Presentation on theme: "Developing an Effective Oral Analgesic Regimen"— Presentation transcript:
1Developing an Effective Oral Analgesic Regimen Theresa Kristopaitis, MDDepartment of Internal Medicine, Division of General MedicineAssociate Medical Director, Loyola Hospice
2General Principles Assess pain thoroughly Know your patient Know the medicationsDose to reduce pain by at least 50%Reassess frequently
3Pain Pain is a personal, complex experience with 3 components Sensory EmotionalCognitive
4Review Neuroscience lectures on pain physiology! P&T lectures on NSAIDs and opiates!
5Pain pathophysiology Acute pain Chronic pain identified event, resolves days–weeksusually nociceptiveChronic paincause often not easily identified, multifactorialindeterminate durationnociceptive and / or neuropathicSomatic pain – body surface tissue or musculoskeletal tissue. Localized, sharpVisceral – not well localized -= visceral do not contain many nociceptors. Result of compression, obstruction, infiltration, ischemia, strethcing, inflammation, or thoracic, abdominal or pelvic visceralNociceptive pain – results from actual or potential tissue damage. Resultof ongoing activation of nociceptors on primary afferent nerves bynoxious stimuliSomative vs visceral
7“Adjuvant Analgesic”Drug which has a primary indication other than pain managementActs as analgesic in some painful conditionsAntidepressantsCorticosteroidsAnticonvulsantsLocal anestheticsOsteoclast inhibitorsRadiopharmaceuticalsMuscle relaxantsBenzodiazepenes
8Our Case Continuous pain Moderate intensity Chronic, non-neuropathic Worsens with certain activites
9Where to begin? Begin low dose immediate release oral opioid Examples Hydrocodone 5mgMorphine 5mgOxycodone 3mgHydromorphone 1mgHospice and Palliative Care Training for Physicians: UNIPAC 3Assessment and Treatment of Physical Pain Associated with Life-Limiting Illness, CP Storey et al, edEPERC, Fast Facts
11Opioids vs Narcotics Opioid Narcotic Naturally occurring, semisynthetic, and synthetic drugs which produce effects by combining with opioid receptors and antagonized by nalaxoneNarcotic“numbness” or “stupor”Describes morphine like drugs and drugs of abuse (including coca/cocaine derivates)
12Opioids vs Narcotics “Who’s got the opioid keys?” “Who’s got the narc keys?”“Who’s got the opioid keys?”
13Immediate Release Oral Opioid Administered assingle agentscombination productsPeak analgesic effect occurs in minutesExpected total duration of analgesia of 2-4 hours.Standard reference sources generally cite a 4 hour dosing interval for the single-agent opioids4-6 or 6 hour intervals for combination productsAgency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline (1994) recommends dosing intervals for all short-acting opioids at an interval or every 3-4 hours, an interval more consistent with patient reports of pain relief and the half-life of oral opioids.
14Combination opiate/nonopiate -50 different opioid combination productsContain either acetaminophen, aspirin or ibuprofen, with an opioidrange of tablet strengths and liquidstypically used for moderate pain that is episodicFor persistent pain administered on around-the-clock basis
15Step 2 Opioid Combos Potency Oxycodone > hydrocodone > codeinePropoxyphene = aspirin or acetaminophenThe dose limiting property of all the combination products is?aspirin, acetaminophen or NSAID
17Our patient On Percocet Combination opioid/nonopioid Oxycodone/acetaminophenStrengths2.5/3255/3257.5/3257.5/50010/32510/650
18Initial Plan Oxycodone/acetaminophen Not helping - still 5-6/10 pain 2.5/325 q 6 hoursNot helping - still 5-6/10 painTitrationIncrease 25-50% for mild-moderate painIncrease % for moderate – severe painMost short acting opiates can be safely titrated every 2 hoursSide effect evaluationSedation
19EPIC In-Box Oxycodone/acetaminophen 5/325 tab 1-2 tabs every 6 hours as needed
20Case Options? Increase dose of oxycodone/acetaminophen? 10/325 tabs – take 1 ½, not relieved, take 2Change dosing interval?Q 4 hoursScheduled vs PRN dosing?ScheduledChange to another opiate combo?Oxycodone most potentChange to non-combo opiate?Soon - reaching acetaminophen maxAdd breakthrough dose of opiate?Yes, but will need an agent without acetaminophenAdd an adjuvant?Re-evaluarte characteristics of painBegin long acting opiate?When stable daily dosage requirements determined
21Plan Relief!! Oxycodone 10/325 1 1/2 tabs q 4 hours scheduled 2 days later, a little better, not sleepy2 tabs q 4hours scheduledTitrated oxycodone from 40mg /24 hours to 120mg/24 hours(acetaminophen 3900mg/24 hours)Relief!!
26Extended-release opiate preparations MorphineMorphine ER, MS Contin, Kadian, AvinzaOxycodoneOxycodone ER, OxycontinFentanylTransderm patch (Duragesic)
27Extended-release opioid preparations Dose q 8, 12, or 24 h (product specific)Don’t crush or chew capsulesNo capsules down feeding tubesmay flush time-release granules (Kadian) down feeding tubesAdjust dose q 2–4 days (once steady state reached)Fentanyl transderm q 72 hoursAdjust dose at 6 days (once steady state achieved)
28Extended-release opioid preparations Should not be used for rapid titration in patients with severe pain
30Could we use extended release morphine? Could we use transdermal fentanyl?
31Fentanyl Lipid soluble -Crosses skin and oral mucosa Transdermal fentanyl25 mg patch » 45–135 (likely 50–60) mg PO morphine / 24 h12 mg patch is available now
32Fentanyl Transdermal Patch onset after application 24 hourseffect 72 hours (some patients 48 hours)ensure adherence to skinincreased absorption with increased body tempmay not be as effective in cachexia (minimal adipose tissue)
33Our patientConvert to FentanylOxycodone 120mg/24 hours
34Equianalgesic doses of opioid analgesics po / pr (mg) Analgesic SC / IV / IM (mg)100 Codeine 6015 Hydrocodone -4 Hydromorphone 1.515 Morphine 510 Oxycodone -
36Breakthrough Pain Incident Idiopathic, spontaneous End-of-dose failure Activity related, identifiable precipitantAnticipate and premedicate with short acting agentsIdiopathic, spontaneousUnpredictablePRN opiate, consider adjuvantEnd-of-dose failureIncrease dose or shorten time between doses of long-acting agent
37Breakthrough Pain Use immediate-release opioids 10%–15% of 24-hr doseoffer after Cmax reachedpo q 1hror 50% regular 4 hour doseDo NOT use extended-release opioids
38Our Case Oxycodone 120mg/24 hours 10-15%Oxycodone 15mg PO q 1 hour PRN breakthrough pain
39Follow-up Oxycodone ER 120mg q 12 hours Oxycodone 15mg breakthrough 3 weeks later EPIC in-boxHas taken 4 breakthrough doses daily x 2 daysRe-evaluate pain60mg additional oxycodoneIncrease oxycodone ER to150mg q 12 hoursNew breakthrough dose?Oxycodone 30mg q 1 hours PRN