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Pain
Manag
em
ent
Up
date
s
Dr
Am
y Y
ea
tma
n
Th
e N
eu
ro T
ea
m a
t B
elli
n H
ea
lth
•N
one
Fin
ancia
l D
isclo
sure
s:
•B
oa
rd C
ert
ifie
d in
An
esth
esio
log
y
•B
oa
rd C
ert
ifie
d in
Pa
in M
an
ag
em
en
t
•B
oa
rd C
ert
ifie
d in
In
terv
en
tio
na
l P
ain
Ma
na
ge
me
nt
(AB
IPP
)
•F
ello
w o
f th
e W
orld
In
stitu
te o
f P
ain
(F
IPP
)
•In
str
uc
tor
for
the
Am
eric
an
So
cie
ty o
f In
terv
en
tio
na
l P
ain
P
hysic
ian
s
•B
oa
rd E
xa
min
er
for
the
Am
eric
an
Bo
ard
of
Inte
rve
ntio
na
l P
ain
(A
BIP
P)
•In
tern
atio
na
l In
str
uc
tor
for
the
Wo
rld
In
stitu
te o
f P
ain
•P
resid
en
t o
f th
e N
eu
ro A
dvis
ory
Bo
ard
at
Be
llin
Ou
tlin
e
•In
su
ran
ce/f
ed
era
l re
qu
ire
me
nts
fo
r p
resc
rib
ing
c
on
tro
lled
su
bsta
nc
es
•C
ha
ng
es in
th
e w
ay o
f h
ow
we
tre
at
pa
in in
th
e
Un
ite
d S
tate
s
•Im
po
rta
nt
Dru
g t
o O
pio
id I
nte
rac
tio
ns y
ou
sh
ou
ld k
no
w
•B
rie
f o
ve
rvie
w o
f a
na
tom
y a
nd
mo
st
co
mm
on
in
jec
tio
ns
Ob
jec
tive
s
•U
nd
ers
tand
what you m
ust d
ocum
ent if y
ou p
rescrib
e p
ain
med
ications
•U
nd
ers
tand
the c
hang
ing
clim
ate
for
pain
med
ication
pre
scrib
ing
•U
nd
ers
tand
op
ioid
to d
rug
inte
ractions a
nd
the m
echanis
m o
f
inte
raction
•U
nd
ers
tand
the c
om
mon C
YP
P450 g
enetic m
uta
tions involv
ed
in
op
ioid
s a
nd
when y
ou s
hould
consid
er
testing
for
ab
norm
alit
ies
•U
nd
ers
tand
the m
ost com
mon s
pin
al in
jections a
nd
their
ind
ications
CD
C’s
Re
co
mm
en
da
tio
ns f
or
Pre
sc
rib
ing
O
pio
ids f
or
Ch
ron
ic P
ain
•M
US
T:
•C
on
du
ct
a p
hysic
al e
xa
m,
pa
in h
isto
ry,
pa
st
me
dic
al
his
tory
an
d f
am
ily/s
oc
ial h
isto
ry
•C
on
du
ct
urin
e d
rug
te
stin
g,
wh
en
ap
pro
pria
te
•C
on
sid
er
all
tre
atm
en
t o
ptio
ns,
we
igh
be
ne
fits
an
d t
he
risks o
f o
pio
id t
he
rap
y, a
nd
usin
g o
pio
ids w
he
n
alte
rna
tive
s t
rea
tme
nts
are
in
effe
ctive
•S
tart
pa
tie
nts
on
th
e lo
we
st
effe
ctive
do
se
CD
C’s
Re
co
mm
en
da
tio
ns f
or
Pre
sc
rib
ing
O
pio
ids f
or
Ch
ron
ic P
ain
•Im
ple
ment p
ain
tre
atm
ent ag
reem
ents
(ob
tain
info
rmed
consent
is a
lso r
ecom
mend
ed
- n
ot sp
ecifi
