Transcript Opioid Selection for Acute and Chronic Pain Control

Opioid Selection for Acute
and Chronic Pain Control
J K Lilly MD MS
Appalachian Pain Therapy Institute
Charleston, WV
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Objectives
 Identify the difference between acute and chronic pain
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treatment in opioid- naive verses opioid-tolerant patients.
Identify medications appropriate for treatment of each type
of pain.
Know the Equianalgesic Doses of IV Morphine, Dilaudid
and Fentanyl & convert to oral doses (enterohepatic=1.3).
Know about Iatrogenic Abstinence Syndrome
Realistically apply the Visual Analog Pain Score to
evaluating response to opioids.
Differentiate Addiction Disorder from Chronic Pain and
Chronic Pain Behavior
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Equianalgesic Dosing
Pure Opioids
Drug
PO Dose
IM Dose
& 1/2 life
Morphine
1
30-60
10 (=)
Hydrocodone
1
30-60
n/a (=)
1.3
15-30
20 (=)
20 acute (1.3)
2-4 chronic (8-12)
10 (++)
400 mcg
0.1 (+)
2-4
2-4 (+)
4-8
1.5 (=)
Oxycodone
Methadone
Fentanyl
Levorphanol
Hydromorphone
“Dilaudid”
100
15
5
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Equianalgesic Dosing
Weak Opioids and Mixed Agonists
Drug
PO
IM & ½ Life
Meperidine
Codiene
0.1
0.5
300
60-120
100-200 (=)
130-160 (=)
Propoxyphene
0.15
450
n/a (+)
Buprenorphine
Nalbuphine
Butorphanol
Pentazocine
10
1
~25
0.15
n/a (30)
n/a
n/a
325
.32-.96 (+)
10 (=)
5 (=)
30-60 (=/+)
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Equianalgesic Dosing
 Consider the example of switching from
Methadone 10 tid to Oxycodone-SR
 First, determine the Morphine equivalent dose to
current drug,
 Then, estimate dose of new drug from the
Morphine equianalgesic dose
i.e. Methadone → Morphine → Oxycodone
30 mg/d x 8 = 240 mg/d x .66= 160mg/day
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Equianalgesic Dosing
 Convert from Fentanyl 50 mcg/hr patch plus
Percocet 10/650 up to tid for recurrent pain plus
IV Demerol 25 mg up to once per shift for “bad”
pain to IV Morphine infusion dose (real example)
Fent 50 x24hr=1200 mcg/day x100= 120mg MS;
Oxycod 30 x1.3= ~ 40mg MS;
Demerol 75 = 75x.1= ~8-10mg MS =>
120+~40+~10= ~180mg MS equivalent dose/day
or IV-infusion hourly dose of 6.6 mg/hr
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Acute Pain Control Plan
 Acute Pain: physical discomfort, short duration
(hours to weeks), usually severe, usually
associated with disease, birthing process or injury
 Opioid-Naïve (narcotic celibacy)
 Opioid-Tolerant (taking the equivalent of
>25 mg/ day of Oxycodone or equivalent dose of
any sustained release opioid preparation)
 Visual Analog Pain Score (0-10) only advisory!
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Chronic Pain Control Plan
 Pain lasting longer than six months
 Persists disproportionately beyond the initial cause
 May not respond in the same way as acute pain to
techniques and medications
 Cause may not be resolvable!
 May require combined treatment modalities
 Long Term Opioid Therapy (LTOT) may be the
final therapeutic (last/ best) alternative
 Chronic Pain Syndrome and its attendant behavior
ARE NOT equivalent to Addiction Disorder
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Opioid -Naive
With PCA (preferred)
 Continuous (controversial)-
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MS 2mg/hr or second line drug
in equianalgesic dose (0.2 mg/
hr HM, 20 mcg/ hr Fentanyl)
Demand Bolus - MS 1 mg or
equianalgesic dose
Lockout – 10-15 minutes
Rescue – RN administered
intermittent rescue ~ twice the
dose of PCA bolus q 1 hr prn
until reviewed
Review & adjust orders q 12 hrs
Continuous Oximetry
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Opioid -Naive
Without PCA (but IV)
 First Line:
Morphine 2mg IV q 5 min prn
‘til comfortable or AE
 Second Line:
 Hydromorphone 0.2 mg IV q 5
min prn or
Fentanyl 20 mcg IV q 5 min
prn, (1st if creatanine >2.5)
Meperidine not recommended!!
