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Developing an Effective Oral Analgesic Regimen Theresa Kristopaitis, MD Department of Internal Medicine, Division of General Medicine Associate Medical.

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Presentation on theme: "Developing an Effective Oral Analgesic Regimen Theresa Kristopaitis, MD Department of Internal Medicine, Division of General Medicine Associate Medical."— Presentation transcript:

1 Developing an Effective Oral Analgesic Regimen Theresa Kristopaitis, MD Department of Internal Medicine, Division of General Medicine Associate Medical Director, Loyola Hospice

2 General Principles Assess pain thoroughly Know your patient Know the medications Dose to reduce pain by at least 50% Reassess frequently

3 Pain Pain is a personal, complex experience with 3 components Sensory Sensory Emotional Emotional Cognitive Cognitive

4 Review Neuroscience lectures on pain physiology! P&T lectures on NSAIDs and opiates!

5 Pain pathophysiology Acute pain identified event, resolves days–weeks identified event, resolves days–weeks usually nociceptive usually nociceptive Chronic pain cause often not easily identified, multifactorial cause often not easily identified, multifactorial indeterminate duration indeterminate duration nociceptive and / or neuropathic nociceptive and / or neuropathic Nociceptive pain – results from actual or potential tissue damage. Result of ongoing activation of nociceptors on primary afferent nerves by noxious stimuli Somative vs visceral

6 WHO 3-Step Ladder Step 1 - Mild Step 2 - Moderate Step 3 - Severe Aspirin Acetaminophen NSAIDs Codeine/… Hydrocodone/… Oxycodone/… …/ acetaminophen or NSAID Tramadol Morphine Hydromorphone Methadone Oxycodone Fentanyl Always consider adding an adjuvant Rx

7 “Adjuvant Analgesic” Drug which has a primary indication other than pain management Acts as analgesic in some painful conditions Antidepressants Antidepressants Corticosteroids Corticosteroids Anticonvulsants Anticonvulsants Local anesthetics Local anesthetics Osteoclast inhibitors Osteoclast inhibitors Radiopharmaceuticals Radiopharmaceuticals Muscle relaxants Muscle relaxants Benzodiazepenes Benzodiazepenes

8 Our Case Continuous painContinuous pain Moderate intensityModerate intensity Chronic, non-neuropathicChronic, non-neuropathic Worsens with certain activitesWorsens with certain activites

9 Where to begin? Begin low dose immediate release oral opioidBegin low dose immediate release oral opioid Examples Examples Hydrocodone 5mgHydrocodone 5mg Morphine 5mgMorphine 5mg Oxycodone 3mgOxycodone 3mg Hydromorphone 1mgHydromorphone 1mg Hospice and Palliative Care Training for Physicians: UNIPAC 3 Assessment and Treatment of Physical Pain Associated with Life- Limiting Illness, CP Storey et al, ed EPERC, Fast Facts

10 Community Service Announcement

11 Opioids vs Narcotics Opioid Naturally occurring, semisynthetic, and synthetic drugs which produce effects by combining with opioid receptors and antagonized by nalaxone Naturally occurring, semisynthetic, and synthetic drugs which produce effects by combining with opioid receptors and antagonized by nalaxoneNarcotic “numbness” or “stupor” “numbness” or “stupor” Describes morphine like drugs and drugs of abuse (including coca/cocaine derivates) Describes morphine like drugs and drugs of abuse (including coca/cocaine derivates)

12 Opioids vs Narcotics “Who’s got the narc keys?” “Who’s got the opioid keys?”

13 Immediate Release Oral Opioid Administered as single agents single agents combination products combination products Peak analgesic effect occurs in minutes Expected total duration of analgesia of 2-4 hours. Standard reference sources generally cite a 4 hour 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) 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.

14 Combination opiate/nonopiate -50 different opioid combination products Contain either acetaminophen, aspirin or ibuprofen, with an opioid Contain either acetaminophen, aspirin or ibuprofen, with an opioid range of tablet strengths and liquids range of tablet strengths and liquids typically used for moderate pain that is episodic typically used for moderate pain that is episodic For persistent pain administered on around-the- clock basisFor persistent pain administered on around-the- clock basis

15 Step 2 Opioid Combos Potency Oxycodone > hydrocodone > codeine Oxycodone > hydrocodone > codeine Propoxyphene = aspirin or acetaminophen The dose limiting property of all the combination products is? aspirin, acetaminophen or NSAID aspirin, acetaminophen or NSAID

16 WHO Step 2 Tramadol Centrally acting synthetic analgesic  opioid receptor binding  opioid receptor binding Weak inhibition of serotonin uptake Weak inhibition of serotonin uptake Weak inhibition of norepinephrine uptake Weak inhibition of norepinephrine uptakeCautions: Serotonin syndrome Serotonin syndrome Lowers seizure threshold Lowers seizure threshold

17 Our patient On Percocet Combination opioid/nonopioid Combination opioid/nonopioidOxycodone/acetaminophenStrengths 2.5/ /325 5/325 5/ / / / /500 10/325 10/325 10/650 10/650

18 Initial Plan Oxycodone/acetaminophen 2.5/325 q 6 hours 2.5/325 q 6 hours Not helping - still 5-6/10 pain Titration Titration Increase 25-50% for mild-moderate pain Increase % for moderate – severe pain Most short acting opiates can be safely titrated every 2 hours Most short acting opiates can be safely titrated every 2 hours Side effect evaluation Sedation

