Yale 20: Opioids in Pain Management

Transcript

• 00:00Hi everyone. My name is Julia Joseph.
• 00:04I'm a current third year Internal
• 00:06Medicine resident at Yale New Haven
• 00:07Hospital and this is part two of
• 00:09our pain management series that I've
• 00:11created with the help of our palliative
• 00:13care faculty member, Doctor Persic.
• 00:15In our last video we discussed non
• 00:18opioid pain options and here we
• 00:20will focus on opioids largely again
• 00:23from the inpatient perspective.
• 00:25Shown here is
• 00:26The Who analgesic ladder.
• 00:28Our last video focused
• 00:30on step one analgesics.
• 00:32We are only going to briefly mention
• 00:34the Step 2 analgesics largely because
• 00:36they have fallen out of favor and the
• 00:38focus of our talk will be an intro
• 00:40to Step 3 analgesics that are listed here.
• 00:43Keep in mind that you may encounter
• 00:45patients who require further step up
• 00:47in therapy as noted here in Step 4,
• 00:49including PCA pumps and spinal stimulators.
• 00:54Our talk is divided into two parts.
• 00:56We will first discuss what the right
• 00:58drug for a patient might be by going
• 01:00through different types of opioids.
• 01:01We will then focus on dosing strategies.
• 01:05So the first question we want to
• 01:07answer is this the right drug?
• 01:09So let's dive in.
• 01:12Let's start with morphine,
• 01:14an old and very commonly used drug.
• 01:16It comes in many types of
• 01:18formulations including immediate
• 01:19and extended release, oral tablets,
• 01:21liquid form and sub Q amongst many others.
• 01:25So this allows you to use morphine
• 01:27in many types of patients.
• 01:29It's also very cheap and easily
• 01:31accessible for patients.
• 01:32So consider this when prescribing to
• 01:34a patient's outpatient's pharmacy.
• 01:36Low doses to start include two milligrams
• 01:40IV or five to 10 milligrams PO.
• 01:42Morphine is also the standard when
• 01:44it comes to comparing the dosing to
• 01:46other types of opioids where you
• 01:48can actually calculate a patient's
• 01:50daily MME requirement or morphine
• 01:52milligram equivalent.
• 01:52Finally,
• 01:53make sure to avoid this in patients
• 01:56with renal impairment because of the risk
• 01:58of accumulation of toxic metabolites.
• 02:01So patients,
• 02:01especially with a GFR of less than 45,
• 02:04make sure to avoid morphine.
• 02:08Oxycodone
• 02:09is another type of opioid that
• 02:10you're likely to encounter.
• 02:11It's a bit more potent than morphine
• 02:13with a ratio of two to three.
• 02:15It comes in immediate and
• 02:16sustained release forms in the
• 02:17common starting dose for it is
• 02:195 milligrams immediate release.
• 02:21Some data suggests
• 02:22that it may cause less delirium than
• 02:24morphine, but it's drawback is that
• 02:26there's No 4 formulation available.
• 02:28Dilaudid is much more potent than
• 02:31morphine with a ratio of one to four.
• 02:33Both PO and four formulations
• 02:35are available out of the three
• 02:37opioids we've mentioned so far,
• 02:39Dilaudid is much safer to use and is
• 02:41preferred to be used in renal patients.
• 02:44For starting doses,
• 02:45you can initially start with 0.25
• 02:48milligrams of IV or two milligrams PO.
• 02:53The next two medications that we'll
• 02:54talk about are ones that you're
• 02:56unlikely to actually prescribe,
• 02:58but you may care for patients
• 02:59who are on them.
• 03:00So these are some pearls
• 03:01that you should know.
• 03:02The 1st is fentanyl, which is not
• 03:04for patients who are opioid naive.
• 03:06It comes in patch form and you typically
• 03:09have to change the patch every 72 hours,
• 03:11but it takes 24 hours to
• 03:13reach the full effect.
• 03:15Like Dilaudid,
• 03:15it is safe to use in renal patients and
• 03:18is actually the preferred formulation
• 03:19in patients with a history of ESRD.
• 03:22Be aware that when using heat
• 03:23or patients who are spiking,
• 03:25high temperatures may end up having
• 03:27increased absorption from the patch.
