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Opioid Selection for Acute and Chronic Pain Control

J K Lilly MD MS

Appalachian Pain Therapy Institute Charleston, WV

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Objectives Identify the difference between acute and chronic pain

treatment in opioid- naive verses opioid-tolerant patients. Identify medications appropriate for treatment of each type

of pain. Know the Equianalgesic Doses of IV Morphine, Dilaudid

and Fentanyl & convert to oral doses (enterohepatic=1.3). Know about Iatrogenic Abstinence Syndrome Realistically apply the Visual Analog Pain Score to

evaluating response to opioids. Differentiate Addiction Disorder from Chronic Pain and

Chronic Pain Behavior

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Equianalgesic Dosing

Pure Opioids

Drug PO Dose IM Dose

& 1/2 life

Morphine 1 30-60 10 (=)

Hydrocodone 1 30-60 n/a (=)

Oxycodone 1.3 15-30 20 (=)

Methadone 20 acute (1.3)

2-4 chronic (8-12)

10 (++)

Fentanyl 100 400 mcg 0.1 (+)

Levorphanol 15 2-4 2-4 (+)

Hydromorphone

“Dilaudid” 5

4-8 1.5 (=)

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Equianalgesic DosingWeak Opioids and Mixed Agonists

Drug PO IM & ½ Life

Meperidine 0.1

Codiene 0.5

Propoxyphene 0.15

Buprenorphine 10

Nalbuphine 1

Butorphanol ~25

Pentazocine 0.15

300

60-120

450

n/a (30)

n/a

n/a

325

100-200 (=)

130-160 (=)

n/a (+)

.32-.96 (+)

10 (=)

5 (=)

30-60 (=/+)

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Equianalgesic Dosing Consider the example of switching from

Methadone 10 tid to Oxycodone-SR First, determine the Morphine equivalent dose to

current drug, Then, estimate dose of new drug from the

Morphine equianalgesic dose

i.e. Methadone → Morphine → Oxycodone 30 mg/d x 8 = 240 mg/d x .66= 160mg/day

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Equianalgesic Dosing Convert from Fentanyl 50 mcg/hr patch plus

Percocet 10/650 up to tid for recurrent pain plus IV Demerol 25 mg up to once per shift for “bad” pain to IV Morphine infusion dose (real example)

Fent 50 x24hr=1200 mcg/day x100= 120mg MS; Oxycod 30 x1.3= ~ 40mg MS; Demerol 75 = 75x.1= ~8-10mg MS => 120+~40+~10= ~180mg MS equivalent dose/dayor IV-infusion hourly dose of 6.6 mg/hr

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Acute Pain Control Plan Acute Pain: physical discomfort, short duration

(hours to weeks), usually severe, usually associated with disease, birthing process or injury

Opioid-Naïve (narcotic celibacy) Opioid-Tolerant (taking the equivalent of

>25 mg/ day of Oxycodone or equivalent dose of any sustained release opioid preparation)

Visual Analog Pain Score (0-10) only advisory!

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Chronic Pain Control Plan Pain lasting longer than six months Persists disproportionately beyond the initial cause May not respond in the same way as acute pain to

techniques and medications Cause may not be resolvable! May require combined treatment modalities Long Term Opioid Therapy (LTOT) may be the

final therapeutic (last/ best) alternative Chronic Pain Syndrome and its attendant behavior

ARE NOT equivalent to Addiction Disorder

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Opioid -Naive

With PCA (preferred) Continuous (controversial)-

MS 2mg/hr or second line drug in equianalgesic dose (0.2 mg/ hr HM, 20 mcg/ hr Fentanyl)

Demand Bolus - MS 1 mg or equianalgesic dose

Lockout – 10-15 minutes Rescue – RN administered

intermittent rescue ~ twice the dose of PCA bolus q 1 hr prn until reviewed

Review & adjust orders q 12 hrs Continuous Oximetry

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Opioid -NaiveWithout PCA (but IV) First Line:

Morphine 2mg IV q 5 min prn ‘til comfortable or AE

Second Line: Hydromorphone 0.2 mg IV q 5

min prn orFentanyl 20 mcg IV q 5 min prn, (1st if creatanine >2.5)Meperidine not recommended!!

Review orders q 12 hrs Continuous Oximetry Convert to Oral ASAP Avoid 3rd & 4th Line Agents

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Opioid Tolerant (taking opioid equivalent to >25 mg Oxycodone/ 24 hrs )

With PCA (preferred) Continuous Infusion = PCA Background – baseline 24 hr opioid dose X .3 per day, (ie. MS Contin 60mg q12h = 120 x .3 = 40mg/24hrs, or 2.5mg/ hr infusion – round-up to 3mg/ hr)

PCA Demand- 50-100% of hourly rate, Lockout – q10-15 min

Review adjust at least q 12h, titrate systematicallyContinuous Oximetry

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Opioid Tolerant(taking opioid equivalent to >25 mg Oxycodone/ 24 hrs )

Without PCA10-20% of 24 hr doseq 1-3 hrs prn “basal dose”

RN administered IV “Rescue Doses” @ 2x the “basal dose”

Continuous Oximetry

Adjust doses q 12h

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Pain Taxonomy Acute Pain-

tissue injury, distention or inflammation

Episodic Pain- related to activityrecurrent, breakthrough, incident

Chronic Pain- constant and unremittingwaxes & wanes but seldom subsides

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Episodic Pain Short acting opioids indicated Oral route preferred Usually treated Schedule III (+APAP or IB) Exertion/ Activity related

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Constant Pain

Sustained Response (SR) oral agents indicated Consider Immediate Response (IR) agents for

rescue doses – start at ~10% of 24 hr dose of long acting agent q4-8 hrs prn

SR formulations are designed for q 12 hr dosing but mean effective dose may be shorter duration (q 8-10 hr)

Use coanalagesics and anticipate adverse effects Addiction risk is 3% or less (large studies)

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Analgesic Selection

Mu () Opioid Receptor Agonists – most familiar to clinicians as to effects and side-effects; best for initiating opioid therapy for moderate to severe pain (VAPS 5-10/10).

