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E
P
E
C
EE
PP
EE
CC
Pain Management WorkshopPain Management Workshop
Stacie Levine MD
Section of GeriatricsDepartment of Medicine
Stacie Levine MDStacie Levine MD
Section of GeriatricsSection of GeriatricsDepartment of MedicineDepartment of Medicine
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OutlineOutline
Pain assessment
WHO analgesic ladder
Opiate conversions
Barriers
Management of side effects Potential pitfalls in prescribing
Case examples
Pain assessmentPain assessment
WHO analgesic ladderWHO analgesic ladder
Opiate conversionsOpiate conversions BarriersBarriers
Management of side effectsManagement of side effects
Potential pitfalls in prescribingPotential pitfalls in prescribing
Case examplesCase examples
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An unfolding case (L.T.)An unfolding case (L.T.)
75 y.o. female CAD, spinal stenosis
Recent hospital discharge for angina,precipitated by severe lumbar radicular
pain
Discharged home with medicalmanagement, T#3 and neurontin for pain
Sees you first time for follow-up, c/onausea from T#3, did not help pain
WHAT DO YOU DO?
75 y.o. female CAD, spinal75 y.o. female CAD, spinal stenosisstenosis
Recent hospital discharge for angina,Recent hospital discharge for angina,precipitated by severe lumbarprecipitated by severe lumbar radicularradicular
painpain
Discharged home with medicalDischarged home with medicalmanagement, T#3 andmanagement, T#3 and neurontinneurontin for painfor pain
Sees you first time for followSees you first time for follow--up, c/oup, c/onausea from T#3, did not help painnausea from T#3, did not help pain
WHAT DO YOU DO?WHAT DO YOU DO?
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Rule #1:Choose your medRule #1:Choose your med
Pain history
Nociceptive vs. Neuropathic
Use a pain scale wheneverpossible
Choose a route of administration
Pain historyPain history
NociceptiveNociceptive vs.vs. NeuropathicNeuropathic
Use a pain scale wheneverUse a pain scale whenever
possiblepossible
Choose a route of administrationChoose a route of administration
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No Pain Worst Pain
0 1 2 3 4 5 6 7 8 9 10
Numeric ScaleNumeric Scale
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No Pain0
Mild1
Moderate2
Severe3
Very Severe4
Worst5
Verbal Descriptive ScaleVerbal Descriptive Scale
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Faces Pain Scale andPain ThermometerFaces Pain Scale andPain Thermometer
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WHO 3-stepLadderWHO 3-stepLadder
1 mild1 mild
2 moderate2 moderate
3 severe3 severe
MorphineHydromorphone
Methadone
LevorphanolFentanyl
Oxycodone
Adjuvants
MorphineHydromorphone
Methadone
LevorphanolFentanyl
Oxycodone
Adjuvants
A/CodeineA/Hydrocodone
A/Oxycodone
Tramadol Adjuvants
A/CodeineA/Hydrocodone
A/Oxycodone
Tramadol Adjuvants
ASA/NSAIDs
Acetaminophen
Cox-2
Adjuvants
ASA/NSAIDs
Acetaminophen
Cox-2
Adjuvants
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Step 1: Non-opioidsStep 1: Non-opioids
Acetaminophen
NSAIDS
Cox-2
Adjuvants Non-systemic therapies
Non-medication modalities
AcetaminophenAcetaminophen
NSAIDSNSAIDS
CoxCox--22
AdjuvantsAdjuvants NonNon--systemic therapiessystemic therapies
NonNon--medication modalitiesmedication modalities
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Step 2: Mild Opioids,Opioid-likeStep 2: Mild Opioids,Opioid-like
Codeine (e.g. T #3)
Hydrocodone (e.g. Vicodin)
Oxycodone (e.g. Percocet)
Tramadol (Ultram) +/- Adjuvants
