Developing an Developing an Effective Oral Effective Oral Analgesic Regimen Analgesic Regimen Theresa Kristopaitis, MD Theresa Kristopaitis, MD Department of Internal Medicine, Department of Internal Medicine, Division of General Medicine Division of General Medicine Associate Medical Director, Loyola Associate Medical Director, Loyola Hospice Hospice
Developing an Effective Oral Analgesic Regimen. Theresa Kristopaitis, MD Department of Internal Medicine, Division of General Medicine Associate Medical Director, Loyola Hospice. General Principles. Assess pain thoroughly Know your patient Know the medications - PowerPoint PPT Presentation
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Developing an Effective Developing an Effective Oral Analgesic RegimenOral Analgesic Regimen
Theresa Kristopaitis, MDTheresa Kristopaitis, MDDepartment of Internal Medicine, Division of Department of Internal Medicine, Division of
General MedicineGeneral MedicineAssociate Medical Director, Loyola HospiceAssociate Medical Director, Loyola Hospice
General PrinciplesGeneral Principles
Assess pain thoroughlyAssess pain thoroughly
Know your patientKnow your patient
Know the medicationsKnow the medications
Dose to reduce pain by at least 50%Dose to reduce pain by at least 50%
Reassess frequentlyReassess frequently
PainPain
Pain is a personal, complex experience Pain is a personal, complex experience with 3 componentswith 3 components SensorySensory EmotionalEmotional CognitiveCognitive
ReviewReview
Neuroscience lectures on pain physiology!Neuroscience lectures on pain physiology!
P&T lectures on NSAIDs and opiates!P&T lectures on NSAIDs and opiates!
Chronic painChronic pain cause often not easily identified, multifactorialcause often not easily identified, multifactorial indeterminate durationindeterminate duration nociceptive and / or neuropathicnociceptive and / or neuropathic
Nociceptive pain – results from actual or potential tissue damage. Resultof ongoing activation of nociceptors on primary afferent nerves bynoxious stimuliSomative vs visceral
WHO 3-Step LadderWHO 3-Step Ladder
Step 1 - Mild
Step 2 - Moderate
Step 3 - Severe
Aspirin
Acetaminophen
NSAIDs
Codeine/…
Hydrocodone/…
Oxycodone/…
…/acetaminophenor NSAID
Tramadol
Morphine
Hydromorphone
Methadone
Oxycodone
Fentanyl
Always consider adding an adjuvant Rx
““Adjuvant Analgesic”Adjuvant Analgesic”
Drug which has a primary indication other than Drug which has a primary indication other than pain managementpain managementActs as analgesic in some painful conditionsActs as analgesic in some painful conditions AntidepressantsAntidepressants CorticosteroidsCorticosteroids AnticonvulsantsAnticonvulsants Local anestheticsLocal anesthetics Osteoclast inhibitorsOsteoclast inhibitors RadiopharmaceuticalsRadiopharmaceuticals Muscle relaxantsMuscle relaxants BenzodiazepenesBenzodiazepenes
Hospice and Palliative Care Training for Physicians: UNIPAC 3Assessment and Treatment of Physical Pain Associated with Life-Limiting Illness, CP Storey et al, ed
EPERC, Fast Facts
Community Service AnnouncementCommunity Service Announcement
Opioids vs NarcoticsOpioids vs Narcotics
OpioidOpioid Naturally occurring, semisynthetic, and Naturally occurring, semisynthetic, and
synthetic drugs which produce effects by synthetic drugs which produce effects by combining with opioid receptors and combining with opioid receptors and antagonized by nalaxoneantagonized by nalaxone
NarcoticNarcotic ““numbness” or “stupor”numbness” or “stupor” Describes morphine like drugs and drugs of Describes morphine like drugs and drugs of
““Who’s got the narc keys?”Who’s got the narc keys?”
““Who’s got the opioid keys?”Who’s got the opioid keys?”
Immediate Release Oral OpioidImmediate Release Oral OpioidAdministered as Administered as single agents single agents combination productscombination products
Peak analgesic effect occurs in 60-90 minutesPeak analgesic effect occurs in 60-90 minutesExpected total duration of analgesia of 2-4 Expected total duration of analgesia of 2-4 hours. hours. Standard reference sources generally cite a 4 Standard reference sources generally cite a 4 hour dosing interval for the single-agent opioidshour dosing interval for the single-agent opioids 4-6 or 6 hour intervals for combination products 4-6 or 6 hour intervals for combination products
Agency for Health Care Policy and Research (AHCPR) Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline (1994) recommends dosing Clinical Practice Guideline (1994) recommends dosing intervals for all short-acting opioids at an interval or every 3-4 intervals for all short-acting opioids at an interval or every 3-4 hours, an interval more consistent with patient reports of pain hours, an interval more consistent with patient reports of pain relief and the half-life of oral opioids. relief and the half-life of oral opioids.
