1. Calvin Lui, MD PGY2 February 8, 2014

2.  Common Opioid Agents and Good Starting Dosages  Opioid Conversion  Use of Patient Controlled Analgesia and Good Starting Dosages

3. A 74-year-old male recently fell and suffered a hip fracture. He is brought to the OR for reduction and hip replacement? He has left the OR and has been transferred to your Medicine service. How would you manage his pain postoperatively day 1?

4. A 74-year-old male recently fell and suffered a hip fracture. He is brought to the OR for reduction and hip replacement? He has left the OR and has been transferred to your Medicine service how would you manage his pain postoperatively day 1? Answer: Consider a PCA

5. Good for when a condition/surgery that cannot be easily controlled with IV pushes Basal, lockout period, and rescue options Use basal, if pain has been relatively controlled with PCA, but patient constantly has to push Many patients will not need a basal dosage Typical lock out period=10-15 minutes number of rescue dosages in a hour (4-6) One may also set number of dosages/hr Each day, check how much a patient has used and see if they can be converted to IV push or PO regimen

6.  Morphine: lockout of 10 minutes, 0.5-1 mg for rescue, 0 basal  Hydromorphone: lockout 10 minutes, 0.1-0.2 mg for rescue, 0 for basal  Fentanyl: lockout 10 minutes, 10-25 mcg for rescue, 0 for basal

7.  Let’s Start him on a regimen of Hydromorphone: lockout 10 minutes, 0.1- 0.2 mg for rescue, 0 for basal  By day 2, he needs 2.2 mg of hydromorphone throughout the day.  Consider converting him to IV pushes of medications to get him off the PCA

8. Morphine Oral solution: 5-10 mg PO q4-6H PRN IV: 2-4 mg q3-4H PRN, uptitrate as needed Check renal function Hydromorphone 0.3-0.4 mg IV q3-4 PRN, uptitrate as needed 4 mg PO q4H PRN Can use without checking renal function first Hydrocodone/APAP: 5mg/325mg PO 1-2 tabs q4H PRN Oxycodone/APAP: 5mg/325mg PO 1-2 tabs q4H PRN Codeine: 15-60 mg q4-6H PRN Fentanyl, IV: 25-25 mcg q30-60 min PRN for SEVERE PAIN

9.  Let’s start him on Hydromorphone 0.3 mg q3H PRN.  He will be using short acting medications, but we have given him at least an equivalent amount of medication to his PCA.

10.  We are preparing to send our gentleman to a skilled nursing facility, but would like to provide him with basal pain regimen that needs opioids. He still uses about 2.2 mg of hydromorphone per day. What should we do?  Answer: Long Acting opioids

11. 1) Calculate total amount used in 24 hours 2) Convert to everything to oral equivalents 3) Account for Cross-Tolerance 4) Convert to different opiate 5) PRN’s/breakthrough pain 6) Bowel regimen

13.  Add up amount from 24 hr period and convert into one of the following split BID or TID:  Oxycontin: usual doses 10-15 mg BID  MS Contin: usual doses of 30 mg daily or BID  Methadone: start 5 mg BID or TID  Fentanyl Patches: will vary, calc 24 hr oral morphine equivalent then look up equivalent on micromedex or uptodate  Keep rescue doses on previous pain medications

14.  Step 1: IV  PO conversion  2.2 mg IV Dilaudid to PO morphine  2.2 x 20 = 44 mg PO Morphine  Step 2: Cross tolerance?  YES! Reduce by 15% PO Morphine = 37.4mg  Step 3: Schedule PO Dosing frequency  MS CONTIN = BID Dosing. 37.4 in BID dosing  30/2 = 15mg MS Contin BID  Step 3: calculate breakthrough dosing  = minimum of 30-50% total daily requirement 37.4X0.5 = 18.7 mg / day  18.7 mg divided into q4h dosing = 18.7 / 6 = ~3 mg q4h PRN round to 5 mg q4H PRN with oral morphine solution  Step 4:add senna 17.2 mg qHS and colace 250 daily as bowel regimen

15.  Constipation is a given, no tolerance develops, use stimulants (Senokot, Bisocodyl, Pericolace)  Nausea/vomiting – tolerance can occur in 2- 5 days (tx with zofran/compazine/reglan)  Sedation – tolerance can occur in 2-3 days  Clonic jerks  Respiratory suppression

16.  Opioid medications are important for nocireceptive pain and need appropriate titration  PCAs are good for postsurgical patients and conditions needing heavy pain control  Consider long acting medications for basal control in patients requiring opioids for pain control