Pain Morning Report Robin Staib, PharmD December 22, 2011

Equianalgesic Doses (100%) 1)4mg IV morphine ______ PO morphine 4mg IV M x 3 = 12mg PO morphine 2)2mg IV dilaudid ______ PO dilaudid 2mg IV M x5 = 10mg PO dilaudid 3)50mcg IV fentanyl _______ IV morphine 0.05mg x 10/0.1= 5mg IV morphine 4)30mg PO morphine _______ PO oxycodone 30mg PO M x 20mg PO O/30mg PO M = 20mg PO oxy 5)12mg PO dilaudid _______ PO morphine 12mg PO D x 30mg PO M/7.5mg PO D = 48mg PO morphine (7.5:30) 1:3 1:5 0.1:10 30:20 7.5:30

Patient 1

69 y/o male with Multiple Myeloma (MM) and ESRD on PD who presents with a 2 wk hx of R sided pleuritic thoracic back pain ▫Thoracic x-ray shows compression fx at T11, T12 and diffuse lytic lesions Home Pain regimen ▫oxycodone IR 5mg #180 (30mg oxy/day) Hospital regimen ▫oxycontin 10mg BID, oxycodone IR 5-10mg Q4 hrs prn, & hydromorphone IV 0.25mg Q 3 hrs prn

Pt stating pain 10/10 ▫24 hr pain medication utilization:  Oxycontin (10mg bid) = 20mg  Oxycodone IR (5-10mg Q 4hrs prn) = 50mg  Hydromorphone IV (0.25mg Q 3hrs prn) = 0 How would you adjust pt’s pain regimen A) Increase oxycodone 10-15mg Q 3 hrs prn B) Increase Hydromorphone IV dose 0.5mg Q 3hrs prn C) Increase Oxycontin to 20mg BID (20 to 40) D) Increase Oxycontin to 10mg TID (20 to 30) Goal is to use orals mg

After the increase to Oxycontin 20mg BID pt still complaining of 10/10 pain Do you feel patient would benefit from a fentanyl patch? ▫A) Yes ▫B) No

Fentanyl Patch Indicated for the management of persistent mod-to- severe pain when around the clock pain control is needed  Criteria met? Not for use in opioid-naïve patients ▫Pt should be tolerating a stable dose of at least 30mg oral morphine or its equivalent/day before placing 12mcg/hr patch  Criteria Met? (70mg oxy = ______________) ~100x more potent than morphine ▫(10mcg fentanyl ~ 1mg morphine) mg morphine

So if wanted to start fentanyl patch, which dose would you start? A) Fentanyl 12mcg B) Fentanyl 25mcg C) Fentanyl 50mcg D) Fentanyl 75mcg 70mg Oxy x 30mg Mor /20mg Oxy = 105mg Mor x 0.65 = mg po morphine PO Morphine mg/24hrs Fentanyl Patch mcg/hr mcg/hr mcg/hr mcg/hr

Patient 2

20 yo male with right dental swelling; dental abscess Current Pain Regimen Hydromorphone 1-1.5mg IV Q 3hrs prn Morphine 2-4mg IV Q 3hrs prn Pt expected to go to surgery either later today or first thing tomorrow morning How do you want to control pt’s acute pain? A) Continue IV pushes B) Start a PCA

PCA 1) Which Opioid? A) Fentanyl B) Hydromorphone C) Morphine 1.5mg IV Hydro = 10 mg IV morphine ** Hydromorphone should not be first line therapy- should be reserved for pt’s unable to tolerate morphine/fentanyl or those who have failed therapy 2) Dose (Basal? Demand?) Basal? Demand ? NO (1.5mg Q 3hrs prn) (4mg Q 3hrs prn)

ConcentrationMorphineHydromorphoneFentanyl Infusion Rate (Continuous Rate): ________mg/hr 0-2mg/hr *(1mg/hr) ________mg/hr 0-0.3mg/hr *(0.2mg/hr) ________mcg/hr 0-25mcg/hr *(10mcg/hr) Demand Dose________mg mg *(1mg) ________mg mg *(0.2mg) ________mcg 10-25mcg *(10mcg) Lockout Interval_________min 8-12 min *(12min) _________min 6-12 min *(8min) _________min 4-8 min *(6min) 4 Hr Lockout________mg mg ________mg 6-10 mg ________mcg mcg 2mg 12min

Recommend Demand dose of 2mg Q 12min with a bolus of 2mg Q 2hrs prn Following day, POD1- after extraoral and intraoral I&D R submandibular, sublingual and lateral pharyngeal odontogenic abscess with extraction of #32 ▫Pt used 21 doses ( ) over past 10hrs  21 x 2mg = IV = Oral morphine Plan to convert to oral pain regimen in preparation for discharge 42mg 126mg

Oral Pain Regimen? (126mg po morphine/10hrs) A) MS Contin and MSIR B) Fentanyl Patch C) Lortab Elixer D) Percocet Plan: Lortab Elixer 7.5mg hydrocodone/15ml (501mg APAP) Q 4hrs prn pain Morphine IV 2-4mg Q 2hr prn

Patient 3

35 yo male with necrotizing pancreatitis complaining of severe pain No opioid history Started on Fentanyl IV pushes Fentanyl 50mcg Q2hrs prn Fentanyl 200mcg Q 1hr prn mcg Fentanyl = ____mg IV morphine 0.1mg Fentanyl = 10mg IV morphine So 0.2mg = morphine 20mg IV morphine = dilaudid 20 mg IV 3 mg IV

PCA ConcentrationFentanyl Infusion Rate (Continuous Rate) ____mcg/hr 0-25mcg/hr (*10mcg/h) Demand Dose_____mcg 0-25mcg (*10mcg) Lockout Interval____min 4-8 min (*6min) 4 Hr Lockout_____mcg mcg Basal Rate: 0 Demand Dose: 25mcg Q 20min 4Hr Lockout: 225mcg/4hr (56mcg/hr) Over 18hrs used 35doses out of 61 attempts 35 x 25mcg = 875mcg (48mcg/hr) How do you want to adjust pt’s PCA? a)Add basal rate b)Increase demand dose c)Decrease interval d)Change to morphine

Patient 4

26 yo female admitted 0300 with a new DVT and history of heroin abuse Pt reports being maintained on methadone 100mg daily for heroin withdrawal avoidance What do you do? A) Start Methadone 100mg daily B) Nothing, wait and see if pt actually withdrawals C) Start Methadone 10mg BID and use prn methadone if pt starts having withdrawal sxms D) Add prn IV morphine and call clinic in morning to verify methadone dose

Started methadone 10mg BID Pharmacy called SW behavioral health and was told that pt had not been seen for >30days At 36hrs, pt evaluated and was lying in bed calm and without diaphoresis or other obvious signs of withdrawal Discharge occurred within 48hrs and ▫Sparred 80mg/day of methadone administration ▫Avoided potential harm to pt with high dose methadone (>30days) ▫Didn’t increase maintenance demand with our dosing ▫Successfully controlled sxms of withdrawal

Patient 5

26yo female on oxycontin 80mg TID and dilaudid 8mg Q 3hrs prn Admitted and made NPO including meds for surgery Plan to start dilaudid PCA Would you start a basal rate? And if so what rate? A)1mg/hr B)0.25mg/hr C)0.5mg/hr D)0.75mg/hr 240mg oxycodone x 7.5mg po dilaudid x 1.5mg IV dilaudid = 12-18mg 20mg oxycodone 7.5mg po dilaudid 12/24hrs =0.5 mg/hr 18/24hr = 0.75 mg/hr

Thank you and Happy Holidays