-50 different opioid combination products-50 different opioid combination products• Contain either acetaminophen, aspirin or Contain either acetaminophen, aspirin or
ibuprofen, with an opioidibuprofen, with an opioid• range of tablet strengths and liquidsrange of tablet strengths and liquids• typically used for moderate pain that is typically used for moderate pain that is
episodic episodic • For persistent pain administered on around-the-For persistent pain administered on around-the-
Propoxyphene = aspirin or acetaminophenPropoxyphene = aspirin or acetaminophen
The dose limiting property of all the The dose limiting property of all the combination products is?combination products is? aspirin, acetaminophen or NSAIDaspirin, acetaminophen or NSAID
WHO Step 2WHO Step 2TramadolTramadol
Centrally acting synthetic analgesicCentrally acting synthetic analgesic opioid receptor bindingopioid receptor binding Weak inhibition of serotonin uptakeWeak inhibition of serotonin uptake Weak inhibition of norepinephrine uptakeWeak inhibition of norepinephrine uptake
Not helping - still 5-6/10 painNot helping - still 5-6/10 pain TitrationTitration
Increase 25-50% for mild-moderate painIncrease 25-50% for mild-moderate painIncrease 50-100% for moderate – severe painIncrease 50-100% for moderate – severe pain
Most short acting opiates can be safely titrated every 2 Most short acting opiates can be safely titrated every 2 hourshours
Side effect evaluationSide effect evaluationSedationSedation
• 1-2 tabs every 6 hours as needed1-2 tabs every 6 hours as needed
Case Options?Case Options?Increase dose of oxycodone/acetaminophen?Increase dose of oxycodone/acetaminophen? 10/325 tabs – take 1 ½, not relieved, take 210/325 tabs – take 1 ½, not relieved, take 2
Scheduled vs PRN dosing?Scheduled vs PRN dosing? ScheduledScheduled
Change to another opiate combo?Change to another opiate combo? Oxycodone most potentOxycodone most potent
Change to non-combo opiate?Change to non-combo opiate? Soon - reaching acetaminophen maxSoon - reaching acetaminophen max
Add breakthrough dose of opiate?Add breakthrough dose of opiate? Yes, but will need an agent without acetaminophenYes, but will need an agent without acetaminophen
Add an adjuvant?Add an adjuvant? Re-evaluarte characteristics of painRe-evaluarte characteristics of pain
Begin long acting opiate?Begin long acting opiate? When stable daily dosage requirements determinedWhen stable daily dosage requirements determined
PlanPlan
Oxycodone 10/325Oxycodone 10/325 1 1/2 tabs q 4 hours scheduled1 1/2 tabs q 4 hours scheduled 2 days later, a little better, not sleepy2 days later, a little better, not sleepy 2 tabs q 4hours scheduled2 tabs q 4hours scheduled
Titrated oxycodone from 40mg /24 hours to 120mg/24 Titrated oxycodone from 40mg /24 hours to 120mg/24 hourshours
Dose q 8, 12, or 24 h (product specific)Dose q 8, 12, or 24 h (product specific) Don’t crush or chew capsulesDon’t crush or chew capsules No capsules down feeding tubesNo capsules down feeding tubes
may flush time-release granules (Kadian) down feeding may flush time-release granules (Kadian) down feeding tubestubes
Adjust dose q 2–4 days (once steady state Adjust dose q 2–4 days (once steady state reached)reached)
Fentanyl transderm q 72 hoursFentanyl transderm q 72 hours Adjust dose at 6 days (once steady state achieved)Adjust dose at 6 days (once steady state achieved)
Oxycodone 15mg PO q 1 hour PRN Oxycodone 15mg PO q 1 hour PRN breakthrough painbreakthrough pain
Follow-upFollow-up
Oxycodone ER 120mg q 12 hoursOxycodone ER 120mg q 12 hoursOxycodone 15mg breakthroughOxycodone 15mg breakthrough 3 weeks later EPIC in-box3 weeks later EPIC in-box Has taken 4 breakthrough doses daily x 2 daysHas taken 4 breakthrough doses daily x 2 days
Re-evaluate painRe-evaluate pain
60mg additional oxycodone60mg additional oxycodoneIncrease oxycodone ER toIncrease oxycodone ER to 150mg q 12 hours150mg q 12 hours