opioid presentation
TRANSCRIPT
Pain ManagementDivya Suri
Patient Case• RS is a 62 yo male presents with worsening pain over the past
two days to midsternal chest and right ribs radiating to upper back accompanied with shortness of breath despite treatment with oxycodone. Patient usually has shortness of breath with increased pain. Baseline pain is 5/10 and has been waxing and waning today. Patient had CT pulmonary angiogram performed in ED with no PE evident. Patient received MS 6 IV with pain relief. Patient denies cough, nausea, vomiting, diarrhea, fever, chills.
• Height: 167.64cm (5’6”)• Weight:88.5kg• BMI = 31.5 kg/m2
Patient CaseVS• On Admission: • BP 145/105 RR 26 HR 113 T 97.7F• 6/27:• BP 142/96 RR 18 HR 72 T 98.4FLabs (latest results):• WBC: 8.8 K/uL (WNL) (normal = 4.5 – 10 K/uL)• RBC: 3.91 M/uL (low) (normal = 4.5 – 5.5 M/uL)• Hg: 11.1 g/dL (low) (normal = 13.5 – 16.5 g/dL)• Hct: 33.0% (low) (normal = 41 – 50%)• Serum creatinine: 0.50 mg/dL (0.5 – 1.1 mg/dL)• Creatinine Clearance: 77.13 mL/min
Patient Case• Home Medications
1. Oxycodone 10 mg PO tablet: 1 T PO Q4-6H PRN - breakthrough moderate pain
2. Fentanyl 75 mcg/hr transdermal film, ER: 1 patch transdermally Q72H
3. Tamsulosin 0.4 mg capsule: 1 C PO QD (after a meal)4. Atenolol 50 mg PO tablet: 1 T PO QD5. Senna PO tablet: 2 TS PO HS6. Docusate sodium 100 mg PO capsule: 1 C PO BID7. Polyethylene glycol 3350 oral powder for reconstitution: 17
grams PO QD8. Atorvastatin 40 mg PO tablet: 1 T PO HS
Patient Case• Hospital Medications
• Enoxaparin Injectable: 40mg SQ Q24H (DVT prophylaxis?)• Lactulose Syrup: 30 grams PO BID (constipation)• Magnesium Hydroxide Suspension (Milk of Magnesia): 30 mL PO QD PRN
for constipation• Hydromorphone PCA (1mg/mL)
• Initial bolus dose: 0 mg• Initial demand dose: 0.5 mg• Lockout: 15 minutes• Continuous rate: 0.8 mg/hour• Four hour limit: 11.2 mgs
• Naloxone Injectable: 0.1 mg IV push every 3 minutes PRN for ANY of the following change in patient status: RR of 10 breaths/minute; Oxygen saturation less than 90%; Sedation score of 6, stop after 4 doses (opioid overdose)
• Ondansetron Injectable: 4 mg IV push Q8H PRN for nausea• Dexamethasone Injectable: 4 mg IV push BID at 6AM and 2PM• Gabapentin capsule: 400 mg PO TID
Patient Case• Hospital Medications (Continued):
• Cyclobenzaprine tablet: 5 mg PO TID PRN for muscle spasm• Acetaminophen tablet: 650mg PO Q6H PRN for temperature over 37.9C• Acetaminophen tablet: 650mg PO Q6H PRN for mild pain• Atenolol tablet: 50 mg PO QD (HTN)• Atorvastatin tablet: 40 mg PO HS (hyperlipidemia)• Docusate capsule: 100 mg PO TID (constipation)• Senna tablet: 2 tablets PO HS (constipation)• Polyethylene glycol 3350: 17 grams PO QD – dissolve in 8 oz water, juice,
cola, or tea (constipation)• Tamsulosin: 0.4 mg PO QD (BPH)
Pain Assessment• ABCDE
• Ask about the pain regularly and assess the pain systemically (aching, throbbing, sharp, shooting, burning, dull, cramping, etc.)
