Katy Trinkley, PharmDAngie Thompson, PharmD

 Opioid risks and risk prevention strategies  Medication treatment by pain type  Fundamental principles of opioid therapy

 Opioid prescribing is on the rise  Benefit of opioids after 1 year  Opioid dose is directly related to mortality Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686

 Opioid prescribing is on the rise  Benefit of opioids after 1 year  No evidence!  Opioid dose is directly related to mortality Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686

 Opioids  Avoid  Minimize  Prolong initiation  Only indicated when safer alternatives are exhausted

Nat Rev Drug Discov. 2010;9:589

 Visceral  Highly variable by specific condition  Neuropathic or fibromyalgia  Many opioid alternatives  Nociceptive  Some opioid alternatives

Neuropathic or fibromyalgia pain  Topicals  Lidocaine cream/patch, capsaicin  Gabapentin  SNRI  Venlafaxine, duloxetine  TCA  Nortriptyline  Pregabalin

Nociceptive pain  Acetaminophen  4 grams/d  Topicals  Lidocaine cream/patch, diclofenac gel, capsaicin  SNRI for low back pain  NSAIDs  Aspirin, naproxen  Tramadol IR/ER  Opioids Ann Intern Med. 2015;163:JC10. Circulation. 2007; 115:1634. BMJ. 2011;342:c7086

 Goals of therapy  Selection of opioid  Initiation  Monitoring  Titration  Breakthrough pain

 Dependent on type of pain  Discussion of patient and provider expectations  Set realistic goals  Acute pain – rapid pain relief  Chronic pain – improve or maintain level of day to day functioning, overall well being, relationships, reduce drug dependency

 Route of administration  Constant pain vs. intermittent pain  Renal/hepatic function  Previous exposure to opioids

 Short term trial  No evidence supporting one opioid over another  No evidence supporting short acting vs. long acting  Generally considered safer to use short-acting opioids for initial therapy  Choice of opioid, starting dose, and titration schedule will be very patient specific

 In general start with:  Typical starting dose  Immediate release formulations  Insufficient evidence to recommend around the clock or scheduled opioids  Titrate up slowly ▪ Especially true for geriatric patients

 Monitor for effectiveness and adverse effects  4 A’s ▪ Analgesia ▪ Activity ▪ Aberrant drug behavior ▪ Adverse effects  Assessment frequency will vary based on patient’s pain

 Dose decreases:  Slow titration : 10% per week  Rapid titration: 25-50% every few days  Dose increases:  20-50% increases in daily dose  Equivalent to “breakthrough” dosing needed if on sustained release products  Transition to equivalent dose of sustained released product, once pain control is achieved  Maintain immediate release product for breakthrough pain  Goal: Maximize sustained release/minimize immediate release

 Brief, transitory, exacerbation of moderate to severe pain while on stable doses of long acting opioid therapy or around the clock parenteral therapy  May be due to underlying condition or new/unrelated pain  Typically treated with as need immediate release opioid therapy  10-20% of total daily opioid dose  Rescue doses for breakthrough pain should be dosed frequently  Outpatient setting: Every 4-6 hours is typical

 If using rescue doses consistently, consider titrating long acting opioids  Recalculate dose of rescue therapy every time dose of long acting opioids is adjusted  Typically use same drug for both rescue and long acting therapy

 In theory, there is no maximum ceiling dose for opioid therapy  Best evidence indicates 120 mg/day of morphine or morphine equivalent  Maximum studied doses in randomized controlled trials  Higher doses may indicate substance abuse/diversion and/or need for opioid rotation or taper