Morphine, Hydromorphone, Oxycodone, Hydrocodone, Fentanyl, Codeine, Hydrocodeine, Levorphanol, Methadone, Meperidine.

.

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Analgesic Selection Agonist/ Antagonists & Partial Agonists –

Primarily activate the Kappa () receptor and antagonize or partially occupy the Mu receptor ( antagonists), analgesic ceiling effect, risk iatrogenic abstinence syndrome when given with agonist tolerant patients, watch out in ER!no proven advantage in avoiding abuse.

Pentazocine, Butorphanol, Nalbuphine and the “partial agonists” Buprenorphine and Dezocine (VAPS 4-7/10)

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3rd & 4th Line Analgesic Agents

Limited Proven Analgesic Efficacy

Adverse Effects Drug-to-Drug

Interaction Toxic Metabolites Organ-limited

Elimination

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3rd & 4th Line Analgesic Agents Propoxyphene equianalgesic to Extra Strength Tylenol in

blind studies (VAPS 1-3/10 = mild)norpropoxyphene-cardio & neurotoxic

Tramadol weak agonist but primarily active on spinal adrenergic receptors similar to tricyclics (VAPS 4-5/10 = moderate)

Meperidine short acting (450-90 mins), metabolites accumulate within 48 hrs, side-effects commonnormeperidine- cardio & neurotoxic

Codiene effective pain relief but many side-effects at analgesic doses

Hydrocodiene isn’t routinely monitored on UDS NSAIDs, APAP and AEDs, TCAD are “co-analgesics”

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Dosing for Relief Around-The-Clock (ATC) dosing is associated with

more consistent relief PRN-dosing is associated with more unpredictability

and side-effects Optimal analgesic dosing varies widely among patients;

review regularly; titrate systematically Anticipate side effects; most subside with time For some, NO dose of opioid will sufficiently relieve

ALL of their pain...aim for TOLERABLE pain levels (VPA3-4/10), improved functionality and controlled side effect

Transition quickly from IV to PO (enterohepatic)

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Opioids and Addiction

Physical Dependence

Physiologic occurrence usually within 3 days of initiating therapy;

Pharmacological property characterized by withdrawal syndrome after abrupt discontinuation;

Abstinence symptoms usually lacking or attenuated with “wean to discontinue” orders

NOT synonymous with tolerance or addiction!

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Opioids and Addiction

Tolerance Spectrum of acquired physiologic responses to

therapy Pharmacological property of the class drug;

With chronic use, larger dose may be needed for same effect

Countered with drug rotations, furloughs, tolerance inhibitors, prescriptive boundaries

NOT synonymous with physical dependence or addiction!

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Opioids and Addiction

Pseudo-addiction Usually attributable to provider practice

pattern, ergo iatrogenic Unrealistic expectation by prescriber Misconceived safety concern by providers Patient motivation: ”relief, not rush” NOT synonymous with physical

dependence, tolerance or addiction!

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Opioids and AddictionAddiction

Psychological and physiologic state (<3 & >0.3% of chronic pain suffers) characterized by obsessive pursuit of access to medication- regardless of consequences, for psychological effects

Not a pharmacological property of a given drug NOT synonymous with tolerance or physical

dependence!

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Plan if Addiction is Recognized-Be Humane - Intervene and Wean to withdrawal-Evaluation, treatment and extended recovery care

by addiction professionals is optimal-Know community and regional resources for

treatment & extended recovery care when initiating LTOT

-Prescribing opioids to treat addiction (Methadone Clinics) is advisable only for specially certified addiction medicine and psychiatry physicians

-Buprenorphine Addiction Treatment (Subtex) requires additional training and additional DEA certification…too new to assess.

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Opioid Therapy

Current Clinical Guidelines Pain relief is defined as a primary care (PCP) function Remain reasonable, rational, responsible and available Examine thoroughly and review regularly Utilize LTOT Informed Consent to Treat and Opiate Access

Agreement Document & define providers & pharmacy Require patient to notify all providers of Opiate Access

Agreement participation Monitor compliance (pill counts, UDS, etc.) and response to

therapy (functional assessments, charts, diaries, surveys, etc.), Review OAA violation consequences regularly Match the tool to the problem-SR opioid for continual pain,

IR for recurrent pain; pick analgesics sensibly

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Opioid TherapyCurrent Clinical Guidelines (cont.)

Consult and co-manage appropriately, require formal behavioral assessment periodically

Stipulate that verified non-clinical information may be considered when deciding whether to continue LTOT

Beware of 90 day prescription “Prescription Drug Benefit Requirements” -cost saving scheme that may be technically illegal for opioids; i.e.. unmonitored and unlicensed warehousing of Class II & III medications in homes not supported by law or regulation

Recognize that LTOT may be the therapy of last resort

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Opioid Options on the Near Horizon

Lipid-Based Sustained Release Opioid & Local Anesthetic Vehicles

Vanilloid and Cannabinoid Receptor Agonists

New Spinally-infused Drugs Abuse-resistant Opioid Preparations Co-analgesic Use of Anti-seizure Drugs Deep-Brain and Motor Cortex Stimulation

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Thanks! I Enjoyed your attention!

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Opioid Selection for Acute and Chronic Pain Control

Thanks for you’re your questions!!

It’s time to head home.