Codeine (e.g. T #3)Codeine (e.g. T #3)
HydrocodoneHydrocodone (e.g.(e.g. VicodinVicodin))
OxycodoneOxycodone (e.g.(e.g. PercocetPercocet))
TramadolTramadol ((UltramUltram)) +/+/-- AdjuvantsAdjuvants
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Step 3: Strong OpioidsStep 3: Strong Opioids
Morphine
Oxycodone
Hydromorphone (Dilaudid)
Fentanyl
Levorphanol Methadone
+/- Adjuvants
MorphineMorphine
OxycodoneOxycodone
HydromorphoneHydromorphone ((DilaudidDilaudid)) FentanylFentanyl
LevorphanolLevorphanol MethadoneMethadone
+/+/-- AdjuvantsAdjuvants
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Opioid PharmacologyOpioid Pharmacology
Block the release ofneurotransmitters in the spinal cord
Mu, delta, kappa Conjugated in liver
Excreted via kidney (90%95%)
First-order kinetics
Block the release ofBlock the release ofneurotransmitters in the spinal cordneurotransmitters in the spinal cord
MuMu, delta, kappa, delta, kappa Conjugated in liverConjugated in liver
Excreted via kidney (90%Excreted via kidney (90%95%)95%) FirstFirst--order kineticsorder kinetics
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PlasmaC
oncentra
tion
PlasmaC
oncentra
tion
PlasmaC
oncentra
tion
000 Half-life (t1/2
)HalfHalf--life (tlife (t1/21/2
)) TimeTimeTime
IVIVIV
po / prpo / prpo / pr
SC / IMSC / IMSC / IM
CmaxCCmaxmax
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Opioid pharmacology . . .Opioid pharmacology . . .
Cmax (peak) after
po, pr 1 hSC, IM 30 minIV 6 15 min
half-life at steady state
po / po / SC / IM / IV 3-4 h
CCmax (peak)max (peak) afterafter
popo, pr, pr 1 h1 hSC, IMSC, IM
30 min30 min
IVIV 66 15 min15 min halfhalf--life at steady statelife at steady state
popo // popo / SC / IM / IV/ SC / IM / IV 33--4 h4 h
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. . . Opioid pharmacology. . . Opioid pharmacology
Steady state after 45 half-lives
steady state after 1 day (24 hours)
Duration of effect of immediate-release formulations (exceptmethadone)
35 hours po / pr
shorter with parenteral bolus (1-2 hours)
Steady state after 4Steady state after 45 half5 half--liveslivessteady state after 1 day (24 hours)steady state after 1 day (24 hours)
Duration of effect of immediateDuration of effect of immediate--release formulations (exceptrelease formulations (except
methadone)methadone)
335 hours po / pr5 hours po / pr
shorter with parenteral bolus (1shorter with parenteral bolus (1--2 hours)2 hours)
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Opioid management forcontinuous painOpioid management forcontinuous pain
PRN not appropriate
Dose find:
-begin with short-acting opioid ATC-know if patient is opioid nave or not
-allow breakthrough based on Cmaxand patients metabolism
PRN not appropriatePRN not appropriate
Dose find:Dose find:
--begin with shortbegin with short--actingacting opioidopioid ATCATC--know if patient isknow if patient is opioidopioid nave or notnave or not
--allow breakthrough based onallow breakthrough based on CmaxCmaxand patients metabolismand patients metabolism
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What do we do for L.T.?What do we do for L.T.?
Lets use Morphine IR
Morphine 15 mg po q 4 hr, ATC
Breakthrough
-With normal metabolic function
-Morphine 15 mg po q 1 hr, prn
What else do we write for?
Lets use Morphine IRLets use Morphine IR
Morphine 15 mgMorphine 15 mg popo q 4 hr, ATCq 4 hr, ATC
BreakthroughBreakthrough
--With normal metabolic functionWith normal metabolic function
--Morphine 15 mgMorphine 15 mg popo q 1 hr,q 1 hr, prnprn
What else do we write for?What else do we write for?