• Believe the patient and family in their reports of pain (along with reports of what works and what doesn’t)
• Choose pain control options appropriate for the patient, family, and setting
• Deliver interventions in a timely and coordinated fashion• Empower patients and their families and enable patient and their
family to control their treatment to the greatest extent possible
http://learn.chm.msu.edu/painmanagement/assessment.asp#a
Pain Assessment• PQRSTU
• Provoke/Palliate - what makes the pain better or worse?• Quality: What does the pain feel like? (stabbing, dull, etc.)• Radiation• Severity• Time (when did it start?)• U (what impact has the pain had on you?)
Pain Assessment• OLDCARTS
• Onset (acute vs. chronic)• Location (+radiation) – does it stay in one place? (Somatic vs.
visceral)• Duration – does it come and go or stay throughout the day?
(Constant vs. intermittent)• Characteristics – how does it feel? (Ex. if it’s tingling, burning,
radiating, it’s neuropathic. If it’s short, dull, and achy, it’s nociceptive)
• Aggravating factors (moving vs. sitting)• Relieving factors – what have you done to try to relieve the pain?• Treatment – what have you tried? Including OTC
(pharmacological vs. nonpharmacological)• Severity: Pain scales
Pain Rating Scales• Numerical Scale (1 – 10)• Wong – Baker FACES Pain Rating Scale
http://onlinelibrary.wiley.com/store/10.1111/j.1553-2712.2009.00620.x/asset/j.1553-2712.2009.00620.x.pdf;jsessionid=5BCBD1A94E21389494C504C5437B11A9.f01t01?v=1&t=hx1nwoqy&s=e3afe8cf9aa4fac7e07cfbb1147235ab7b69f191
Pain Rating Scales • Behavioral Pain Scale
• None (0) – relaxed, calm expression, moves easily• Mild (1-3) – stressed, tense expression, occasional grimace, frown, able to comfort• Moderate (4-6) – guarded movement, grimacing, squirming, more reassurance to
comfort• Severe (7-9) – moaning, restless, rigid movement, difficult to comfort• Worst pain (10) – crying out, unable to comfort
• FLACC
Pain Rating Scales• PAIN AD (Pain Assessment IN Advanced Dementia)
WHO Pain Relief Ladder
http://www.who.int/cancer/palliative/painladder/en/
Natural Opioids: Phenanthrene Rings• Morphine• Codeine
Semi-Synthetic Opioids: Phenanthrene Rings• Hydrocodone
• Hydromorphone
O
OH
O
N+ CH3
H
H Cl
O
CH3O
O
N+ CH3
H
HCOO-
OH
OH
COOH
Semi-Synthetic Opioids (Phenanthrene)• Oxymorphone
O
OH
O
N+ CH3
OH
H Cl
Synthetic Opioids: Phenylpiperidines• Fentanyl
• Meperidine
O
N+
H
N
n
O
OO
O OH
O
OH
2
N+
CH3
H
O O
Cl
Synthetic Opioids: Phenylheptane• Methadone
O
CH3
N+
CH3
HCH3 Cl
Opioids: Allergy vs. Pseudoallergy
Short Acting vs. Long ActingCategory Benefits Drugs
Short-acting:
for intermittent and breakthrough pain1
Easier to titrate More rapidly
attained steady-state plasma concentrations2
Morphine sulfate Hydromorphone
Codeine Fentanyl Hydrocodone Oxymorphone Oxycodone Levorphanol
Long-acting:
For treating chronic pain in patients with consistent pain levels3,4
Makes around-the-clock therapy possible
Dosing convenience and flexibility
Relative steady-state concentrations of opioid concentrations in the blood3,4
Morphine (sustained-release)
Oxycodone (sustained-release)
Transdermal fentanyl Hydromorphone
(sustained-release)
How to Calculate a Long Acting Opioid Dose
• Calculate total daily dose (TDD) of opiates used• Use ~ 80% of dose and divide into appropriate dosing intervals• However if patient not currently controlled, can use 100%• Reassess as needed
How to Calculate an Immediate Release Dose• After calculating LA dose/day, take 50-70% and divide into
appropriate dosing intervals
Immediate Release Opioid
Onset of Analgesia (minutes)
Duration of Effect (hours)
Morphine PO 30 – 40 4
Oxycodone PO 30 4
Oxymorphone PO 30 4 – 6
Hydromorphone PO 30 4
Methadone PO 10 – 15 4 – 8
Fentanyl Transmucosal 5 – 10 1 - 2
Patient Controlled Analgesia• Precise and convenient method of providing opioid therapy to
patients with moderate to severe acute or chronic pain.• Uses a computerized pump that has a syringe, cartridge, or infusion
bag that contains the opioid locked inside the pump.• Onset of IV opioids range from 1 – 4 minutes with a peak effect of
15 – 20 minutes.
