Safe Opioid Prescribing Flashcards
Synthetic opioid – selective for mu receptor
Higher doses increase the affinity for the receptors
Can be prescribed in primary care for pain management, not MAT (unless licensed)
Not first line opioid for pain management
Use caution with dose conversion due to increased receptor affinity with dose escalation
Methadone
Synthetic opioid – binds to the mu receptor
Indications:
Moderate- severe pain
Pre-op/post-op analgesia
Anesthesia adjunct
50-100x more potent than morphine
Rapid onset
Available transdermally, buccal tablet/film/lozenge, IV
Transdermal patch most common – Duragesic
Highly lipophilic – good penetration of the skin
Replaced every 72 hours, rotate sites
Caution with disposal
Fentanyl
Semisynthetic – binds to mu- opioid receptor
Indicated for moderate to severe pain
Only available in combination with acetaminophen (Vicodin) and ibuprofen
Many different dosages available
Most common 5/325
Very similar chemically to oxycodone
Similar efficacy and abuse potential
Can be used as a cough suppressant (Hycodan)
Hydrocodone
Semisynthetic – binds to mu, kappa and delta opioid receptors
1.5x as potent as morphine
Indicated for moderate-severe pain
Available in IR and ER formulation
IR formulation available in combination with APAP or NSAIDs or alone
Oxycodone acetaminophen (Percocet) 2.5/325, 5/325, 7/325, 10/325mg
Oxycodone IR: 5, 10, 15, 20, 30mg tabs
Oxycontin (ER): 10, 20, 40, 80mg
Oxycontin has higher abuse potential
Oxycodone
Codeine
Natural opioid – selective for mu receptor
1/10th as potent as morphine
Schedule III or V drug depending on dose
Indicated for mild to moderate pain
Commonly prescribed with Tylenol (Tylenol #3) or as a cough suppressant with guaifenesin or phenylephrine
Dose 15-60mg q 4-6 hours, not to exceed 360mg in 24 hours
Nausea very common
Opioids for Acute Pain
Don’t forget non-pharmacologic methods for pain control – RICE, heat, stretching, PT, etc
Acetaminophen and NSAIDs are first line for mild-moderate pain
Don’t forget topical therapies and other adjuvant medications if appropriate
If opioids indicated:
Initial rx no more than 7 days (per MA law)
3-5 days typically enough
Do not prescribe extra “just in case”
Rx SIG should include: “partial refill by request”
Lowest effective dose
Always use IR formulations
Use in combination with non-opioids
Set reasonable expectations for pain management
Close follow-up
Acute Conditions I may rx opioids for include: kidney stones, broken bones, burns
I try to avoid rx’ing for: acute back pain, acute arthritis pain, sprains/strains, dysmenorrhea, migraine/headaches
Prescribing Opioids
Most opioids are schedule II
No refills, generally limited to 30 day supply (max)
Requires Federal DEA to Rx
Codeine and buprenorphine are schedule III
Tramadol schedule IV
Codeine cough medications are schedule V
Prescription Drug Monitoring Programs (PDMP)
Regulations vary by states
MA: required to check EVERY time a schedule II or III narcotic or a benzodiazepine are prescribed
Document, document, document!!
Major Side Effects Opioids (CNS)
Euphoria
Relaxed and dreamy state
Mental clouding
Dysphoria may occur in place of euphoria
Sedation
More likely to occur in the elderly
Less likely to occur with synthetic opioids
Additive with other CNS depressants
Other Opioid Side Effects
Gastrointestinal tract
Constipation a long recognized effect of opioids
High density of opioid receptors in GI tract
Motility decreased in the stomach
Peristalsis diminished in large intestine
Cardiovascular
Bradycardia, otherwise no significant effects on the heart, cardiac rhythm or blood pressure
Miosis – oculomotor nerve
Nausea and Vomiting – chemoreceptor trigger zone
Cough suppression – depression of cough center
Major Effects Opioids
Analgesia
Great effect on pain tolerance than pain threshold
Respiratory depression
↓ sensitivity of the respiratory center to CO2
Truncal rigidity may complicate ↓ respiration
Respiratory failure the major toxicity of opioids
Analgesia and respiratory depression are inseparable and increase with dose in parallel
Opioid Receptors
Mu (μ) – main target
Located at supraspinal and spinal sites and the gut
Analgesia and respiratory depression
Mioisis, euphoria, reduced g.i. motility
Kappa (κ)
Dorsal horn of spinal cord and brain stem
Analgesia, miosis, sedation
Delta (δ)
Diffusely found in the brain and spinal cord
Weaker analgesic effect but also fewer side effects such as respiratory depression
Can have some mood related effects including dysphoria, delusions, hallucinations
Opioid Treatment Agreement
Useful in defining the responsibility of the provider and the patient
Helps to facilitate discussion
Should include risks and benefits of treatment
Review of office/provider policies surrounding chronic opioid prescribing
Frequency of follow-up visits
Utilization of UDT and pill counts
Use of opioids from multiple providers
Plan for lost/stolen prescriptions
Plan if agreement is broken
Data on efficacy in preventing misuse/adverse outcomes is unclear
Patients can find stigmatizing, can harm patient provider/relationship or seen as punitive
How to Taper
Consider tapering if:
No meaningful improvement in pain and function
Doses > 50 MME/day
Signs of substance use disorder
Overdose/serious adverse effects
How to taper
Goal: minimize withdrawal symptoms
If on opioids >1 year – decrease by 10% per month
If <1 year could consider decrease by 10% per week
Monitor patients response and adjust accordingly
Optimize non-opioid pain management and psychosocial support
Discuss risk for overdose if abrupt return to higher dosages
Monitor for signs of depression, anxiety and opioid use disorder
Morphine Milliequivalents
Calculate total daily dose of opioids
Helps ID patients at higher risk of overdose requiring closer monitoring, possible taper, naloxone rx
Goal is the least MME possible but try to keep under 50MME/day
Avoid or carefully justify any dosage ≥ 90MME/day
CDC Guidelines: 12 Recommendations
Non-pharmacologic therapy, and non-opioid pharmacologic therapy is preferred
Establish realistic goals around pain management prior to beginning opioid therapy and review why/when opioid therapy will be discontinued
Discuss all potential risks and benefits of opioid therapy prior to initiating and periodically throughout treatment
Immediate Release opioids should be used (as opposed to extended release) when beginning treatment
Start with the lowest effective dosage (Start low – go slow)
Acute pain: low dose for short duration. 3-5 days often enough, no more than 7 days should be needed
Evaluate benefits and harms within 1-4 weeks of initiation or dose escalation in chronic pain; re-evaluate at least every 3 months
Evaluate risk factors for opioid-related harm before starting and periodically during opioid therapy
Review PDMP before beginning and periodically during therapy
Utilize urine drug testing before starting and at least annually in chronic use
Avoid opioids and benzodiazepines together whenever possible
Offer/arrange MAT for patients with opioid use disorder
Chronic Opioid Prescribing in Non-Cancer Patients
Tramadol
Is it an opioid???
Binds to mu receptors in the CNS inhibiting pain pathways, altering pain perception and response, inhibiting uptake of norepinephrine and serotonin
1/10 analgesic potency of morphine
Common side effects: nausea, dizziness, vomiting, constipation
Less risk for respiratory depression than other opioids
Dependency is possible with prolonged use
Caution for serotonin syndrome
Schedule IV drug
