Rogers Pain Part 3 Flashcards
Uses of opioids
Acute and chronic pain
Opioid side effects
-Antitussive
-Constipation
-Nausea and vomiting
-Itching
-Orthostatic hypotension
-Urinary retention
-Sedation
-Respiratory depression
Opioid clinical pearls
-Consider starting stool softener and/or stimulant laxative
-Potential for tolerance, dependence and addiction
-Schedule 2 controlled substances besides tramadol and codeine
Available formulation for codeine
-Tablet
-Cough syrup
Codeine clinical pearls
-Schedule 5, 3, or 2 controlled substances
-Metabolized to morphine via CYP 2D6
-Not recommended in breastfeeding mothers or children less than 12
Codeine brand name
Tylenol #3
Tramadol available formulations
-Capsule ER 24hr
-Tablet - IR and ER 24hr
-Oral solution
-Combination products with acetaminophen and celecoxib available
Tramadol 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 4 controlled substance
Tramadol brand name
-Ultram-discontinued
-Conzip
-Qdolo
Morphine available formulations
-Capsule ER 24hr
-Tablet - IR and 12hr ER (MS contin)
-Oral solution
-Solution for injection (IM, IV, subQ)
-Suppository
Morphine 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 renal disease)
-US boxed warning: avoid alcohol while taking ER capsules - leads to increased morphine plasma levels and potentially fatal overdose
Hydromorphone available formulations
-IR and ER tablets
-Oral solutions
-Solution for injection
-Suppository
Hydromorphone clinical pearls
US boxed warning about dosing errors when prescribing, dispensing, and administering:
-Oral solution - do not confuse mg and mL
-IV solution - do not confuse high potency solution with other solutions
Hydromorphone brand name
Dilaudid
Hydrocodone +/- acetaminophen available formulations
-Oral solution
-ER tablet
-Tablet
Hydrocodone +/- acetaminophen clinical pearls
-Counsel patients on acetaminophen use
-US boxed warning: Use with CYP 3A4 inhibitors may increase hydrocodone plasma concentrations
Oxycodone +/- acetaminophen available formulations
-Tablet (IR and ER 12hr)
-Capsule (IR and ER 12hr)
-Oral solution
Oxycodone +/- acetaminophen clinical pearls
-Counsel patients on acetaminophen use with combination product
-ER capsules/tablets are abuse-deterrent
-US boxed warning: use with CYP 3A4 inhibitors may increase oxycodone plasma concentrations
Oxycodone brand names
-Oxycontin
-Xtampza
Oxycodone + acetaminophen brand name
Percocet
Fentanyl available formulations
-Buccal tablet
-Sublingual liquid
-Lozenge
-Injectable solution
-Patch
Fentanyl clinical pearls
-US boxed warning: monitor patients receiving CYP 3A4 inhibitors or inducers
-Can be used in renal impairment
-Less hypotension than morphine or hydromorphone at similar doses
-Non-injectable forms are only indicated with patients who are opioid-tolerant
-Doses are not converted from one fentanyl product to another on a mcg-per-mcg basis
What is opioid tolerance?
Taking morphine 60mg per day (or equivalent) for at least 1 week
Fentanyl brand name
Duragesic
Fentanyl patch counseling
-Apply one patch every 72 hours (3 days)
-Apply the patch to the chest, back, flank, or upper arm
-Do not cut patches or use a patch that is torn or damaged (could cause an overdose)
-Do not use the patch over broken skin
-Do not let the patch get too warm while wearing (body will absorb too much)
Methadone available formulations
-Oral solution
-Injectable solution
-Tablet
Methadone brand name
Methadose
Meperidine available formulations
-Injectable solution
-Oral solution
-Tablet
Methadone uses
-Last line treatment for chronic pain
-Opioid detoxification
Methadone clinical pearls
-US boxed warning: QTc prolongation (check baseline ECG before initiation)
-US boxed warning: monitor patients receiving CYP #A4 inhibitors or inducers
-Long half life (8-59 hours)
Meperidine 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 (MAOIs)
-Metabolized by the liver into an active metabolite (accumulation of this metabolite can cause delirium and seizures)
-Not commonly used due to adverse effects
Which opioid has serotonergic activity?
Tramadol
What do opioids with serotonergic activity have the risk to do?
-Lower seizure threshold
-Cause serotonin syndrome when used with other agents with serotonergic activity
Initial dosing of codeine in opioid naive patients
15-60mg PO Q4H PRN
Initial dosing of tramadol in opioid naive patients
25-50mg PO Q4-6H PRN
Initial dosing of morphine in opioid naive patients
-5-10mg PO Q4H PRN
-2.5-5mg IV Q3-4H PRN
Initial dosing of hydromorphone in opioid naive patients
-2.4mg PO Q4-6H PRN
-0.2-1mg IV Q2-3H PRN
Initial dosing of hydrocodone in opioid naive patients
2.5-10mg PO Q4-6H PRN
Initial dosing of oxycodone in opioid naive patients
5-15mg PO Q4-6H PRN
Initial dosing of fentanyl in opioid naive patients
25-50mcg Q30-60min PRN
Which opiates are natural opiates?
-Morphine
-Codeine
Which opiates are semi synthetic opioids?
-Hydromorphone
-Oxycodone
-Oxymorphone
-Hydrocodone
-Buprenorphine
Which opiates are synthetic opioids?
-Fentanyl
-Methadone
-Meperidine
-Tramadol
Is there allergic cross reaction for natural opiates with other opioids?
Yes, avoid in patients with allergy to other natural opiates and semi synthetic opioids
Is there allergic cross reaction for semi synthetic opioids with other opioids?
Yes, avoid in patients with allergy to other natural opiates and semi synthetic opioids
Is there allergic cross reaction for synthetic opioids with other opioids?
No, can be used if patient has an allergy to another synthetic opioid, semi synthetic opioid or natural opiate
How do you switch between opioids?
-Calculate daily consumption for each opioid
-Convert each opioid to oral morphine
-Add morphine doses together to get total daily oral morphine dose
-Due to cross-tolerance, reduce the equal analgesic dose by 25-30%
-Split total daily dose into appropriate dosing interval based on opioid selected (duration of action)
