pharmacy intro opioids and other drugs we use on palliative care

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Pharmacy Intro Opioids and other drugs we use on palliative care

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Page 1: Pharmacy Intro Opioids and other drugs we use on palliative care

Pharmacy IntroPharmacy IntroOpioids and other drugs we use on palliative

careOpioids and other drugs we use on palliative

care

Page 2: Pharmacy Intro Opioids and other drugs we use on palliative care

ObjectivesObjectives

Discuss the role of opioids in end of life care

Discuss the pharmacology and side effects of opioids

Discuss opioid equivalencies and conversions

Review basics of methadone

Discuss other medications commonly used

Discuss the role of opioids in end of life care

Discuss the pharmacology and side effects of opioids

Discuss opioid equivalencies and conversions

Review basics of methadone

Discuss other medications commonly used

Page 3: Pharmacy Intro Opioids and other drugs we use on palliative care

Objectives (cont’d)Objectives (cont’d)

Discuss other medications commonly usedDiscuss other medications commonly used

Page 4: Pharmacy Intro Opioids and other drugs we use on palliative care

Barriers to opioid useBarriers to opioid use

PhysicianPhysician Patient

Page 5: Pharmacy Intro Opioids and other drugs we use on palliative care

Why use opioidsWhy use opioids

Pain is experienced by over 80% of patients

Over 60% will be moderate to severe

Dyspnea present in 80% of advanced cancer

95% COPD at end of life

75% of advanced disease (all comers)

Pain is experienced by over 80% of patients

Over 60% will be moderate to severe

Dyspnea present in 80% of advanced cancer

95% COPD at end of life

75% of advanced disease (all comers)

Page 6: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioids in CanadaOpioids in Canada

Page 7: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioid PharmacokineticsOpioid Pharmacokinetics

All have similar PK (except methadone)

onset of action 15-30 mins

duration of action 4-5 hrs

LA 8-12hrs

All have similar PK (except methadone)

onset of action 15-30 mins

duration of action 4-5 hrs

LA 8-12hrs

Page 8: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioid PharmacokineticsOpioid Pharmacokinetics

Fentanyl and Sufentanil

Onset 10-15 mins

Duration 45 mins

First pass metabolism

Highly lipophilic (SL/IN)

Fentanyl and Sufentanil

Onset 10-15 mins

Duration 45 mins

First pass metabolism

Highly lipophilic (SL/IN)

Page 9: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioid DosingOpioid Dosing

No ceiling effect

↑dose = ↑analgesic effect (log-linear)

Dose increased until symptom relief or limiting side effects

No ceiling effect

↑dose = ↑analgesic effect (log-linear)

Dose increased until symptom relief or limiting side effects

Page 10: Pharmacy Intro Opioids and other drugs we use on palliative care

Start with IR dosing

“Start Low and Go Slow”

Q4H

PO = SL = PR

SC/IV = 50% of PO

Reassess regularly

Start with IR dosing

“Start Low and Go Slow”

Q4H

PO = SL = PR

SC/IV = 50% of PO

Reassess regularly

Page 11: Pharmacy Intro Opioids and other drugs we use on palliative care

Breakthrough DoseBreakthrough Dose

IR

50-100% of the Q4H dose or 10% of the 24hr dose

Q1H - PO/SL

Q30Min - SC

Q10Min - IV

For simplicity... all routes are Q1H prn

IR

50-100% of the Q4H dose or 10% of the 24hr dose

Q1H - PO/SL

Q30Min - SC

Q10Min - IV

For simplicity... all routes are Q1H prn

Page 12: Pharmacy Intro Opioids and other drugs we use on palliative care

Do Not Use Extended Release Opioid for BreakthroughDo Not Use Extended Release Opioid for Breakthrough

Page 13: Pharmacy Intro Opioids and other drugs we use on palliative care

TitrationTitration

Increase equal to total 24 hours breakthrough dose

Mild to moderate pain - 50%

If no response

Increase more rapidly

Switch to parenteral

Increase equal to total 24 hours breakthrough dose

Mild to moderate pain - 50%

If no response

Increase more rapidly

Switch to parenteral

Page 14: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioid RotationOpioid Rotation

Why?

Inadequate analgesia despite appropriate escalation

Intractable/Intolerable side effects

Altered renal/hepatic function

Drug shortages

Why?