Patient Controlled Analgesia• Converting to PCA Infusions to opioid intolerant patients
• Step 1: determine the patient’s current opioid regimen and calculate a conversion to the parenteral opioid you will be using
• Step 2: if the patient’s current opioid regimen is effective, go with the dose calculated in step 1 If not, increase the dose by 25 – 100%
• Step 3: If the continuous infusion you will be starting represents a dosage increase from the patient’s previous opioid regimen, provide a loading dose (not necessary in this case) so it will boost their blood level of the opioid so they won’t have to wait several hours to receive pain relief
• Step 4: Bolus calculation: 50 – 150% of the hourly infusion rate.• Step 5: Select a dosing interval for the PCA bolus dose• Step 6: Assess the patient! Assess for therapeutic effectiveness and potential
adverse effects every 10 – 15 minutes until the patient is stable.• Step 7: Assess the patient! Reassess the need to alter continuous infusion
rate every 6 – 8 hours. If the patient isn’t getting adequate relief, don’t increase the continuous infusion rate more than 100% at any one time. When increasing continuous infusion, give a loading dose to more rapidly achieve steady state blood levels of the opioid.
Potential Adverse EffectsSystem/Type Adverse Effect
Gastrointestinal Constipation
Nausea and vomiting
Central nervous system Sedation
Cognitive impairment: “mental clouding”/confusion
Respiratory Respiratory depression
Dermal Pruritus
Endocrine Decrease in libido
Hypogonadism
Treatment Options for Potential Adverse EffectsAdverse Effect Treatment
Nausea and vomiting Use antiemetic; switch opioids
Constipation Treat preemptively with diet and regular use of stool softeners and laxatives
Sedation Reduce dose; add nonopioid or adjuvant analgesic; add mild stimulants
Mental clouding Eliminate nonessential medications with central nervous system effects; consider neuroleptics for persistent delirium
Respiratory depression Stop opioid and administer naloxone, only if strongly indicated
Pruritus Switch opioids; use antihistamines
Endocrine dysfunction/ decreased libido
Monitor endocrine function; use replacement therapy, endocrine consultation
Naloxone
• FDA approved indications• Opioid antagonist indicated for emergency treatment of
known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression
• Immediate administration as emergency therapy in settings where opioids may be present
• Warnings/Precautions• Acute opioid withdrawal
• Symptoms: pain, HTN, sweating, agitation, irritability• CV: Pulmonary edema and cardiovascular instability,
including ventricullar fibrillation, associated with abrupt reversal when using opioid antagonists in those with CV disease or patients receiving medications with potential CV effects (ex. hypotension, arrhythmias)
Naloxone• Adverse Reactions: related to reversing dependency and
precipitating withdrawal• CV: cardiac arrest, fever, flushing, hypertension,
hypotension, tachycardia, ventricular fibrillation, ventricular tachycardia
• CNS: agitation, coma, encephalopathy, hallucination, irritability, nervoussness, restlessness
• GI: abdominal cramps, NVD• Neuromuscular and skeletal: paresthesia, piloerection,
tremor, weakness• Respiratory: dyspnea, hypoxia, pulmonary edema,
respiratory depression, rhinorrhea, sneezing