Rita Mannarino - Opioids for the Non

Rita Mannarino, RN(EC), BN, MScN, PHC-NP
I have no financial or personal
relationships to disclose
* Demonstrate the use of appropriate starting doses of
narcotics, appropriate breakthrough doses and dosing
frequencies
* Discuss improving patient compliance with pain medication
by anticipating, treating and preventing common opioid
related side effects
* Discuss how and when to start long acting narcotics,
including the fentanyl patch
Pete is a 65 year old male, recently diagnosed with
metastatic lung cancer. He has extensive boney metastases
He is married for 45 years to his high school sweetheart
Lorraine. Together they have 3 grown children and 9
grandchildren
He is a retired steelworker
He tells you that he has always had a “bad back” and over
the last 6 months it has gotten much worse and now
interferes with his ADL and quality of life
* Pete is an ex-smoker, having quit about 12 years ago just
prior to the birth of his first grandchild and after he
started having issues with dyspnea for which he required
the use of puffers
* Pete has experienced increased dyspnea and increased
pain for about 6 months; he sought medical attention after
he started coughing up blood
* Pete has been using NSAIDs and acetaminophen OTC and
not getting very good pain relief
More
* He was given a prescription for hydromorphone but has
never used it
* Pete tells you that he is afraid to use narcotics for fear of
addiction….besides he says, “they only use morphine when
people are dying right!”
* He reports his pain at best is 4/10 and at its worst 6/10
* His wife interjects and tells you that she thinks it is much
worse because sometimes he can’t get out of bed because
of the pain and has been to emergency department twice
in the last few weeks due to pain crisis
* Is Pete minimizing his pain?
* What misconceptions may Pete have about “narcotics”
* Identifying and addressing misconceptions are integral to
educating patients about pain management
* If we don’t understand what his hesitation is about taking
the pain medication, then we will not be able to help him
overcome them
* "If I use an opioid medication, I will become an addict“
* If I am given this medication, it must mean that I am dying."
* "I am being given this medication, there must be no other
treatment options.“
* Concerned about not being a “good” patient
* Concern that strong medications like opioids should be
saved for when they are “really” needed.
* Pain medications always cause heavy sedation
* Patient education needs to address the patients’ own
fears and concerns
* Lack of education can lead to medication
noncompliance and misuse
* Education needs to include discussion about tolerance
of medication versus addiction, possible side effects,
proper management of pain, opioid dosing etc.
Prevention and early
management of
medication-related
side effects must be
part of providing
optimal pain
management relief
Common
* Constipation (ongoing, scheduled laxatives)
* Nausea – usually resolves after a few days
- metoclopramide or domperidone first few days
* Somnolence – usually resolves after a few days
Less Common
* Opioid Neurotoxicity
* Sweating, dry mouth, pruritis
* Respiratory depression
Ensuring that the patient
understands how to properly
use the medication,
including route, dose and
timing.
And never assume that they
will know what you mean!
Opioid
oral
s/c or
IV
Other
Long Acting
Codeine
Codeine,
Tabs 15mg, 30mg Tylenol #1,2, 3
Syrup 5mg/mL
&4
(tabs/liquid)
s/c, IV
Morphine
5mg, 10mg,
25mg, 30mg,
50mg
Morphine,
statex,
Morphine
sulphate
(tabs/liquid)
S/C, IV
Hydromorphone
1mg, 2mg, 4mg,
8mg
Hydromorphone S/C, IV
dilaudid
(tabs/liquid)
HydromorphContin3mg,
6mg, 12mg, 18mg,
24mg, 30mg
Percocet,5mg +
325mg
acetaminophen
oxycocet (tabs)
OxyNeo
Oxycodone5mg,
10mg 20mg
P/R supps M-Eslon, MSContin,
Kadian
10mg, 15mg,
30mg,60mg, 100mg
*
Fentanyl
Methadone
CodeineContin
s/c, IV,
S/L
Methadone,
Duragesic Patches
P/R supps
* Preferred route – oral
* When unable to swallow – s/c, IV, transdermal
* Special situations – s/l (fentanyl or sufentanyl)
* Intraspinal (epidural or intrathecal)
* DO NOT USE IM
DRUG
Morphine
Codeine
Hydromorp
hone
Oxycodone
Fentanyl
ORAL
10mg
100mg*
2mg
PARENTERAL
5mg
N/A
1mg
5mg
N/A
A 25mcg patch =
60-130mg of oral
morphine
required over
24hrs
Equianalgesia Table
Onset of Pain Relief
Oral Opioids
15-30 minutes
s/c Opioids
5-10 minutes
IV Opioids
3- 5 minutes
Duration of Pain Relief
Short Acting Opioids
3-5 hours
Long Acting Opioids
8-12 hours
Fentanyl patches
48-72 hours
IV or S/C Opioids
2-4 hours
IV or S/C Fentanyl
40 minutes
* Morphine
* Hydromorphone
* Oxycocet/oxycodone
5mg Q4hr PO
1mg Q4hr PO
2.5mg-5mg Q4hr PO
* Add a breakthrough dose q1-3 hours PRN if giving
scheduled dose
* Consider smaller amounts in frail, elderly patients
or opioid naive patients
* Analgesic effectiveness can be reassessed after 24
hours as it takes five half lives to reach a steady
state (5 x 4 hrs = 20 hrs)
* The breakthrough dose should be approximately 10%
of the total daily opioid dose given q1-3 hours
* you may need to titrate the dose according to
patient needs: 5%-25% of total daily opioid dose
* Use the same opioid as being used for regular
regimen except with fentanyl patches (although
fentanyl or sufentanyl s/c or s/l can be used for pain
control)
* We had decided to start Pete on the hydromorphone 1mg
PO 4hr with a breakthrough dose of 0.5mg every 1hr PRN
* We are now completing a full assessment of
control and use of the hydromorphone
Pete’s pain
* He has used 7.5mg in the last 24 hours and per day
consistently and his pain is controlled and “better than it
has ever been”
* Should we start him on a long acting?
calculate his dose?