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Rule #2: Address concernsRule #2: Address concerns
Addiction
Dependence
Pseudoaddiction
Tolerance Side effects
AddictionAddiction
DependenceDependence
PseudoaddictionPseudoaddiction
ToleranceTolerance
Side effectsSide effects
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Opioid adverse effectsOpioid adverse effects
Common UncommonConstipation Bad dreams / hallucinations
Dry mouth Dysphoria / deliriumNausea / vomiting Myoclonus / seizures
Sedation Pruritus / urticaria
Sweats Respiratory depression
Urinary retention
SIADH
CommonCommon UncommonUncommonConstipationConstipation Bad dreams / hallucinationsBad dreams / hallucinations
Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium
Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures
SedationSedation Pruritus / urticariaPruritus / urticaria
SweatsSweats Respiratory depressionRespiratory depression
Urinary retentionUrinary retention
SIADHSIADH
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Managing GI Effects of
Opioids
Managing GI Effects of
OpioidsConstipation
Prevent with scheduled softeners PLUS stimulantsAvoid bulking agents
Nausea and Vomiting
Encourage patients to eat frequent, small mealsProvide promotility agents (metoclopramide),
serotonergic blocking agents (odansetron,granisetron) or dopaminergic blocking agents
(haloperidol, metoclopramide, prochlorperazine)
If symptoms are related to head movements, considermeclizine or scopolamine
ConstipationConstipation
Prevent with scheduled softeners PLUS stimulantsPrevent with scheduled softeners PLUS stimulants
Avoid bulking agentsAvoid bulking agents
Nausea and VomitingNausea and Vomiting
Encourage patients to eat frequent, small mealsEncourage patients to eat frequent, small mealsProvide promotility agents (metoclopramide),Provide promotility agents (metoclopramide),
serotonergic blocking agents (odansetron,serotonergic blocking agents (odansetron,
granisetron) or dopaminergic blocking agentsgranisetron) or dopaminergic blocking agents
(haloperidol, metoclopramide, prochlorperazine)(haloperidol, metoclopramide, prochlorperazine)
If symptoms are related to head movements, considerIf symptoms are related to head movements, consider
meclizine or scopolaminemeclizine or scopolamine
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Managing Sedation and
Delirium of Opioids
Managing Sedation and
Delirium of Opioids
If pain control is adequate, decrease dose by 25%
Change to a different opioid preparation
Use small doses of psychostimulants (2.5 to 5 mgmethylphenidate or dextroamphetamine) forexcessive somnolence
Use nonsedating antipsychotics (haloperidol,risperidone) for delirium
If pain control is adequate, decrease dose by 25%If pain control is adequate, decrease dose by 25%
Change to a different opioid preparationChange to a different opioid preparation
Use small doses of psychostimulants (2.5 to 5 mgUse small doses of psychostimulants (2.5 to 5 mgmethylphenidate or dextroamphetamine) formethylphenidate or dextroamphetamine) forexcessive somnolenceexcessive somnolence
UseUse nonsedatingnonsedating antipsychotics (haloperidol,antipsychotics (haloperidol,risperidone) for deliriumrisperidone) for delirium
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Managing Respiratory
Depression of Opioids
Managing Respiratory
Depression of OpioidsDoes not occur in patients on long-term
opioids
Can occur in opioid-nave patients and thosewhose opioid dose is rapidly escalated
Is always preceded by slowly progressivesomnolence
Tolerance to respiratory depressant effects
develops rapidly (48-72 hours)If you must treat:
-Dilute naloxone (10:1) in saline and infuse
until breathing pattern returns to normal
Does not occur in patients on longDoes not occur in patients on long--termtermopioidsopioids
Can occur in opioidCan occur in opioid--nanave patients and thoseve patients and thosewhose opioid dose is rapidly escalatedwhose opioid dose is rapidly escalated
Is always preceded by slowly progressiveIs always preceded by slowly progressivesomnolencesomnolence
Tolerance to respiratory depressant effectsTolerance to respiratory depressant effects
develops rapidly (48develops rapidly (48
--72 hours)72 hours)
If you must treat:If you must treat:
--Dilute naloxone (10:1) in saline and infuseDilute naloxone (10:1) in saline and infuse
until breathing pattern returns to normaluntil breathing pattern returns to normal
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AddictionAddictionA psychologic dependence on drugs and
