanyl 1 patch q48-72h,
Methadone 2.5mg IM/SC/PO q8-12h, Titrate up by 2.5mg q5-7 days as necessary
Opioid Dosing Strategy
For short acting (IR - Immediate Release) opioids PO – morphine, oxycodine, hydromorphone – the peak reached is after about 1 hour, IV 10min, PR 20min.
If after 1 hour PO, pain is not controlled, repeat the dose.
If after successive doses pain is not controlled, increase the dose 25-50% for moderate pain, and 50-100% for severe pain.
Consider a long acting (ER/CR - Extended Release, Controlled Release) for patients who consistenly require multiple daily doses of short acting opioids.
Use 50-75% of total daily short acting dose into long acting dose (ex. Long acting morphine, oxycontin)
When breakthrough pain occurs use short acting opioid.
Use 10-20% of total daily long acting dosage for breakthrough dose of short acting opioid.
Opioid Continuous Infusion
Analgeisa pump programmed for hourly basal rate. Breakthrough dose is typically 50-100% of the hourly basal rate.
** Sedated patient with a patient-controlled analgesia pump should be promptly evaluated.
Opioid Conversion
PO-PO
For every 1 Morphine, you need 8 Codeine (1:8). Codeine is 8x weaker than Morphine.
For every 1.5 Morphine, you only need 1 of Oxycodone (1.5:1). Oxycodone is 1.5x stronger than Morphine.
For every 5 Morphine, you only need 1 of Hydrocodone (5:1). Hydromorphone is 5x stronger than Morphine.
PO to IV/SC
For every 2 Morphine PO, you only need 1 Morphine IV/SC (2:1).
For every 2 Oxycodone PO, you only need 1 Oxydocone IV/SC (2:1).
For every 2 Hydromorphone PO, you only need 1 Hydromorphone IV/SC (2:1)
** IV/SC Morphine, Oxycodone and Hydromorphone is 2x stronger than PO.
Recipere
Opioid Side Effects
Nausea
Constipation
RECIPERE]
P/Naus]
Haloperidol (Haldol) 0.5-2mg PO q6-12h PRN
Prochlorperazine (Compazine) 5-10mg PO/IV q6-8h
OR
Metaclopramide (Reglan) 5-10mg PO/IV q6h
If from chemo/radiation/post-op:
Ondansetron (Zofran) 4mg PO/IV q6-12h
P/Org(Gastrointestino, constipation]
Softener
Docusate (Colace, softener) 100-400mg PO OD-BID
Laculose (osmotic) 15-60mL PO OD
PEG (osmotic) 17g in 8oz water PO OD
Stimulant
Senna (Senokot) 2 tabs PO OD-BID
Bisacodyl (Dulcolax) 10-15mg PO OD-TID
** Need a Softener AND a Stimulant
Recipere
Pruritis
Four main types: prurioreceptive, neuropathic, neurogenic, psychogenic.
Prurioreceptive - peripherally induced - histamine (H1), serotonin (5HT2/3), opioid (u/k-opioid), neuropeptides (substanceP) in the skin.
Neurogenic - centraly induced - uremic and cholestatic itch, serotonin and opioid receptors reset itch threshold by alternal centrally inhibiting circuits. Not responsive to anti-histamines.
**Serotonin is the key neurotransmitter thought to play a role in pruritis - Cholestasis, Uremia, Opioid-induced pruritis, Malignancy.
RECIPERE]
P/Org(Pruritis)] Paroxetine 5-10mg PO QHS
Mirtazapine 7.5-15mg PO QHS
Ondansetron 4-8mg PO/IV/SL BID-TID
Recipere
Neuropathic Pain
RECIPERE]
P/Poine(Neuropathic)]
Methadone 2.5-5mg IM/SC/PO q8-12h, titrate up 2.5 mg
q5-7 days
Gabapentin (Neurontin) 300mg PO QHS to start with a maximum dosage of 3600mg a day
Pregabalin (Lyrica) 50mg PO TID to start, can titrate up to 100mg TID within a week
Nortriptyline 25mg PO OD-QID, effective dose 75-100mg, max dose 150mg
Opioid Overdose Protocol
Triad of: miosis, respiratory depression, coma.
Check the following:
- Reponse to verbal and tactile stimuli.
- SO2 sats.
- Respiratory rate.
O/E: RR<10, SaO2<90 or decreased
If no responding to verbal or tactile stimuli and RR<6 give dilted Naloxone (1:10, 1cc Naloxone in 9cc NS).
If no sedation or drowsy, RR<6 and SO2<90% give diluted Naloxone.
Repeat diluted Naloxone q5-10min until patient rouses. Continue monitoring q60min until vitals are back to baseline.
Opioid in Renal and Hepatic Dysfunction
Do not use codeine in Renal and Hepatic dysfunction as metabolites can accumulate.
Use morphine, oxycodone and hydromorphone with caution.
