1. Calculate total mg dose taken in past 24-h.
2. Determine equi-analgesic dose (table).
3. If pain is controlled on current opioid, reduce the new opioid daily dose by 30–50 % to account for cross-tolerance.
4. If inpatient with proper monitoring, methodically titrate to achieve analgesic effect during first 24 h and/or consider patient controlled analgesia (PCA)
5. Monitor for adverse events and effectiveness.
Buprenorphine (IM/IV): 0.4 mg
Meperidine (IV/IM/SC): 75 mg
Butorphanol (IM/IV): 2.0 mg
Meperidine (PO): 300 mg
Codeine (IM/IV): 120 mg
Methadone (acute IV): 5.0 mg
Codeine (PO): 200 mg
Methadone (acute PO): 10 mg
Fentanyl (IM/IV): 0.1 mg
Morphine (IV/IM/SC): 10 mg
Fentanyl (Transdermal): 0.2 mg
Morphine (acute PO): 60 mg
Hydrocodone (PO): 30 mg
Morphine (chronic PO): 30 mg
Hydromorphone (IV/IM/SC): 1.5 mg
Oxycodone (PO): 20 mg
Hydromorphone (PO): 7.5 mg
Oxymorphone (IV/IM/SC): 1.0 mg
Oxymorphone (PO): 10 mg
Chronic Opioid Prescribing Best Practices to Mitigate Opioid Overdose [5]
1.
Confirmation of pathology which warrants opioids via a thorough history and physical exam as well as appropriate diagnostic testing.
2.
Exhaust non-opioid based medications when possible.
3.
Review of medical records to rule out potential contraindications (suicide, diversion, illicit drug use, addiction, noncompliance, lack of legitimate diagnosis, etc.)
4.
Implement patient–physician opioid agreement.
5.
Screen for opioid diversion: routine urine/oral drug screening, review of online state-controlled prescription monitoring program (if available) to assess if receiving opioids from several different providers (rule out “doctor shopping” or “double dipping”), rule out multiple early refill requests, random pill counts, etc.
Opioid medications should only be used for the treatment of pain when the severity of the pain warrants it and with confirmed pathology. Typically, this potent medication should only be considered when the patient’s pain is affecting their activities of daily living and function, and when multiple non-opioid pain medications have failed to adequately control the patient’s pain. Visual Analogue Scale (VAS) pain scores alone can be misleading. Each patient’s physiological response to opioid treatments will be unique and a tailored approach should be implemented to reduce the possibility of over-medicating. When treatment is initiated, it should be required by the physician that the patient agrees to abide by a patient–physician opioid agreement. This agreement specifies the patient is not to consume any alcohol, marijuana, or other illegal substances. Patients must also agree to undergo periodic and unscheduled urine drug screens (UDS) to test for illegal substance abuse as well as to monitor if the prescribed medication is being utilized. UDS are a simple test that can screen for metabolites of commonly abused substances and medications. An example of this is patients who use heroin in conjunction with prescribed opioids will test positive for 6-monoacetylmorphine (6-MAM) for approximately 12 h after substance abuse occurs (Fig. 11.1). Beyond this 12 h window only morphine will be present in the patients UDS. The following image illustrates the metabolites of heroin and its eventual metabolism to morphine in the body. Tramadol, methadone, and ketamine are also very effective pain management medications that have both opioid receptor activity and NMDA receptor activities. Methadone and ketamine have very complex pharmacodynamics and pharmacokinetics with a high propensity for overdose potential; thus, they are often reserved for proficient pain specialists.
Fig. 11.1
Morphine-based metabolites
Tailoring Opioid Doses for Patient-Specific Needs
A tailored approach requires the potency and dose of opioids to be increased incrementally as pain symptoms and patient comorbidities dictate.
Contraindications for Opioids
Lack of appropriate pathology
Severe respiratory instability
Severe psychiatric instability or suicide risk
Unaddressed or recent substance use disorder
Severe opioid allergy/side effects
Co-administration of drugs capable of inducing life-threatening interactions.
Inappropriate use of medication (providing medication to others, concurrent alcohol use, concurrent or illegal substance use
For cases of mild pain, the initial regimen should be a nonsteroidal anti-inflammatory drug (NSAIDs) or acetaminophen. For moderate levels of pain, an opioid receptor agonist such as tramadol, hydrocodone, or oxycodone can be paired alongside with NSAIDs or acetaminophen when deemed appropriate. In cases of severe pain, a higher potency opioid receptor agonist such as morphine, hydromorphone, oxymorphone, methadone, or fentanyl may be considered for use. DNA testing appears to be a promising new method of tailored prescribing. Genetic testing can assist a physician in determining which opioids are most appropriate for a specific patient. Genetic sampling of saliva is easily done during the initial patient evaluation.
Several of the opioids listed above can be modified to increase the duration of their effectiveness. These modified opioids are typically found in forms such as extended-release tablets. These long-acting opioid treatments should only be given to patients who are considered to have high opioid tolerance and when treatment with short-acting opioids alone provides suboptimal pain relief. Patients who fall into this category of treatment must be closely monitored for adverse effects. Extended-release tablets should never be used to treat acute or postoperative pain, or opioid-naive patients. Patients should be warned to never split extended-release pills into partial doses or crush medications. Such actions can cause immediate release of 12–24 h amount of dosing, thus causing adverse effects such as respiratory depression and overdose/death.
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