a behavioral syndrome characterizedby compulsive drug use and continueduse despite harm to self and others
Opioids do NOT cause psychologicdependence
Use of opioids for pain managementdoes NOT cause addiction
A psychologic dependence on drugs andA psychologic dependence on drugs and
a behavioral syndrome characterizeda behavioral syndrome characterizedby compulsive drug use and continuedby compulsive drug use and continueduse despite harm to self and othersuse despite harm to self and others
Opioids doOpioids do NOTNOT cause psychologiccause psychologicdependencedependence
Use of opioids for pain managementUse of opioids for pain managementdoesdoes NOTNOT cause addictioncause addiction
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PseudoaddictionPseudoaddictionOccurs in context of
undertreatment of painbehavioral, family, or psychologic dysfunction
Consists of behaviors that are reminiscent ofaddiction but driven by untreated orundertreated pain
Disappears once pain control is adequate
Occurs in context ofOccurs in context of
undertreatment of painundertreatment of painbehavioral, family, or psychologic dysfunctionbehavioral, family, or psychologic dysfunction
Consists of behaviors that are reminiscent ofConsists of behaviors that are reminiscent ofaddiction but driven by untreated oraddiction but driven by untreated or
undertreatedundertreated painpain
Disappears once pain control is adequateDisappears once pain control is adequate
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ToleranceToleranceReduced effects of a given dose of medicationover time
Tolerance to analgesic effects is rare
Doses remain unchanged when pain stimulus
is stable
Tolerance to unwanted side effects is
observed and is desired
Disease progression (not tolerance), should besuspected when increasing doses arerequired for pain control
Reduced effects of a given dose of medicationReduced effects of a given dose of medication
over timeover time
Tolerance to analgesic effects is rareTolerance to analgesic effects is rare
Doses remain unchanged when pain stimulusDoses remain unchanged when pain stimulus
is stableis stable
Tolerance to unwanted side effects isTolerance to unwanted side effects is
observed and is desiredobserved and is desired
Disease progression (not tolerance), should beDisease progression (not tolerance), should be
suspected when increasing doses aresuspected when increasing doses are
required for pain controlrequired for pain control
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Physical Dependence on
Opioids/Withdrawal
Physical Dependence on
Opioids/Withdrawal
Develops if opioids are abruptly discontinued
or dose is rapidly decreased
Results from neuropsychologic changes fromexogenous opioids
Symptoms: Nausea, vomiting, diarrhea,abdominal pain, body aches, psychosis andhallucinations
Treatment: If pain stimulus lessens, reducedose by 50% every 2 to 3 days
Develops if opioids are abruptly discontinuedDevelops if opioids are abruptly discontinued
or dose is rapidly decreasedor dose is rapidly decreasedResults from neuropsychologic changes fromResults from neuropsychologic changes from
exogenousexogenous opioidsopioids
Symptoms:Symptoms: Nausea, vomiting, diarrhea,Nausea, vomiting, diarrhea,abdominal pain, body aches, psychosis andabdominal pain, body aches, psychosis andhallucinationshallucinations
Treatment: If pain stimulus lessens, reduceTreatment: If pain stimulus lessens, reducedose by 50% every 2 to 3 daysdose by 50% every 2 to 3 days
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Rule #3: Adjust the doseappropriatelyRule #3: Adjust the doseappropriately
24 hours later: L.T. still c/o pain
What do you want to know?
How do you adjust the dose?
adjust dose daily
mild / moderate pain 25%50%severe / uncontrolled pain 50%100%
adjust more quickly for severe
uncontrolled pain
24 hours later: L.T. still c/o pain24 hours later: L.T. still c/o pain
What do you want to know?What do you want to know?
How do you adjust the dose?How do you adjust the dose?
adjust dose dailyadjust dose daily
mild / moderate painmild / moderate pain 25%25%50%50%severe / uncontrolled painsevere / uncontrolled pain 50%50%100%100%
adjust more quickly for severeadjust more quickly for severe
uncontrolled painuncontrolled pain
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L.T. next day after doseadjustmentL.T. next day after doseadjustment
Feels great on new regimen
-Morphine IR 15 mg 2 tabs po q 4 hr
Wants to take less pills
How do we switch to long-acting
oral? How do we calculate the
breakthrough dose?