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Review orders q 12 hrs
Continuous Oximetry
Convert to Oral ASAP
Avoid 3rd & 4th Line Agents
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Opioid Tolerant
(taking opioid equivalent to >25 mg Oxycodone/ 24 hrs )
With PCA (preferred)
Continuous Infusion = PCA Background –
baseline 24 hr opioid dose X .3 per day,
(ie. MS Contin 60mg q12h = 120 x .3 = 40mg/24hrs, or 2.5mg/ hr infusion –
round-up to 3mg/ hr)
PCA Demand- 50-100% of hourly rate,
Lockout – q10-15 min
Review adjust at least q 12h,
titrate systematically
Continuous Oximetry
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Opioid Tolerant
(taking opioid equivalent to >25 mg Oxycodone/ 24 hrs )
Without PCA
10-20% of 24 hr dose
q 1-3 hrs prn “basal dose”
RN administered IV
“Rescue Doses” @
2x the “basal dose”
Continuous Oximetry
Adjust doses q 12h
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Pain Taxonomy
 Acute Pain-
tissue injury, distention or inflammation
 Episodic Pain-
related to activity
recurrent, breakthrough, incident
 Chronic Pain-
constant and unremitting
waxes & wanes but seldom subsides
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Episodic Pain
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Short acting opioids indicated
Oral route preferred
Usually treated Schedule III (+APAP or IB)
Exertion/ Activity related
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Constant Pain
 Sustained Response (SR) oral agents indicated
 Consider Immediate Response (IR) agents for
rescue doses – start at ~10% of 24 hr dose of long
acting agent q4-8 hrs prn
 SR formulations are designed for q 12 hr dosing
but mean effective dose may be shorter duration (q
8-10 hr)
 Use coanalagesics and anticipate adverse effects
 Addiction risk is 3% or less (large studies)
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Analgesic Selection
 Mu (m) Opioid Receptor Agonists – most
familiar to clinicians as to effects and sideeffects; best for initiating opioid therapy for
moderate to severe pain (VAPS 5-10/10).
 Morphine, Hydromorphone, Oxycodone,
Hydrocodone, Fentanyl, Codeine,
Hydrocodeine, Levorphanol, Methadone,
Meperidine.
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Analgesic Selection
 Agonist/ Antagonists & Partial Agonists –
Primarily activate the Kappa (k) receptor and
antagonize or partially occupy the Mu receptor
(m antagonists), analgesic ceiling effect, risk
iatrogenic abstinence syndrome when given with
m agonist tolerant patients, watch out in ER!
no proven advantage in avoiding abuse.
 Pentazocine, Butorphanol, Nalbuphine and the
“partial agonists” Buprenorphine and Dezocine
(VAPS 4-7/10)
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3rd & 4th Line Analgesic Agents
 Limited Proven
Analgesic Efficacy
 Adverse Effects
 Drug-to-Drug
Interaction
 Toxic Metabolites
 Organ-limited
Elimination
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3rd & 4th Line Analgesic Agents
 Propoxyphene equianalgesic to Extra Strength Tylenol in
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blind studies (VAPS 1-3/10 = mild)
norpropoxyphene-cardio & neurotoxic
Tramadol weak m agonist but primarily active on spinal
adrenergic receptors similar to tricyclics (VAPS 4-5/10 =
moderate)
Meperidine short acting (450-90 mins), metabolites
accumulate within 48 hrs, side-effects common
normeperidine- cardio & neurotoxic
Codiene effective pain relief but many side-effects at
analgesic doses
Hydrocodiene isn’t routinely monitored on UDS
NSAIDs, APAP and AEDs, TCAD are “co-analgesics”
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Dosing for Relief
 Around-The-Clock (ATC) dosing is associated
with more consistent relief
 PRN-dosing is associated with more
unpredictability and side-effects
 Optimal analgesic dosing varies widely among
patients; review regularly; titrate systematically
 Anticipate side effects; most subside with time
 For some, NO dose of opioid will sufficiently
relieve ALL of their pain...aim for TOLERABLE
pain levels (VPA3-4/10), improved functionality
and controlled side effect
 Transition quickly from IV to PO (enterohepatic)
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Opioids and Addiction
Physical Dependence
 Physiologic occurrence usually within 3 days of
initiating therapy;
 Pharmacological property characterized by
withdrawal syndrome after abrupt discontinuation;
 Abstinence symptoms usually lacking or
attenuated with “wean to discontinue” orders
 NOT synonymous with tolerance or addiction!
