INTRODUCTION TO OPIOID MANAGEMENT

Calvin Lui, MD

PGY2

February 8, 2014

LEARNING OBJECTIVES Common Opioid Agents and Good Starting

Dosages

Opioid Conversion

Use of Patient Controlled Analgesia and Good Starting Dosages

CLINICAL CASE A 74-year-old male recently fell and

suffered a hip fracture. He is brought to the OR for reduction and hip replacement? He has left the OR and has been transferred to your Medicine service.

How would you manage his pain postoperatively day 1?

CLINICAL CASE A 74-year-old male recently fell and

suffered a hip fracture. He is brought to the OR for reduction and hip replacement? He has left the OR and has been transferred to your Medicine service how would you manage his pain postoperatively day 1?

Answer: Consider a PCA

PATIENT CONTROLLED ANALGESIA: PCAS Good for when a condition/surgery that cannot

be easily controlled with IV pushes Basal, lockout period, and rescue options

Use basal, if pain has been relatively controlled with PCA, but patient constantly has to push

Many patients will not need a basal dosage Typical lock out period=10-15 minutes

number of rescue dosages in a hour (4-6) One may also set number of dosages/hr

Each day, check how much a patient has used and see if they can be converted to IV push or PO regimen

PCA TYPICAL STARTING REGIMENS Morphine: lockout of 10 minutes, 0.5-1

mg for rescue, 0 basal Hydromorphone: lockout 10 minutes,

0.1-0.2 mg for rescue, 0 for basal Fentanyl: lockout 10 minutes, 10-25

mcg for rescue, 0 for basal

PCA REGIMEN FOR OUR PATIENT Let’s Start him on a regimen of

Hydromorphone: lockout 10 minutes, 0.1-0.2 mg for rescue, 0 for basal

By day 2, he needs 2.2 mg of hydromorphone throughout the day.

Consider converting him to IV pushes of medications to get him off the PCA

COMMON BREAKTHROUGH OPIOID OPTIONS Morphine

Oral solution: 5-10 mg PO q4-6H PRN IV: 2-4 mg q3-4H PRN, uptitrate as needed Check renal function

Hydromorphone 0.3-0.4 mg IV q3-4 PRN, uptitrate as needed 4 mg PO q4H PRN Can use without checking renal function first

Hydrocodone/APAP: 5mg/325mg PO 1-2 tabs q4H PRN Oxycodone/APAP: 5mg/325mg PO 1-2 tabs q4H PRN Codeine: 15-60 mg q4-6H PRN Fentanyl, IV: 25-25 mcg q30-60 min PRN for SEVERE

PAIN

IV PUSH REGIMEN FOR OUR PATIENT Let’s start him on Hydromorphone 0.3

mg q3H PRN. He will be using short acting

medications, but we have given him at least an equivalent amount of medication to his PCA.

POD #3 We are preparing to send our

gentleman to a skilled nursing facility, but would like to provide him with basal pain regimen that needs opioids. He still uses about 2.2 mg of hydromorphone per day. What should we do?

Answer: Long Acting opioids

OPIOID CONVERSION PRINCIPLES1) Calculate total amount used in 24

hours2) Convert to everything to oral

equivalents3) Account for Cross-Tolerance 4) Convert to different opiate5) PRN’s/breakthrough pain6) Bowel regimen

LONG ACTING OPIOID Add up amount from 24 hr period and

convert into one of the following split BID or TID:

Oxycontin: usual doses 10-15 mg BID MS Contin: usual doses of 30 mg daily or BID Methadone: start 5 mg BID or TID Fentanyl Patches: will vary, calc 24 hr oral

morphine equivalent then look up equivalent on micromedex or uptodate

Keep rescue doses on previous pain medications

OPIOID CONVERSION Step 1: IV PO conversion

2.2 mg IV Dilaudid to PO morphine 2.2 x 20 = 44 mg PO Morphine

Step 2: Cross tolerance? YES! Reduce by 15%

PO Morphine = 37.4mg Step 3: Schedule PO Dosing frequency

MS CONTIN = BID Dosing. 37.4 in BID dosing 30/2 = 15mg MS Contin BID

Step 3: calculate breakthrough dosing = minimum of 30-50% total daily requirement

37.4X0.5 = 18.7 mg / day 18.7 mg divided into q4h dosing =

18.7 / 6 = ~3 mg q4h PRN round to 5 mg q4H PRN with oral morphine solution

Step 4:add senna 17.2 mg qHS and colace 250 daily as bowel regimen

OPIOID SIDE EFFECTS Constipation is a given, no tolerance

develops, use stimulants (Senokot, Bisocodyl, Pericolace)

Nausea/vomiting – tolerance can occur in 2-5 days (tx with zofran/compazine/reglan)

Sedation – tolerance can occur in 2-3 days

Clonic jerks Respiratory suppression

SUMMARY Opioid medications are important for

nocireceptive pain and need appropriate titration PCAs are good for postsurgical patients and

conditions needing heavy pain control Consider long acting medications for basal

control in patients requiring opioids for pain control