cally
sta
ted
in the C
DC
guid
e
lines)
•M
onitor
pain
and
tre
atm
ent p
rog
ress w
ith d
ocum
enta
tion, usin
g
gre
ate
r vig
ilance a
t hig
h d
oses
•U
se s
afe
and
effective m
eth
od
s for
dis
continuin
g o
pio
ids
(tap
ering
, m
akin
g a
pp
rop
riate
refe
rrals
to m
ed
ication-a
ssis
tance
pro
gra
ms, sub
sta
nce u
se s
pecia
lists
, or
oth
er
serv
ices
•U
se
da
ta f
rom
Pre
sc
rip
tio
n D
rug
Mo
nito
rin
g P
rog
ram
s t
o id
en
tify
p
ast
an
d p
rese
nt
op
ioid
pre
sc
rip
tio
ns o
n in
itia
l a
sse
ssm
en
t a
nd
d
urin
g t
he
mo
nito
rin
g p
ha
se
•B
ased
on R
efe
rence 1
AP
S a
nd
AA
PM
Clin
ical G
uid
elin
es for
the
Use o
f C
hro
nic
Op
ioid
Thera
py in C
hro
nic
N
on-C
ancer
Pain
•B
efo
re in
itia
tin
g a
nd
on
an
on
go
ing
ba
sis
du
rin
g
tre
atm
en
t w
ith
ch
ron
ic o
pio
id t
he
rap
y (
CO
T)
ob
tain
an
H
&P,
ap
pro
pria
te t
estin
g,
risk a
sse
ssm
en
t o
f su
bsta
nc
e
ab
use
, m
isu
se
or
ad
dic
tio
n
•P
ain
is d
ee
me
d t
o b
e m
od
era
te t
o s
eve
re,
ha
vin
g a
n
ad
ve
rse
im
pa
ct
on
fu
nc
tio
n o
r q
ua
lity o
f lif
e a
nd
th
e
po
ten
tia
l th
era
pe
utic
be
ne
fits
ou
twe
igh
th
e p
ote
ntia
l h
arm
s
AP
S a
nd
AA
PM
Clin
ical G
uid
elin
es for
the
Use o
f C
hro
nic
Op
ioid
Thera
py in C
hro
nic
N
on-C
ancer
Pain
•W
he
n s
tart
ing
CO
T o
bta
in in
form
ed
co
nse
nt,
co
nsid
er
a
writt
en
CO
T a
gre
em
en
t
•C
linic
ian
s s
ho
uld
re
ga
rd in
itia
l tr
ea
tme
nt
with
op
ioid
s a
s
a t
ria
l to
de
term
ine
if
CO
T is a
pp
rop
ria
te
•C
linic
ian
s s
ho
uld
re
asse
ss p
atie
nts
on
CO
T p
erio
dic
ally
a
s w
arr
an
ted
by c
ha
ng
ing
circ
um
sta
nc
es
AP
S a
nd
AA
PM
Clin
ical G
uid
elin
es for
the
Use o
f C
hro
nic
Op
ioid
Thera
py in C
hro
nic
N
on-C
ancer
Pain
•In
hig
h r
isk p
atie
nts
or
tho
se
with
a h
isto
ry o
f a
be
rra
nt
dru
g-r
ela
ted
be
ha
vio
rs,
clin
icia
ns s
ho
uld
ob
tain
urin
e
dru
g s
cre
en
s o
r o
the
r in
form
atio
n t
o c
on
firm
ad
he
ren
ce
•In
pa
tie
nts
on
CO
T w
ho
are
no
t a
t h
igh
ris
k,
clin
icia
ns
sh
ou
ld c
on
sid
er
ob
tain
ing
urin
e d
rug
sc
ree
ns o
r o
the
r in
form
atio
n t
o c
on
firm
ad
he
ren
ce
AP
S a
nd
AA
PM
Clin
ical G
uid
elin
es for
the
Use o
f C
hro
nic
Op
ioid
Thera