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Opioids and Addiction
Tolerance
 Spectrum of acquired physiologic responses to
therapy
 Pharmacological property of the class drug;
With chronic use, larger dose may be needed for
same effect
 Countered with drug rotations, furloughs,
tolerance inhibitors, prescriptive boundaries
 NOT synonymous with physical dependence or
addiction!
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Opioids and Addiction
Pseudo-addiction
 Usually attributable to provider practice
pattern, ergo iatrogenic
 Unrealistic expectation by prescriber
 Misconceived safety concern by providers
 Patient motivation: ”relief, not rush”
 NOT synonymous with physical
dependence, tolerance or addiction!
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Opioids and Addiction
Addiction
 Psychological and physiologic state (<3 & >0.3%
of chronic pain suffers) characterized by obsessive
pursuit of access to medication- regardless
of consequences, for psychological effects
 Not a pharmacological property of a given drug
 NOT synonymous with tolerance or physical
dependence!
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Plan if Addiction is Recognized
-Be Humane - Intervene and Wean to withdrawal
-Evaluation, treatment and extended recovery care
by addiction professionals is optimal
-Know community and regional resources for
treatment & extended recovery care when
initiating LTOT
-Prescribing opioids to treat addiction (Methadone
Clinics) is advisable only for specially certified
addiction medicine and psychiatry physicians
-Buprenorphine Addiction Treatment (Subtex)
requires additional training and additional DEA
certification…too new to assess.
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Opioid Therapy
Current Clinical Guidelines
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Pain relief is defined as a primary care (PCP) function
Remain reasonable, rational, responsible and available
Examine thoroughly and review regularly
Utilize LTOT Informed Consent to Treat and Opiate
Access Agreement
Document & define providers & pharmacy
Require patient to notify all providers of Opiate Access
Agreement participation
Monitor compliance (pill counts, UDS, etc.) and
response to therapy (functional assessments, charts,
diaries, surveys, etc.),
Review OAA violation consequences regularly
Match the tool to the problem-SR opioid for continual
pain, IR for recurrent pain; pick analgesics sensibly
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Opioid Therapy
Current Clinical Guidelines (cont.)
 Consult and co-manage appropriately, require
formal behavioral assessment periodically
 Stipulate that verified non-clinical information
may be considered when deciding whether to
continue LTOT
 Beware of 90 day prescription “Prescription
Drug Benefit Requirements” -cost saving
scheme that may be technically illegal for
opioids; i.e.. unmonitored and unlicensed
warehousing of Class II & III medications in
homes not supported by law or regulation
 Recognize that LTOT may be the therapy of
last resort
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Opioid Options on the Near Horizon
 Lipid-Based Sustained Release Opioid &
Local Anesthetic Vehicles
 Vanilloid and Cannabinoid Receptor
Agonists
 New Spinally-infused Drugs
 Abuse-resistant Opioid Preparations
 Co-analgesic Use of Anti-seizure Drugs
 Deep-Brain and Motor Cortex Stimulation
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Thanks! I Enjoyed
your attention!
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Opioid Selection for Acute and
Chronic Pain Control
Thanks for you’re
your questions!!
It’s time to head
home.
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