How would we
* What should his breakthrough dose be?
Short Acting Opioids aka Immediate release (IR)
* Opioid naïve patients
* Pain crisis
* Breakthrough doses
Long Acting Opioids aka sustained release
* Reserve for stable pain
* Use in conjunction with short acting (for breakthrough
pain)
* Post operative pain from a C-section
* Incidental pain- ie. occassional pain with exertion
* 91 year old opioid naïve patient
* Cancer patient, normally well controlled pain currently in a
pain crisis
* Palliative patient with well controlled pain, taking statex Q4hrs
RTC
* Pete was using 7.5 mg daily of hydromorphone
Step 1 – divide the daily total by 2 to get a Q12hrly dose
(7/2=3.5) always round up or down to keep it simple and to
accommodate the doses available
Step 2 – once you have your long acting dose then calculate
your breakthrough dose, which should be _____% given
every 1-3 hours
Therefore, Pete’s hydromorphContin dose will be 3mg PO
Q12hrs; with a breakthrough dose of 0.5mg PO Q2hrs PRN
* What if we wanted to switch him to a fentanyl patch?
Or morphine?
* What if Pete had been on morphine and we now
wanted to rotate him to hydromorphone…what would
we do?
* What would we need to know before we could rotate
opioids?
* Morphine is 10 times more potent than codeine
* Hydromorphone is 5 times more potent than morphine
* Oxycodone is 2 times more potent than oral morphine
* Fentanyl is 80 to 100 times more potent than morphine
* Always use morphine as the base upon which all other doses are
calculated
Simple Rules for the
Rotation of Opioids
Fentanyl Patch
(mcg)
Oral morphine
equivalent (mg)
12 mcg
35-59mg
25mcg
60-130mg
50mcg
180-225mg
75mcg
270-315mg
100mcg
360-404mg
Fentanyl patch & oral
morphine equivalency
Step 1 – add total daily opioid
* Pete is now on 3mg PO Q12hr (total 6mg)
* Breakthrough doses of 0.5mg X 12 doses daily (total 6mg)
* Total 24 hours dose = 12mg of hydromorphone
* Then what?......
Step 2 – rotate to Morphine
* Hydromorphone is 5 times more potent than morphine
* Therefore 12mg of hydromorphone = 60mg of morphine
* Then what?........
What about incomplete cross tolerance?
* It is the phenomenon where the body develops tolerance to an
opioid (therefore side effects often subside)
* But…when the opioid is rotated to another opioid the tolerance
may not be present with the new opioid introduced
* therefore a reduction in the new opioid is required
* Usually the new opioid dose is reduced by about 1/3 in order to
take into consideration incomplete cross tolerance.
* We know 12mg of hydromorphone = 60mg of morphine
* We now know we need to decrease that by 1/3 for possible
incomplete cross tolerance
Step 3 – decrease for incomplete cross tolerance
* 60 mg – 1/3 of the dose (20mg)
= 40 mg of morphine
Step 4 – rotate from morphine to equianalgesic dose of Fentanyl
* 40mg of morphine would be equivalent to 12mcg Fentanyl patch
* Remember the appropriate breakthrough dose is ____% of
the total daily dose
* How do know how much breakthrough to give for a
fentanyl patch if we aren’t using fentanyl as the short
acting (IR)? Remember….keep it simple
* Use the morphine or hydromorphone equivalence for total
daily dose then calculate 10% of that
* Therefore, Pete’s recommended breakthrough dose would
be??
Case #1
* Pt is using M-Eslon 30mg Q12h with 5mg of statex q2h for breakthrough
pain (pt used 8 doses in 24hr). Convert this patient to hydromorphone.
* Step 1 – calculate total morphine/24hrs (include all breakthrough
doses)
* 30 X 2 doses = 60mg
* 5 mg X 10 doses = 40mg
* Total 24 hr morphine dose = 100mg
Morphine to Hydromorphone
conversion
Step #2
* We know hydromorphone is 5 times more potent than
morphine therefore divide the total 24 hr dose of morphine by
5.
* 100mg divided by 5 = 20mg
* Therefore the total 24 hr dose would be equivalent to 20mg of
hydromorphone.
* The hydromorphone dose is reduced by 1/3 (or ~33%) = 13mg
* Remember, when rotating opioids you may have to round up or
down slightly to keep things simple as most opioids come in
specific tablet/capsule amounts.
* therefore the patient would be ordered 12mg as a daily dose
which would be given as HydromorphContin 6mg Q12h PO
* What dose would you recommend as a BT dose? How would you
calculate the BT dose?
* Identifying and addressing misconceptions are integral to educating
patients about pain management
* Education needs to include discussion about tolerance of
medication versus addiction, possible side effects, proper
management of pain, opioid dosing in order to provide optimal pain
management
* The breakthrough dose should be approximately 10% of the total
daily opioid dose given q1-3 hours
* Use the same opioid as being used for regular regimen except with
fentanyl patches
* Always use morphine as the base upon which all other doses are
calculated when rotating opioids
* A thorough pain assessment will provide you will invaluable
information and will help guide your interventions
* Keep it simple and based on each individual patient’s needs;
there are almost always more than one right answer
* Pain is what the person experiencing it, says it is
* Make sure you identify your own misconceptions and past
experiences that may taint your personal view of opioids
* Remember, even though you may not be ordering the opioid, if
you are involved with the patients care, administering the
medication, then you are accountable to ensure that you
understand what doses are appropriate, when initiating,
titrating, dispensing and rotating opioids