Feels great on new regimenFeels great on new regimen
--Morphine IR 15 mg 2 tabsMorphine IR 15 mg 2 tabs popo q 4 hrq 4 hr
Wants to take less pillsWants to take less pills
How do we switch to longHow do we switch to long--actingacting
oral?oral? How do we calculate theHow do we calculate the
breakthrough dose?breakthrough dose?
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Routine oral dosingextended-release preparationsRoutine oral dosingextended-release preparations
Improve compliance, adherence
Dose q 8, 12, or 24 h (product
specific)dont crush or chew tablets
may flush time-release granules down
feeding tubes
Adjust dose q 24 days (once steady
state reached)
Improve compliance, adherenceImprove compliance, adherence
Dose q 8, 12, or 24 h (productDose q 8, 12, or 24 h (product
specific)specific)dont crush or chew tabletsdont crush or chew tablets
may flush timemay flush time--release granules downrelease granules down
feeding tubesfeeding tubes
Adjust dose q 2Adjust dose q 24 days (once steady4 days (once steady
state reached)state reached)
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Breakthrough dosingBreakthrough dosing
Use immediate-release opioids
10% of 24-h dose or 1/3 of one ER dose
offer after Cmax reached
po / pr q 1 hSC, IM q 30 minIV q 1015 min
Do NOT use extended-releaseopioids for breakthrough
Use immediateUse immediate--release opioidsrelease opioids
10% of 2410% of 24--h dose or 1/3 of one ER doseh dose or 1/3 of one ER dose
offer after Coffer after Cmaxmax reachedreached
po / prpo / pr q 1 hq 1 hSC, IMSC, IM q 30 minq 30 minIVIV q 10q 1015 min15 min
Do NOT use extendedDo NOT use extended--releaserelease
opioidsopioids for breakthroughfor breakthrough
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Clearance concernsClearance concerns Conjugated by liver
90%95% excreted in urine
Dehydration, renal failure, severe
hepatic failure dosing interval (extend time) or dosage sizeif oliguria or anuria
STOP routine dosing of morphine
use ONLY prn
Conjugated by liverConjugated by liver
90%90%95% excreted in urine95% excreted in urine
Dehydration, renal failure, severeDehydration, renal failure, severe
hepatic failurehepatic failure dosing interval (extend time)dosing interval (extend time) oror dosage sizedosage sizeif oliguria or anuriaif oliguria or anuria
STOP routine dosing of morphineSTOP routine dosing of morphine
use ONLY prnuse ONLY prn
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Ongoing assessmentOngoing assessment
Increase analgesics until painrelieved or adverse effectsunacceptable
Be prepared for sudden changes inpain
Driving is safe if
pain controlled, dose stable, no adverseeffects
Increase analgesics until painIncrease analgesics until pain
relieved or adverse effectsrelieved or adverse effects
unacceptableunacceptable
Be prepared for sudden changes inBe prepared for sudden changes in
painpain
Driving is safe ifDriving is safe ifpain controlled, dose stable, no adversepain controlled, dose stable, no adverse
effectseffects
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Methadone, an exceptionMethadone, an exception
Mu, kappa, delta agonist
NMDA receptor antagonist
Inhibits reuptake of serotonin andnorepinephrine
Significant inter-individual variability Drug interactions (coumadin-like)
MuMu, kappa, delta agonist, kappa, delta agonist
NMDA receptor antagonistNMDA receptor antagonist
Inhibits reuptake of serotonin andInhibits reuptake of serotonin andnorepinephrinenorepinephrine
Significant interSignificant inter--individual variabilityindividual variability Drug interactions (Drug interactions (coumadincoumadin--like)like)
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MethadoneMethadone
Initial rapid tissue distribution
Slow elimination phase
Long and variable half-life (13-58hours)
Dose interval is variable (q 6 or q 8 h) Dose usually adjusted q 47 days
Minimally impacted by renal disease
Initial rapid tissue distributionInitial rapid tissue distribution
Slow elimination phaseSlow elimination phase
Long and variable halfLong and variable half--life (13life (13--5858hours)hours)
Dose interval is variable (q 6 or q 8 h)Dose interval is variable (q 6 or q 8 h) Dose usually adjusted q 4Dose usually adjusted q 47 days7 days
Minimally impacted by renal diseaseMinimally impacted by renal disease
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Not recommended . . .Not recommended . . .
