Pain Policy UpdateOpioid Update

Stuart Beatty, PharmD, BCPS

Opioids

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

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

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!!!

Opioids

• Hydrocodone (Lortab, Vicodin, Norco)– APAP ranges from 325-750mg/tablet (Norco

has lowest amount)– Street value, abuse

Opioids

• Oxycodone (Percocet, Oxycontin)– Immediate release available + APAP– Sustained release should be dose Q12H

• Can be crushed to remove time release

– Street value, abuse

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

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

Chronic Non-Malignant Pain Policy

• 2006– Pain Registry– 38% violations

• 2007– Move to Martha Morehouse / EMR

• 2008– Revised and reimplemented

• 2009– Current policy introduced

Current Policy

• NO NEW PATIENTS RECEVING CHRONIC NARCOTICS– Exceptions:

• Discharged from GIM service

Controlled Substance Agreement

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

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

OARXRS

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

Interpreting Urine ScreensDrug Drug Tox False Positive

Morphine Morphine; Hydrocodone (high dose); Hydromorphone (high dose)

Heroin

Codeine Codeine; Morphine; Hydrocodone (high dose); Hydromorphone (high dose)

Fentanyl Fentanyl Trazodone

Methadone Methadone Verapamil; diphenhydramine

Oxycodone Oxycodone; Oxymorphone

Oxymorphone Oxymorphone Oxycodone

Hydrocodone Hydrocodone; Hydromorphone

Hyrdromorphone Hydromorphone Hydrocodone

Mayo Clin Proc. 2008;83(1)66-76

Interpreting Urine Screens - Others

Drug Drug Tox False Positive

Alprazolam α-hydroxy-alprazolam Sertraline

Diazepam Nordiazepam; temazepam; oxazepam

Sertraline

Temazepam Temazepam; oxazepam Diazepam; Sertraline

Oxazepam Oxazepam Diazepam; Temazepam; Sertraline

Lorazepam Lorazepam Sertraline

Marijuana 9-carboxy-THC Pantoprazole; efavirenz; NSAIDs

Marinol is true positive

Cocaine Benzoylecgonine

Mayo Clin Proc. 2008;83(1)66-76

Interpreting Urine ScreensDrug Expected time in Urine

Opioids

Morphine

Hydromorphone

Oxycodone

Methadone

2-3 days

2-4 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

Cocaine 2-4 days

Mayo Clin Proc. 2008;83(1)66-76

Opioid ConversionDetermine daily opioid use (LA only)

Opioid Agonist Parenteral Dose

Oral Dose

Morphine 10 mg 30 mg

Hydromorphone (Dilaudid) 1.5 mg 7.5 mg

Fentanyl (Duragesic)* 0.1 – 0.2 mg

Oxycodone (Oxycontin, Percocet) 20 mg

Codeine 200 mg

Hydrocodone (Vicodin, Lortab) 30 mg

*25 mcg patch = ~90 mg morphine per day

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

Opioid Conversion

Convert to daily methadone

Daily Oral Morphine Equivalents

Oral morphine: oral methadone conversion

ratio

< 100 mg 3:1

100 – 300 mg 5:1

300 – 600 mg 10:1

600 – 800 mg 12:1

800 – 1000 mg 15:1

> 1000 mg 20:1

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

Opioid Conversion ExamplePatient is taking Oxycontin 60mg TID and Percocet TID PRN daily.

Opioid Agonist Parenteral Dose

Oral Dose

Morphine 10 mg 30 mg

Hydromorphone (Dilaudid) 1.5 mg 7.5 mg

Fentanyl (Duragesic)* 0.1 – 0.2 mg

Oxycodone (Oxycontin, Percocet) 20 mg

Codeine 200 mg

Hydrocodone (Vicodin, Lortab) 30 mg

*25 mcg patch = ~90 mg morphine per day

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

Opioid Conversion

Convert to daily methadone

Daily Oral Morphine Equivalents

Oral morphine: oral methadone conversion

ratio

< 100 mg 3:1

100 – 300 mg 5:1

300 – 600 mg 10:1

600 – 800 mg 12:1

800 – 1000 mg 15:1

> 1000 mg 20:1

270 mg Morph Eq. = 54 mg methadone

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

QUESTIONS

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