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Opioids and other drugs we use on palliative care

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Presentation on theme: "Opioids and other drugs we use on palliative care"— Presentation transcript:

1 Opioids and other drugs we use on palliative care
Pharmacy Intro Opioids and other drugs we use on palliative care

2 Objectives Discuss the role of opioids in end of life care
Discuss the pharmacology and side effects of opioids Discuss opioid equivalencies and conversions Review basics of methadone Discuss other medications commonly used

3 Objectives (cont’d) Discuss other medications commonly used

4 Barriers to opioid use Physician Patient
Inadequate training in analgesic practices Over-reliance on anecdotal experience Irrational fears of overdosage and addiction (Boston Collaborative survey treated for acute pain... 4 developed addiction) Focus on diagnostic work-up vs. treatment of symptoms (“Need to know what I’m treating”... might mask what is going on) Fear of exacerbating hemodynamic instability (ATLS recommends relief of severe pain is important part of management) Unfounded concerns of masking intra-abdominal pathology (15mg given M v placebo... no pathology masked... may enhance examination by reducing anxiety and increasing cooperation) Overly suspicious that everyone with chronic pain is an addict Fear of confrontation with consultants Patient

5 Why use opioids Pain is experienced by over 80% of patients
Over 60% will be moderate to severe Dyspnea present in 80% of advanced cancer 95% COPD at end of life 75% of advanced disease (all comers)

6 Opioids in Canada

7 Opioid Pharmacokinetics
All have similar PK (except methadone) onset of action mins duration of action 4-5 hrs LA 8-12hrs

8 Opioid Pharmacokinetics
Fentanyl and Sufentanil Onset mins Duration 45 mins First pass metabolism Highly lipophilic (SL/IN)

9 Opioid Dosing No ceiling effect ↑dose = ↑analgesic effect (log-linear)
Dose increased until symptom relief or limiting side effects

10 Start with IR dosing “Start Low and Go Slow” Q4H PO = SL = PR SC/IV = 50% of PO Reassess regularly

11 Breakthrough Dose IR 50-100% of the Q4H dose or 10% of the 24hr dose
Q1H - PO/SL Q30Min - SC Q10Min - IV For simplicity... all routes are Q1H prn

12 Do Not Use Extended Release Opioid for Breakthrough

13 Titration Increase equal to total 24 hours breakthrough dose
Mild to moderate pain - 50% If no response Increase more rapidly Switch to parenteral

14 Opioid Rotation Why? Inadequate analgesia despite appropriate escalation Intractable/Intolerable side effects Altered renal/hepatic function Drug shortages

15 Use a consistent method
Use the same conversion table Consider incomplete cross-tolerance, patient variations, limitation of tables

16 Equianalgesia Dose Ratio
Equianalgesia refers to different doses of two agents that provide approximate pain relief Does not reflect interpatient variability Ratio differs in acute and chronic use Does not use incomplete cross tolerance

17 Opioid Equivalency Oral (mg) Parenteral (mg) Morphine 10 5 Codeine 100
Morphine: Drug Oral (mg) 2:1 Parenteral (mg) Morphine 10 5 Codeine 1:10 100 -- Tramadol 1:5 50 Oxycodone Hydromorphone 5:1 2 1 Fentanyl 100:1 50 (mcg) Sufentanil 1000:1 5 (mcg) Methadone 10:1 Tramacet 37.5mg


19 Fentanyl

20 Morphine BT (mg po) 10 20 30 40 50 80 160 Morphine 24H (mg po) 100 200 300 400 500 800 1600 Fentanyl Transdermal (mcg/h) 25 75 125 Hydromorphone 24H (mg po) 60 240 Hydromorphone BT (mg po) 2 4 6 8 16 24

21 Fentanyl Patch For relatively stable pain
Permeates the skin and a depot is formed 12hrs to develop analgesia Plasma levels stabilize after 2 sequential patch applications Half-life about 17 hours after removal

22 Methadone Opioid agonist (mu, kappa, delta)
N-methyl-d-aspartate (NMDA) antagonist Inhibits reuptake of serotonin and noradrenalin Nociceptive and neuropathic pain

23 Analgesic effect 30-60mins
Duration 4-6hrs T1/ hrs (~30hrs) Peak 1.5-3hrs Large Vd, 80% bioavailability, large protein binding Accumulates in chronic use Metabolized in liver, eliminated in urine and feces Multiple drug interactions

24 Side Effects of Opioids
Nausea (50-70%) and Vomiting (15-20%) Constipation Sedation Confusion Respiratory depression Urinary retention Pruritus ↑ Qt with methadone

25 Other Medications (our cheat sheet)







32 Questions

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