1. Cory Taylor, MD January 15, 2016

2. 56 year-old veteran with obstructive sleep apnea presents with subacute abdominal pain. CT findings are concerning for gastric adenocarcinoma. The patient is complaining of 10/10 pain and the nurse wants to know what you would like to give him…

3.  Understand practical pharmacology behind selecting dose amounts and frequencies  Appreciate the different ways of making opioids available to patients  Bring balance to the Force and order to your opioid selection  Prepare for the possible respiratory side effects of opioid administration

4.  Onset: informs the dose amount  IV speed of onset (fastest-slowest)  Fentanyl ≈ Heroin : Dilaudid : Morphine  PO speed of onset (fastest-slowest)  Oxycodone ≈ Dilaudid : Morphine ≈ Hydrocodone ≈ Codeine*  IV time to max efficacy = 10 min  PO time to max efficacy = 60 min  Duration: informs the dose frequency  Dilaudid, Morphine, Hydrocodone, Oxycodone = 4 hours*  Practically Speaking… Opioids should be dosed at least Q4H to prevent gaps in the maintenance of pain control

5.  PRN or “As Needed” Dosing PROS  Patient triggered – they can only get what they ask for  Added layer of overdose protection  Set it and forget it – less thought, faster ordering CONS  Time to administration can take 30-60 min depending on staff  Leads to coverage gaps, poorly controlled pain  Makes patient’s feel dependent, disempowered, or “seeking”  Creates nursing-patient tension => increased nursing stress  Overlooks altered or less verbal patients  Interferes with patient sleep

6.  Around-the-clock or “Scheduled” Dosing PROS  Better coverage, better control, better sleep  Patients are empowered – reduces patient/nursing tension  Easier on nursing workflow  Don’t need, don’t want: patients can always refuse CONS  Need holding parameters*  Dynamically inflexible with changes in metabolism or mental status  Takes more time and thought

7.  Basal-Breakthrough Dosing  ATC dose provides basal coverage  PRN dose covers breakthrough pain PROS  Less nursing pages  Better satisfaction scores CONS  More time ordering, thinking  Can increase demands on nursing staff*

8.  Enter the PCA Best of every world  Patient finally feels some control over their illness  Nursing can set and forget  Doctor can set and [sort-of] forget Responsiveness + Precision => Finesse  Smaller doses, greater frequencies, immediate delivery  Allows for precise and expeditious titration up or down  No coverage gaps  Streamlines opioid consolidation and conversion No safer alternative than Bolus-only PCA* CONS  Requires cognitive function and trigger-ability  Parenteral administration only

9.  # 1: Opioid Solidarity Stick to a single opioid type Less medication errors Easier for titration and conversion  # 2: Opioid Equivalency No one opioid activates receptors better than others Some opioids are more potent, but potency can be overcome by concentration But some patients will maintain that one opioid “works better for me” than another…

10.  Opioids are more like loop diuretics than antibiotics  With antibiotics, one may “cover” the patient’s infection where another fails  With opioids – Morphine : Lasix as Dilaudid : Bumex*  Consequences of sub-optimal utilization Can inadvertently reinforce drug-anchoring or drug- seeking behaviors Can detract from future encounters and therapeutic relationships

11. You give the patient an basal-breakthrough opioid regimen. Later on that night, the nurses calls to inform you the patient’s oxygen saturation is 80%. He wants to know if you should dial back on the opioids… See Notes Section for Discussion

12.  Not all opioid-related sleep is opioid narcosis  Opioid-induced narcosis produces resistant or refractory somnolence  Healthy opioid-related sleep in wake-able  Opioid overdose always leads to somnolence before respiratory failure  Respiratory failure is caused by decreased respiratory drive*  Keep in mind: respiratory rates of 8-10 are normal in healthy individuals

13.  Responsiveness to naloxone in altered mental status is not diagnostic for opioid-narcosis  Naloxone blocks the body’s natural endorphin- mediated suppression of pain Can cause pain and discomfort, even in healthy individuals Responsiveness to naloxone = responsiveness to noxious stimulus

14.  Morphine SR + percocet for breakthrough  Morphine IVP PRN for moderate pain + Dilaudid IVP PRN for severe pain  Fentanyl drip + oral dilaudid q6h as needed  Norco q4H ATC + Norco Q2H PRN  Oxycontin + tramadol

15. See additional slides for supplemental material*

16. EQUIANALGESIC DOSING GUIDELINES FOR CHRONIC PAIN CHANGING ROUTES OF ADMINISTRATION METHADONE PO/PRIV/SC/IMEpiduralIntrathecal Daily Morphine Dose (mg/24 hrs PO) Conversion Rates 310.10.01 Morphine POMethadone PO < 10031 CHANGING ANALGESICS101 - 30051 OPIOIDS301 - 600101 Enteral Dose (Oral, Rectal) Analgesic Parenteral Dose (SC/IV/IM) 601 - 800121 801 - 1000151 150Meperidine50> 1000201 150Tramadol-> 2000 - 5000401 150Codeine50> 5000801 15Hydrocodone- 15Morphine5METHADONE SC DOSING 10Oxycodone-1. Convert from daily Morphine Equivalent PO Dose / 24 hrs to Methadone 5Oxymorphone- PO Dose / 24 hrs using the Methadone PO Dosing Table above 3Hydromorphone1 2. Then ÷ 2 to convert to Methadone SC Dose/24 hrs 2Levorphanol1 -Fentanyl0.050 mg*ADJUSTING FOR INCOMPLETE CROSS TOLERANCE *1000 mcg = 1 mg: must convert to mg to calculate equianalgesic doseComplete100% Near-complete75% TRANSDERMAL FENTANYLIncomplete33-50% Morphine 50 mg PO in 24 hrs ≈ Fentanyl 25 mcg transdermal patch q 72 hrs Ferris FD and Pirrello RD: Improving Equianalgesic Dosing for Chronic Pain Management, American Association for Cancer Education Annual Meeting, oral presentation, Cincinnati, Ohio, September 2005 These are guidelines only and do not replace clinical judgement. © International Programs, OhioHealth, 2013. Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed To reproduce for all other purposes, contact The International Programs at 1-888-278-6615 or visit IPCRC.net

17.  Faster onset, time to peak, and other factors can increase the euphoria associated with a given opioid  Euphoria is sometimes mistakenly perceived by patients as increased efficacy => increased drug-anchoring/requesting behaviors Euphoria ~> dependency, STREET VALUE

18.  Not all aberrant behavior is drug-seeking behavior Traffickers are not always abusers  Desperate or anchoring behavior ≠ “drug- seeking” behavior Legitimate patients with undertreated pain or opioid withdrawal have genuine needs

19.  Negative or discordant urine drug screen  Inconsistency of story  Splitting  Provider-jumping  Losing prescriptions  Poor self-care or self- investment  Running out of medication  Haggling or making demands  Irrationality, especially regarding equivalent doses RED FLAGS YELLOW FLAGS