Transcript oxycontin pain relief side effects

Palliative Pain management in the er
UBC EM palliative medicine day
Lindsay cohen
july 27, 2016
Objectives

Palliative pain management in the ER :

Basic approach

Opioid equivalencies

Adjuvant therapies

Common pitfalls
Case

Mr. C

65 M, single, lives alone

Hx : prostate CA widely metastatic to bone

CC : severe, diffuse pain


“Hates” the health care system – has previously declined all
treatment, but came into the ED because he is now desperate
Has been going to walk-in clinics for pain meds
Case

Pain “all over”

Difficulty mobilizing over the past week

In the past 2 days, has used :

“tons” of Advil

50 x T#3 (Codeine 30 / Acetaminophen 325)

50 x Percocet (Oxycodone 5 / Acetaminophen 325)
Case

Can’t-miss diagnoses?
Case

Can’t-miss diagnoses :

Hypercalcemia

Malignant spinal cord compression
Case

Ca normal

No focal neuro findings or clinical signs of SCC

You’ve decided that this is most likely pain from his bony mets

Orders?
Opioid Equivalencies

2 x Tylenol #3 = 10 mg PO morphine

2 mg PO hydromorphone = 10 mg PO morphine

7.5 mg PO oxycodone = 10 mg PO morphine (x oxy by 1.5)

25 mcg / h fentanyl patch = 60 – 130 mg PO morphine daily

100 mcg IV fentanyl = 10 mg IV morphine

1 mg Methadone * = 1 – 3 mg PO morphine
* Applies only to Methadone used for pain (TID), not for addiciton (daily)
Equianalgesic Dosing
1.
Convert current opioids to daily oral morphine equivalents (OME)
2.
IV or SC dose = ½ of PO dose
ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC
3.
4.
5.
Breakthrough dose = 10% of total daily dose
Reduce calculated dose by 25 – 50% when switching to a new
opioid to account for cross-tolerance
Start low, be prepared to increase quickly
STEP 1 : Convert to daily OME

20 x T#3 = 100 mg PO morphine ***

25 x 5 mg Oxycodone = approx. 200 mg PO morphine

Total = 300 mg PO morphine
*** We will come back to T3s ***
STEP 2 : IV or SC dose = ½ of PO dose

300 mg OME = 150 mg IV / SC morphine
Now convert to your desired opioid (you can do this at any point) :

150 mg morphine / 5 = 30 mg Hydromorphone
STEP 3 : Breakthrough dose = 10% of total daily dose

30 mg Hydromorphone daily = 3 mg Hydromorphone breakthrough
STEP 4 : 50% reduction for cross-tolerance

3 mg Hydromorphone breakthrough / 2 = 1.5 mg
STEP 5 : Start low, be prepared to increase quickly

3 general presentations of palliative pain in the ED
1.
Severe, acute pain crisis requiring multiple breakthrough doses within
1 h and rapid up-titration; may require an infusion
1.
Moderate pain that is poorly controlled over the course of days –
weeks despite reasonable therapy; may require IV analgesia
2.
Mild-moderate pain that is poorly controlled but with suboptimal
meds; often able to go home if med change and good follow-up
PATIENT 1



Severe, acute pain crisis requiring multiple breakthrough doses within
1 h and rapid up-titration
Hydromorphone 1 – 2 mg IV q 15 min PRN ; call MD if ≥ 3 doses in 1 h
If requiring multiple doses of analgesia within 1 h and still severe pain,
an infusion of fentanyl would be an appropriate next step

To calculate, remember 100 mcg IV fentanyl = 10 mg IV morphine

Consult palliative!
PATIENT 2
Moderate pain that is poorly controlled over the course of days – weeks
despite reasonable therapy; may require IV analgesia

Hydromorphone 1 – 2 mg IV q 1 h PRN

Talk to the RN!

DO NOT flag these orders and put them in the box to wait!

These patients are often inadequately treated :

Under-triage

Nursing discomfort with high-dose opioids / palliative care

DNR status
Adjuvants – Bone Pain
Adjuvants – Bone Pain
ED MANAGEMENT

Opioids

Dexamethasone (8 mg PO / SC / IV bid)

+ / - NSAIDS
OTHER CONSIDERATIONS

Radiation

Bisphosphonates

Interventional / surgical (vertebroplasty)
Tylenol #3
Tylenol #3

Hyper-metabolizers

Hypo-metabolizers

Potential for Acetaminophen toxicity if patient unaware of max.
What’s missing from this opioid prescription?
What’s missing from this opioid prescription?

Bowel protocol!
Case 2

Mrs. T

73 F with lung CA metastatic to brain and bone

Diffuse pain

Followed by GP, medical oncologist, radiation oncologist, pain and
symptom management team
Case 2
Mrs. T’s Pharmanet :

Tylenol #3 1 – 2 tabs PO q4h PRN

Naproxen 500 mg PO bid

Hydromorphone ER 12 mg PO q12h

Hydromorphone 1 – 2 mg PO q4h PRN

Oxycodone 5 – 10 mg PO q1h PRN

Acetaminophen 650mg PO q4h PRN
Case 2

Detailed medication history / pharmacist if available

These patients often have :

Multiple providers

Multiple medications / opioids

High incidence of medication-related side effects

Misunderstanding re: role of various medications, ie. regular vs.
breakthrough vs. incident pain vs. adjuvants
Take Home Points

Use adjuncts to opioids; in ED = Dex (bone pain, SCC, SBO)

Find out what meds patients are ACTUALLY taking (not what PNET says)

Bowel protocol with opioid Rx – always

T#3 – bad

Calcium – vital sign in cancer patients

Talk directly with RNs when dealing with unusual / high dose opioid orders
Summary – Rotating Opioids
1.
Convert current opioids to daily oral morphine equivalents (OME)
2.
IV or SC dose = ½ of PO dose
ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC
3.
4.
5.
Breakthrough dose = 10% of total daily dose
Reduce calculated dose by 25 – 50% when switching to a new opioid to
account for cross-tolerance
Start low, be prepared to increase quickly
References

The Pallium Palliative Pocketbook. 1st Edition. Pallium Canada; 2008.

Ipalapp.com. Providence Health Care Hospice Palliative Care Program


BC Cancer Agency Constipation Protocol. http://www.bccancer.bc.ca/familyoncology-network-site/Documents/SuggestionsforDealingwithConstipation.pdf
Palliative Medicine in the ED. Galicia-Castillo MC et al. emedjournal.com. August 1, 2015.