Meperidine
poor oral absorption, short half-life
normeperidine is a toxic metabolite
-longer half-life (6 hours), no analgesia
-psychotomimetic adverse effects,myoclonus, seizures
-if dosing q 3 h for analgesia,normeperidine builds up
-accumulates with renal failure
MeperidineMeperidine
poor oral absorption, short halfpoor oral absorption, short half--lifelife
normeperidine is a toxic metabolitenormeperidine is a toxic metabolite
--longer halflonger half--life (6 hours), no analgesialife (6 hours), no analgesia--psychotomimeticpsychotomimetic adverse effects,adverse effects,
myoclonusmyoclonus, seizures, seizures
--if dosing q 3 h for analgesia,if dosing q 3 h for analgesia,normeperidine builds upnormeperidine builds up
--accumulates with renal failureaccumulates with renal failure
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Not recommended . . .Not recommended . . .
Propoxyphene (Darvon)no better than placebo
low efficacy at commercially availabledoses
toxic metabolite (norpropoxyphene) athigh doses
PropoxyphenePropoxyphene ((DarvonDarvon))no better than placebono better than placebo
low efficacy at commercially availablelow efficacy at commercially available
dosesdoses
toxic metabolite (toxic metabolite (norpropoxyphenenorpropoxyphene) at) at
high doseshigh doses
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. . . Not recommended. . . Not recommended
Mixed agonist-antagonistspentazocine, butorphanol, nalbuphine,
dezocine
-compete with agonists withdrawal-analgesic ceiling effect
-high risk of psychotomimetic adverseeffects with pentazocine, butorphanol
Mixed agonistMixed agonist--antagonistsantagonistspentazocine, butorphanol, nalbuphine,pentazocine, butorphanol, nalbuphine,
dezocinedezocine
--compete with agonistscompete with agonists withdrawalwithdrawal--analgesic ceiling effectanalgesic ceiling effect
--high risk of psychotomimetic adversehigh risk of psychotomimetic adverse
effects with pentazocine, butorphanoleffects with pentazocine, butorphanol
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Pain poorly responsiveto opioidsPain poorly responsiveto opioids
If dose escalation adverse effects-more sophisticated therapy to
counteract adverse effect
-alternative
route of administration
opioid (opioid rotation)-coanalgesic
-use a nonpharmacologic approach
If dose escalationIf dose escalation adverse effectsadverse effects--more sophisticated therapy tomore sophisticated therapy to
counteract adverse effectcounteract adverse effect
--alternativealternative
route of administrationroute of administration
opioid (opioid rotation)opioid (opioid rotation)--coanalgesiccoanalgesic
--use ause a nonpharmacologicnonpharmacologic approachapproach
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Bolus effectBolus effect
Swings in plasma concentration-drowsiness 1 hour after ingestion
-pain before next dose due Must move to
-extended-release preparation
-continuous SC, IV infusion
Swings in plasma concentrationSwings in plasma concentration--drowsiness drowsiness 1 hour after ingestion1 hour after ingestion
--pain before next dose duepain before next dose due
Must move toMust move to
--extendedextended--release preparationrelease preparation
--continuous SC, IV infusioncontinuous SC, IV infusion
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Rule #4 Changing routesof administrationRule #4 Changing routesof administration
Equianalgesic tableguide to initial dose selection
Significant first-pass metabolism ofpo / pr doses
codeine, hydromorphone, morphine
po / pr to SC, IV, IM
23 1
Equianalgesic tableEquianalgesic tableguide to initial dose selectionguide to initial dose selection
Significant firstSignificant first--pass metabolism ofpass metabolism ofpo / pr dosespo / pr doses
codeine, hydromorphone, morphinecodeine, hydromorphone, morphine
po / prpo / pr toto SC, IV, IMSC, IV, IM
2233 11
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. . . Changing opioids. . . Changing opioids
Cross-tolerancestart with 50%75% of published
equianalgesic dose
more if pain, less if adverse effects
Methadone
start with 10%25% of publishedequianalgesic dose
CrossCross--tolerancetolerancestart with 50%start with 50%75% of published75% of published
equianalgesic doseequianalgesic dose
more if pain, less if adverse effectsmore if pain, less if adverse effects
MethadoneMethadone
start with 10%start with 10%25% of published25% of publishedequianalgesic doseequianalgesic dose
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MethadoneMethadoneDaily Morphine Methadone:Morphine
1000 mg (1:20)
Gazelle. Methadone for the treatment of pain. J Pall Med.