19 EPIC In-Box Oxycodone/acetaminophen 5/325 tab 5/325 tab 1-2 tabs every 6 hours as needed

20 Case Options? Increase dose of oxycodone/acetaminophen? 10/325 tabs – take 1 ½, not relieved, take 2 10/325 tabs – take 1 ½, not relieved, take 2 Change dosing interval? Q 4 hours Q 4 hours Scheduled vs PRN dosing? Scheduled Scheduled Change to another opiate combo? Oxycodone most potent Oxycodone most potent Change to non-combo opiate? Soon - reaching acetaminophen max Soon - reaching acetaminophen max Add breakthrough dose of opiate? Yes, but will need an agent without acetaminophen Yes, but will need an agent without acetaminophen Add an adjuvant? Re-evaluarte characteristics of pain Re-evaluarte characteristics of pain Begin long acting opiate? When stable daily dosage requirements determined When stable daily dosage requirements determined

21 Plan Oxycodone 10/ /2 tabs q 4 hours scheduled 1 1/2 tabs q 4 hours scheduled 2 days later, a little better, not sleepy 2 days later, a little better, not sleepy 2 tabs q 4hours scheduled 2 tabs q 4hours scheduled Titrated oxycodone from 40mg /24 hours to 120mg/24 hours Titrated oxycodone from 40mg /24 hours to 120mg/24 hours (acetaminophen 3900mg/24 hours) Relief!!

22 Q 4 hour ATC meds?

23 Extended-release opiate preparations Improve compliance, adherence

24 Extended Release Opiates NEVER!!!!! In opiate naïve patients!!!!!

25 Extended Release Preparations Extended Release Oral Morphine Extended Release Oral Oxycodone Transdermal Fentanyl

26 Extended-release opiate preparations Morphine Morphine ER, MS Contin, Kadian, Avinza Morphine ER, MS Contin, Kadian, AvinzaOxycodone Oxycodone ER, Oxycontin Oxycodone ER, OxycontinFentanyl Transderm patch (Duragesic) Transderm patch (Duragesic)

27 Extended-release opioid preparations Dose q 8, 12, or 24 h (product specific) Don’t crush or chew capsules Don’t crush or chew capsules No capsules down feeding tubes No capsules down feeding tubes may flush time-release granules (Kadian) down feeding tubes Adjust dose q 2–4 days (once steady state reached) Fentanyl transderm q 72 hours Adjust dose at 6 days (once steady state achieved) Adjust dose at 6 days (once steady state achieved)

28 Extended-release opioid preparations Should not be used for rapid titration in patients with severe pain

29 Case - How? Oxycodone 10/325 2 tabs q 4 hours 2 tabs q 4 hours 120mg oxycodone/24 hours Oxycodone ER 60mg q 12 hours

30 Could we use extended release morphine? Could we use transdermal fentanyl?

31 Fentanyl Lipid soluble -Crosses skin and oral mucosa Transdermal fentanyl 25  g patch  45–135 (likely 50–60) mg PO morphine / 24 h 25  g patch  45–135 (likely 50–60) mg PO morphine / 24 h 12  g patch is available now

32 Fentanyl Transdermal Patch onset after application  24 hours effect 72 hours (some patients 48 hours) ensure adherence to skin increased absorption with increased body temp may not be as effective in cachexia (minimal adipose tissue)

33 Our patient Convert to Fentanyl Oxycodone 120mg/24 hours Oxycodone 120mg/24 hours

34 Equianalgesic doses of opioid analgesics po / pr (mg)AnalgesicSC / IV / IM (mg) 100Codeine60 15Hydrocodone- 4Hydromorphone1.5 15Morphine5 10Oxycodone-

35 Conversion Oxycodone 120mg x Morphine 15mg Oxycodone 10mg Oxycodone 10mg =180mg morphine equivalent 25  g patch  50 mg PO morphine / 24 h 25  g patch  50 mg PO morphine / 24 h Fentanyl 75mcg/hr patch q 72 hrs

36 Breakthrough Pain Incident Activity related, identifiable precipitant Activity related, identifiable precipitant Anticipate and premedicate with short acting agents Idiopathic, spontaneous Unpredictable Unpredictable PRN opiate, consider adjuvant PRN opiate, consider adjuvant End-of-dose failure Increase dose or shorten time between doses of long- acting agent Increase dose or shorten time between doses of long- acting agent

37 Breakthrough Pain Use immediate-release opioids 10%–15% of 24-hr dose 10%–15% of 24-hr dose offer after C max reached offer after C max reached po  q 1hr or 50% regular 4 hour dose or 50% regular 4 hour dose Do NOT use extended-release opioids

38 Our Case Oxycodone 120mg/24 hours 10-15% 10-15% Oxycodone 15mg PO q 1 hour PRN breakthrough pain

39 Follow-up Oxycodone ER 120mg q 12 hours Oxycodone 15mg breakthrough 3 weeks later EPIC in-box 3 weeks later EPIC in-box Has taken 4 breakthrough doses daily x 2 days Has taken 4 breakthrough doses daily x 2 days Re-evaluate pain 60mg additional oxycodone Increase oxycodone ER to 150mg q 12 hours 150mg q 12 hours New breakthrough dose? Oxycodone 30mg q 1 hours PRN Oxycodone 30mg q 1 hours PRN

40 Bowel regimen

41 Final Thoughts Physical pain is the most common source of “suffering”

42 Total Pain Dame Cicely Saunders PhysicalEmotionalSocialSpiritual

43 Questions?


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