py in C
hro
nic
N
on-C
ancer
Pain
•C
linic
ian
s s
ho
uld
be
aw
are
of
cu
rre
nt
fed
era
l a
nd
sta
te
law
s,
reg
ula
tory
gu
ide
line
s,
an
d p
olic
y s
tate
me
nt
tha
t g
ove
rn t
he
me
dic
al u
se
of
CO
T f
or
CN
CP
Ba
se
d o
n R
efe
ren
ce
2
•C
hang
es in the w
ay o
f how
we tre
at p
ain
in
the U
nited
Sta
tes
•S
afe
pre
sc
rib
ing
of
op
ioid
s c
on
tin
ue
s t
o b
e a
su
bje
ct
of
co
ntr
ove
rsy a
nd
de
ba
te
•W
hile
op
ioid
s t
o t
rea
t c
an
ce
r p
ain
are
wid
ely
ac
ce
pte
d,
the
use
of
ch
ron
ic o
pio
ids t
o t
rea
t c
hro
nic
no
n-c
an
ce
r p
ain
(C
NC
P)
rem
ain
s c
on
tro
ve
rsia
l
•C
linic
ian
s a
nd
re
gu
lato
rs a
re t
ryin
g t
o w
ork
to
ge
the
r to
se
ek a
ba
lan
ce
d a
pp
roa
ch
to
op
ioid
use
- a
ckn
ow
led
gin
g t
he
le
gitim
ate
ne
ed
th
at
so
me
pa
tie
nts
h
ave
fo
r o
pio
ids w
ith
CN
CP
wh
ile r
ec
og
niz
ing
th
e
se
rio
us p
ub
lic h
ea
lth
pro
ble
m o
f a
bu
se
Ch
an
ge
s in
th
e w
ay w
e t
rea
t p
ain
in
th
e U
S
Ch
an
ge
s in
CO
T f
or
CN
CP
•If
yo
u d
esire
mo
re in
form
atio
n:
•R
esp
on
sib
le O
pio
id P
resc
rib
ing
: A
Clin
icia
ns G
uid
e
(20
14
) b
y S
co
tt M
. F
ish
ma
n M
D is a
va
ilab
le o
n lin
e.
$
16
.95
an
d y
ou
ca
n c
laim
7.2
5 C
ME
ho
urs
•Yo
u c
an
pa
rtic
ipa
te in
a R
EM
S o
nlin
e c
ou
rse
Ch
an
ge
s in
pre
sc
rib
ing
op
ioid
me
dic
atio
ns
Chang
es in O
pio
id P
ackag
ing
:
-Ab
use d
ete
rrent F
orm
ula
tions
Chang
es in E
R/L
AO
pio
id L
ab
elin
g:
-Curr
ently,
lab
elin
g o
n these E
R/L
A o
pio
ids ind
icate
they a
re for
"the r
elie
f
of m
od
era
te to s
evere
pain
in p
atients
req
uirin
g c
ontinuous, aro
und
-the-
clo
ck o
pio
id tre
atm
ent fo
r an e
xte
nd
ed
period
of tim
e.”
-FD
A is r
eq
uirin
g lab
elin
g that says the d
rug
s a
re "in
dic
ate
d for
the
manag
em
ent of p
ain
severe
enoug
h to r
eq
uire d
aily
, aro
und
-the-c
lock,
long
-term
op
ioid
tre
atm
ent and
for
whic
h a
ltern
ative tre
atm
ent op
tions a
re
inad
eq
uate
.”
Ch
an
ge
s in
pre
sc
rib
ing
op
ioid
me
dic
atio
ns
-Th
e "
limita
tio
ns o
f u
se"
po
rtio
n o
f th
e n
ew
la
be
ling
re
tain
s
lan
gua
ge in
dic
atin
g t
ha
t th
e d
rug
s a
re n
ot
inte
nd
ed
fo
r u
se
as
an
"as-n
ee
de
d"
pa
in r
elie
ve
r.