2003;6(4):620
Daily MorphineDaily Morphine Methadone:MorphineMethadone:Morphine
1000 mg (1:20)(1:20)
Gazelle. Methadone for the treatment of pain.Gazelle. Methadone for the treatment of pain. J Pall Med.J Pall Med.
2003;6(4):6202003;6(4):620
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Back to L.TBack to L.T
Currently taking MSSR 90 mg po q 12 Wants the convenience of the duragesic
patch (Fentanyl)
Adjusting for incomplete cross-tolerance,what dose would you use?
Rule of thumb:
-1 mcg fentanyl patch roughly equals mg po morphine
-OR 25 mcg patch = 60 mg po morphine
Currently taking MSSR 90 mgCurrently taking MSSR 90 mg popo q 12q 12 Wants the convenience of theWants the convenience of the duragesicduragesic
patch (patch (FentanylFentanyl))
Adjusting for incomplete crossAdjusting for incomplete cross--tolerance,tolerance,what dose would you use?what dose would you use?
Rule of thumb:Rule of thumb:
--1 mcg1 mcg fentanylfentanyl patch roughly equals patch roughly equals mgmg popo morphinemorphine
--OR 25 mcg patch = 60 mgOR 25 mcg patch = 60 mg popo morphinemorphine
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Nonpharmacologic painmanagement . . .Nonpharmacologic painmanagement . . .
NeurostimulationTENS, acupuncture
Anesthesiologicnerve block
Surgical
cordotomy
Physical therapy
exercise, heat, cold
NeurostimulationNeurostimulationTENS, acupunctureTENS, acupuncture
AnesthesiologicAnesthesiologicnerve blocknerve block
SurgicalSurgical
cordotomycordotomy
Physical therapyPhysical therapy
exercise, heat, coldexercise, heat, cold
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. . . Nonpharmacologicpain management. . . Nonpharmacologicpain management
Psychological approachescognitive therapies
(relaxation, imagery, hypnosis)
biofeedback
behavior therapy, psychotherapy
Complementary therapiesmassage
art, music, aroma therapy
Psychological approachesPsychological approachescognitive therapiescognitive therapies
(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)
biofeedbackbiofeedback
behavior therapy, psychotherapybehavior therapy, psychotherapy
Complementary therapiesComplementary therapiesmassagemassage
art, music, aroma therapyart, music, aroma therapy
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Common pitfalls to avoidCommon pitfalls to avoid
Changing meds/route on discharge
Writing the prescription
Medication cost
Educating patient/family
Appropriate follow-up
Changing meds/route on dischargeChanging meds/route on discharge Writing the prescriptionWriting the prescription
Medication costMedication cost
Educating patient/familyEducating patient/family
Appropriate followAppropriate follow--upup
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Palliative Care ConsultsPager: PALLPalliative Care ConsultsPager: PALL
Age 18 and older Whos appropriate?
-Seriously ill, prolonged hospital stay-Multiple hospitalizations and ICU stays for
same dx
-Difficult pain and other symptom control
-Challenging family dynamics
-Help with clarification of goals of care
Age 18 and olderAge 18 and older Whos appropriate?Whos appropriate?
--Seriously ill, prolonged hospital staySeriously ill, prolonged hospital stay
--Multiple hospitalizations and ICU stays forMultiple hospitalizations and ICU stays for
samesame dxdx
--Difficult pain and other symptom controlDifficult pain and other symptom control
--Challenging family dynamicsChallenging family dynamics
--Help with clarification of goals of careHelp with clarification of goals of care
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