• 03:29The patch is also not compatible with MRI,
• 03:32so if taken off before a study
• 03:34when the patient is down there,
• 03:36make sure it doesn't actually
• 03:37stay off or you may precipitate
• 03:39a pain crisis in your patient.
• 03:42You may also see patients who are on
• 03:44methadone that is used for chronic pain,
• 03:46especially for cancer pain.
• 03:47It's long acting and is very effective.
• 03:50It's safe in renal and liver patients as well
• 03:53because there are no active metabolites.
• 03:55The things to look out for is that it
• 03:57is associated with a prolonged QTC and
• 03:59has several drug drug interactions and
• 04:02also has a long half life if used for
• 04:06pain indication which is TID dosing.
• 04:08There is actually no special training
• 04:10or waiver that is required.
• 04:12Now, these are the weak
• 04:14opioids or the Step 2 opioids.
• 04:16If you remember from The Who
• 04:17ladder that was shown at the
• 04:19beginning of this presentation,
• 04:20we generally do not employ these.
• 04:23Codeine and hydrocodone are
• 04:25metabolized to morphine, which is how
• 04:27it provides its analgesic effect.
• 04:29The unpredictable metabolism, however,
• 04:31causes unpredictable side effects,
• 04:33and it's also hard to predict
• 04:35its analgesic effect.
• 04:36Tramadol or tramadol is a
• 04:39mixed opioid agonist in SNRI.
• 04:41It also carries a lot of
• 04:43different risks listed here.
• 04:45So in general,
• 04:46we recommend that you prescribe
• 04:48alternative pain options
• 04:49rather than ones listed here.
• 04:53Opioids as a class carry a lot
• 04:55of different adverse effects.
• 04:57Constipation is a very common one.
• 04:59So you always want to make sure
• 05:00your patient is on a bowel regimen.
• 05:02Sena and Miralax is listed
• 05:04here are first line.
• 05:05You can also prescribe peripheral
• 05:07MU opioid receptor antagonists
• 05:09or Pomoras such as methyl
• 05:11nitroxone if the patient
• 05:13is still having refractory
• 05:14Constipation to first line agents.
• 05:17But you want to make sure that your
• 05:18patient does not have malignant
• 05:20bowel involvement because it
• 05:21carries a risk of perforation.
• 05:23Nausea and pruritus or itching
• 05:25is also very common at the
• 05:27initiation of opioids.
• 05:29Myoclonus and opioid
• 05:30hyperalgesia is also reported,
• 05:32but usually quite rare.
• 05:34Somnolence and respiratory
• 05:36depression is a very common
• 05:38side effect and is one that is
• 05:39feared by a lot of internus.
• 05:41But in general, if the respiratory rate is
• 05:43greater than six or the patient is able
• 05:46to maintain O2 sets greater than 92%,
• 05:49you can typically monitor them and
• 05:51wait for the opioid to eventually wear
• 05:54off. You really want to try avoiding Narcan
• 05:56in these patients because
• 05:58precipitating a pain crisis can
• 06:01be very uncomfortable and
• 06:02sometimes even fatal for patients
• 06:04with certain comorbidities.
• 06:07All right, so we talked about whether
• 06:08the patient is on the right drug.
• 06:10Now, how do we know whether the
• 06:11patient is getting the right dose?
• 06:15So these are the reasonable
• 06:16starting doses for morphine,
• 06:18oxycodone and Dilaudid that is
• 06:19included here as a reference slide
• 06:22for patients who you're not sure
• 06:23where to start and are opioid naive.
• 06:28So an easy way to remember how to
• 06:30convert between all of these different
• 06:31opioids is the 1020 thirty rule.
• 06:3410 milligrams of four morphine
• 06:36equals 20 milligrams of oxycodone,
• 06:38which is equal to 30 milligrams of morphine.
• 06:41The Dilaudid dosing is not
• 06:42as easy as to remember,
• 06:43but I've included it here
• 06:44in case you wanted to know.
• 06:46So all of these are equal
• 06:48to 1.75 of four Dilaudid,
• 06:50which is equal to 7.5 of PO Dilaudid. So
• 06:55make sure to ask the patient about
• 06:57function and quality of life.
