1. Pain Policy Update Opioid Update Stuart Beatty, PharmD, BCPS

2. Opioids Tramadol (Ultram) –Not scheduled (still abused) –SNRI activity works for neuropathic pain –Risk of seizures –Interaction with SSRIs (serotonin syndrome)

3. Opioids Schedule III-IV Codeine, Propoxyphene, Hydrocodone Can call Rx in; 5 refills Schedule II Oxycodone, Morphine, Methadone, Fentanyl, Oxymorphone, Hydromorphone Must have written Rx; No refills All patient should receive Senna S or Peri-Colace

4. Opioids Codeine (Tylenol #3) –Low amount of APAP (300mg/tablet) –More constipation than others Propoxyphene (Darvocet) –High APAP dose (650mg/tablet) –Metabolite accumulates in renal dysfunction –DO NOT USE!!!

5. Opioids Hydrocodone (Lortab, Vicodin, Norco) –APAP ranges from 325-750mg/tablet (Norco has lowest amount) –Street value, abuse

6. Opioids Oxycodone (Percocet, Oxycontin) –Immediate release available + APAP –Sustained release should be dose Q12H Can be crushed to remove time release –Street value, abuse

7. Opioids Morphine (MS Contin, Avinza, Kadian) –Lots of dosage forms (immediate and time release) –Active metabolite can accumulate in renal dysfunction Hydromorphone (Dilaudid) –Short-acting only –Very potent

8. Opioids Fentanyl –Patch allows Q72H steady release –DO NOT USE IN CACHETIC PATIENTS Methadone –Long t½ makes it good long-acting option –May cause QT prolongation –Need to wait 3-5 days to adjust dose –Action at NMDA receptor treats neuropathic pain

9. Chronic Non-Malignant Pain Policy 2006 –Pain Registry –38% violations 2007 –Move to Martha Morehouse / EMR 2008 –Revised and reimplemented 2009 –Current policy introduced

10. Current Policy NO NEW PATIENTS RECEVING CHRONIC NARCOTICS –Exceptions: Discharged from GIM service

11. Controlled Substance Agreement

12. Policy Requirements Signed agreement annually (chronic controlled substances = BZD & opioids) –JULY/AUGUST/SEPTEMBER – renew everyone!!! –Review policy with patient –Signed by patient, resident, attending –Scanned into chart –Document under problem list date updated

13. Urine Toxicology Needs to be obtained annually when agreement is signed May be requested by prescriber during any office visit MUST BE OBTAINED IN CLINIC!!! Results will take up to 24 hours Failure to give urine when requested is considered a policy violation

14. OAR X RS Included in database –All controlled substance (II-V) prescriptions –Carisoprodol prescriptions –Tramadol prescriptions Excluded from database –Out-of-state pharmacy –Government pharmacy (e.g., VA, IHS) –Physician dispensed –Inpatient, nursing home, ED administered –ED dispensed < 24 hr supply –C-V OTC sales Should be requested annually when agreement is signed. May be requested during any office visit. Attendings should have access

15. Interpreting Urine Screens DrugDrug ToxFalse Positive MorphineMorphine; Hydrocodone (high dose); Hydromorphone (high dose) Heroin CodeineCodeine; Morphine; Hydrocodone (high dose); Hydromorphone (high dose) Fentanyl Trazodone Methadone Verapamil; diphenhydramine OxycodoneOxycodone; Oxymorphone Oxymorphone Oxycodone HydrocodoneHydrocodone; Hydromorphone HyrdromorphoneHydromorphoneHydrocodone Mayo Clin Proc. 2008;83(1)66-76

16. Interpreting Urine Screens - Others DrugDrug ToxFalse Positive Alprazolam α-hydroxy-alprazolam Sertraline DiazepamNordiazepam; temazepam; oxazepam Sertraline TemazepamTemazepam; oxazepamDiazepam; Sertraline Oxazepam Diazepam; Temazepam; Sertraline Lorazepam Sertraline Marijuana9-carboxy-THCPantoprazole; efavirenz; NSAIDs Marinol is true positive CocaineBenzoylecgonine Mayo Clin Proc. 2008;83(1)66-76

17. Interpreting Urine Screens DrugExpected time in Urine Opioids Morphine Hydromorphone Oxycodone Methadone 2-3 days 2-4 days 3-4 days BZD Short-acting (e.g., lorazepam) Long-acting (e.g., diazepam) 3 days 30 days Marijuana Single use Moderate (2-5x/wk) Daily 3 days 5-7 days 10-30 days Cocaine2-4 days Mayo Clin Proc. 2008;83(1)66-76

18. Opioid Conversion Determine daily opioid use (LA only) Opioid AgonistParenteral Dose Oral Dose Morphine10 mg30 mg Hydromorphone (Dilaudid)1.5 mg7.5 mg Fentanyl (Duragesic)*0.1 – 0.2 mg Oxycodone (Oxycontin, Percocet)20 mg Codeine200 mg Hydrocodone (Vicodin, Lortab)30 mg *25 mcg patch = ~90 mg morphine per day

19. Opioid Conversion Calculate the 24 hour morphine equivalent Current Opioid 24 hr dose of current opioid (from conversion table) Morphine Equivalent 24 hr dose of morphine* (X) (from conversion table) *Use chart if converting to methadone

20. Opioid Conversion Convert to daily methadone Daily Oral Morphine Equivalents Oral morphine: oral methadone conversion ratio < 100 mg3:1 100 – 300 mg5:1 300 – 600 mg10:1 600 – 800 mg12:1 800 – 1000 mg15:1 > 1000 mg20:1

21. Opioid Conversion Begin methadone at BID or TID (available in 5 mg and 10 mg tablets) 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days) When in doubt, go conservative!!! Follow-up appropriately and be prepared to titrate!!! Patient will still need short-acting –Likely require the same to more tablets while converting

22. Opioid Conversion Example Patient is taking Oxycontin 60mg TID and Percocet TID PRN daily. Opioid AgonistParenteral Dose Oral Dose Morphine10 mg30 mg Hydromorphone (Dilaudid)1.5 mg7.5 mg Fentanyl (Duragesic)*0.1 – 0.2 mg Oxycodone (Oxycontin, Percocet)20 mg Codeine200 mg Hydrocodone (Vicodin, Lortab)30 mg *25 mcg patch = ~90 mg morphine per day

23. Opioid Conversion Calculate the 24 hour morphine equivalent Current Opioid 24 hr dose of current opioid (from conversion table) Oxycodone – 20 mg Oxycodone – 180 mg Morphine Equivalent 24 hr dose of morphine* (X) (from conversion table) Morphine – 30 mg Morp Eq. = x = 270 mg *Use chart if converting to methadone

24. Opioid Conversion Convert to daily methadone Daily Oral Morphine Equivalents Oral morphine: oral methadone conversion ratio < 100 mg3:1 100 – 300 mg5:1 300 – 600 mg10:1 600 – 800 mg12:1 800 – 1000 mg15:1 > 1000 mg20:1 270 mg Morph Eq. = 54 mg methadone

25. Opioid Conversion Begin methadone at BID or TID (available in 5 mg and 10 mg tablets) 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days) When in doubt, go conservative!!! Follow-up appropriately and be prepared to titrate!!! Patient will still need short-acting –Likely require the same to more tablets while converting Methadone 15mg TID + Percocet 5/325

26. QUESTIONS ???