Inadequate analgesia despite appropriate escalation

Intractable/Intolerable side effects

Altered renal/hepatic function

Drug shortages

Page 15: Pharmacy Intro Opioids and other drugs we use on palliative care

Use a consistent method

Use the same conversion table

Consider incomplete cross-tolerance, patient variations, limitation of tables

Use a consistent method

Use the same conversion table

Consider incomplete cross-tolerance, patient variations, limitation of tables

Page 16: Pharmacy Intro Opioids and other drugs we use on palliative care

Equianalgesia Dose Ratio

Equianalgesia Dose Ratio

Equianalgesia refers to different doses of two agents that provide approximate pain relief

Does not reflect interpatient variability

Ratio differs in acute and chronic use

Does not use incomplete cross tolerance

Equianalgesia refers to different doses of two agents that provide approximate pain relief

Does not reflect interpatient variability

Ratio differs in acute and chronic use

Does not use incomplete cross tolerance

Page 17: Pharmacy Intro Opioids and other drugs we use on palliative care

Opioid EquivalencyOpioid Equivalency

Morphine: Drug

Oral (mg) 2:1 Parenteral (mg)

Morphine 10 5

Codeine 1:10 100 --

Tramadol 1:5 50 --

Oxycodone 2:1 5 --

Hydromorphone 5:1 2 1

Fentanyl 100:1 -- 50 (mcg)

Sufentanil 1000:1 -- 5 (mcg)

Methadone 10:1 1 --

Page 18: Pharmacy Intro Opioids and other drugs we use on palliative care
Page 19: Pharmacy Intro Opioids and other drugs we use on palliative care

FentanylFentanyl

Page 20: Pharmacy Intro Opioids and other drugs we use on palliative care

Morphine BT (mg po) 10 20 30 40 50 80 160

Morphine 24H (mg po) 100 200 300 400 500 800 1600

Fentanyl Transdermal (mcg/h)

25 50 75 100 125 200 300

Hydromorphone 24H (mg po)

20 40 60 80 100 160 240

Hydromorphone BT (mg po)

2 4 6 8 10 16 24

Page 21: Pharmacy Intro Opioids and other drugs we use on palliative care

Fentanyl PatchFentanyl Patch

For relatively stable pain

Permeates the skin and a depot is formed

12hrs to develop analgesia

Plasma levels stabilize after 2 sequential patch applications

Half-life about 17 hours after removal

For relatively stable pain

Permeates the skin and a depot is formed

12hrs to develop analgesia

Plasma levels stabilize after 2 sequential patch applications

Half-life about 17 hours after removal

Page 22: Pharmacy Intro Opioids and other drugs we use on palliative care

MethadoneMethadone

Opioid agonist (mu, kappa, delta)

N-methyl-d-aspartate (NMDA) antagonist

Inhibits reuptake of serotonin and noradrenalin

Nociceptive and neuropathic pain

Opioid agonist (mu, kappa, delta)

N-methyl-d-aspartate (NMDA) antagonist

Inhibits reuptake of serotonin and noradrenalin

Nociceptive and neuropathic pain

Page 23: Pharmacy Intro Opioids and other drugs we use on palliative care

Analgesic effect 30-60mins

Duration 4-6hrs

T1/2 8-100+ hrs (~30hrs)

Peak 1.5-3hrs

Large Vd, 80% bioavailability, large protein binding

Accumulates in chronic use

Metabolized in liver, eliminated in urine and feces

Multiple drug interactions

Analgesic effect 30-60mins

Duration 4-6hrs

T1/2 8-100+ hrs (~30hrs)

Peak 1.5-3hrs

Large Vd, 80% bioavailability, large protein binding

Accumulates in chronic use

Metabolized in liver, eliminated in urine and feces

Multiple drug interactions

Page 24: Pharmacy Intro Opioids and other drugs we use on palliative care

Side Effects of OpioidsSide Effects of Opioids

Nausea (50-70%) and Vomiting (15-20%)

Constipation

Sedation

Confusion

Respiratory depression

Urinary retention

Pruritus

↑ Qt with methadone

Nausea (50-70%) and Vomiting (15-20%)

Constipation

Sedation

Confusion

Respiratory depression

Urinary retention

Pruritus

↑ Qt with methadone

Page 25: Pharmacy Intro Opioids and other drugs we use on palliative care

Other Medications (our cheat sheet)

Other Medications (our cheat sheet)

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QuestionsQuestions