• 06:58So for example, what dose allows them to do
• 07:00a certain activity that's important to them.
• 07:02Make sure then that you're asking about
• 07:04comfort level and not just about pain.
• 07:06From there you should
• 07:08reassess the pain and adjust.
• 07:09If the patient is still
• 07:11in mild to moderate pain,
• 07:12increase the dose by 25 to 50%.
• 07:15If the patient is in moderate to severe pain,
• 07:18then you can increase the dose by 50 to 100%.
• 07:21In general, you should not increase
• 07:24long acting formulations by over 100%.
• 07:28What about dosing frequency? The first part
• 07:30is to decide if
• 07:31it's OK to keep a patient
• 07:33on PRN or scheduled dosing.
• 07:34If you notice a patient has to
• 07:36keep asking for pain medication,
• 07:38is not getting it at appropriate intervals,
• 07:40and is remaining in a lot of pain,
• 07:42then it may be best to keep the
• 07:44patient on a scheduled regimen.
• 07:45The next part is to decide
• 07:47based on the drug's half life.
• 07:49So for example, patients who are
• 07:51receiving IV pain medication,
• 07:53it may be appropriate to
• 07:55dose every 10 minutes.
• 07:56For IM it would be every 30 minutes,
• 07:58and for oral formulations,
• 07:59it could be every three to four hours.
• 08:02You should consider longer
• 08:03intervals in patients who have
• 08:05renal or hepatic failure.
• 08:07So how do we help this patient?
• 08:09Let's say you have a patient
• 08:11who's prescribed oxycodone,
• 08:125 milligrams every six hours PRN,
• 08:15and you notice that they're
• 08:16using all of their PRN doses.
• 08:17You talk to the patient and they tell you
• 08:19that the pain is being reduced by 80%,
• 08:21but the relief is only lasting 3 hours.
• 08:24By the time the patient is able
• 08:26to take the next PRN dose,
• 08:27their pain has escalated
• 08:28to an intolerable level.
• 08:30So in this situation,
• 08:31it makes sense to fix the dosing interval.
• 08:33Instead of the interval being every six
• 08:36hours, it should really be every three.
• 08:38You can also decide if it's worth putting
• 08:40the patient on a scheduled regimen
• 08:42instead of keeping them on APRN dosing.
• 08:44And eventually,
• 08:45it may be worth considering
• 08:46whether the patient should be
• 08:48on a long acting formulation.
• 08:51Finally,
• 08:51I've included this chart
• 08:52as an easy reference.
• 08:54It has morphine, Dilaudid,
• 08:57fentanyl, methadone, and oxycodone.
• 08:59And the chart includes
• 09:01the IV and PO conversions,
• 09:03the time of duration, its onset,
• 09:06and the time for peak concentration,
• 09:09as well as certain comments.
• 09:10So you can use this chart as
• 09:13a reference table as needed.
• 09:15So to summarize,
• 09:16morphine is a cheap opioid that comes
• 09:18in many types of formulations which
• 09:20should be avoided in renal patients.
• 09:22Oxycodone is associated with
• 09:23less delirium than morphine,
• 09:25but usually only the PO form
• 09:26is available on formulary.
• 09:28Dilaudid is much more potent than
• 09:30morphine and is safer to use in renal
• 09:33patients out of all three listed here.
• 09:35Be careful in those patients who come in
• 09:37with fentanyl patches as they're spiking
• 09:38high fevers or if they need to get an MRI.
• 09:41Watch out for QTC prolongation
• 09:43and drug drug interactions.
• 09:44And those patients on methadone,
• 09:46make sure to avoid prescribing weak
• 09:49opioids which include tramadol,
• 09:50hydrocodone, and Kodi.
• 09:52And finally,
• 09:53when deciding on a regimen,
• 09:54it really is based on the individual patient.
• 09:56So you should decide if a patient
• 09:58is more appropriate to be on a
• 10:00fixed schedule or APRN schedule
• 10:02and also decide the dosing interval
• 10:03based on the type of formulation
• 10:05in terms of the half life.
• 10:07So you can decide based on whether the
• 10:09patient is getting an IV form or APO regimen,
• 10:12for example.
• 10:15Finally, here are some sources that I
• 10:16used for my talk. Thanks for listening.