Fu
rthe
rmore
, th
e n
ew
la
be
ling
ad
ds:
"Be
ca
use
of
the
ris
ks o
f a
dd
ictio
n,
ab
use
and
mis
use w
ith
op
ioid
s,
eve
n a
t re
co
mm
en
de
d d
ose
s,
an
d b
ec
au
se
of
the
gre
ate
r risks o
f o
ve
rdo
se
an
d d
ea
th w
ith
exte
nd
ed
-re
lea
se
op
ioid
fo
rmula
tion
s,
rese
rve [
Tra
de
na
me
] fo
r u
se
in
pa
tie
nts
fo
r w
ho
m
alte
rna
tive t
rea
tme
nt
op
tio
ns (
e.g
., n
on
-op
ioid
an
alg
esic
s o
r im
med
iate
-re
lea
se
op
ioid
s)
are
in
effe
ctive
, n
ot
tole
rate
d,
or
wo
uld
be
oth
erw
ise in
ad
eq
ua
te t
o p
rovid
e s
uffi
cie
nt
ma
nag
em
en
t o
f p
ain
."
Ch
an
ge
s in
pre
sc
rib
ing
op
ioid
me
dic
atio
ns
Chang
es in E
R/L
A O
pio
id L
ab
elin
g:
-This
new
lab
elin
g lang
uag
e e
mp
hasiz
es that p
atients
in p
ain
should
be a
ssessed
not only
by their r
ating
on a
pain
inte
nsity
scale
, b
ut als
o b
ased
on a
more
thoug
htful d
ete
rmin
ation that
their p
ain
- The F
DA
announced
that “E
xte
nd
ed
rele
ase/long
acting
op
ioid
s
are
ind
icate
d for
the m
anag
em
ent of p
ain
SE
VE
RE
enoug
h to
req
uire d
aily
, ro
und
the c
lock, lo
ng
term
op
ioid
tre
atm
ent and
for
whic
h a
ltern
ative tre
atm
ent op
tions a
re inad
eq
uate
”.
- re
call
that “S
EV
ER
E”
pain
is d
esig
nate
d 7
-10/1
0 o
n the V
AS
S
cale C
ha
ng
es in
pre
sc
rib
ing
op
ioid
me
dic
atio
ns
-In
Ju
ne
20
15
tw
o d
oze
n D
em
oc
ratic
me
mb
ers
of
Co
ng
ress s
en
t a
le
tte
r to
th
e F
DA
urg
ing
th
e a
dd
itio
n o
f str
on
gly
wo
rde
d w
arn
ing
s t
o la
be
ls o
f im
me
dia
te-r
ele
ase
(I
R)
op
ioid
s in
an
effo
rt t
o d
ec
rea
se
op
ioid
ab
use
, m
isu
se
a
nd
div
ers
ion
.
-Th
ey h
ave
ca
lled
fo
r th
e s
am
e b
lac
k b
ox la
be
l th
at
is
cu
rre
ntly a
pp
lied
to
ER
/LA
op
ioid
s a
lso
be
pla
ce
d o
n I
R
op
ioid
s
Op
ioid
-D
rug
In
tera
ctio
ns
Op
ioid
-D
rug
In
tera
ctio
ns
•Is
this
really
an issue?!
Well…
•6
7%
of
pa
tie
nts
wh
o r
ec
eiv
ed
op
ioid
me
dic
atio
ns
we
re a
lso
re
ce
ivin
g o
ne
of
mo
re o
the
r p
resc
rip
tio
n
me
dic
atio
ns (
1)
•A
lmo
st
60
% o
f in
div
idu
als
ove
r th
e a
ge
of
65
ye
ars
ta
ke
5 o
r m
ore
diff
ere
nt
me
dic
atio
ns p
er
we
ek (
2)
Op
ioid
-D
rug
In
tera
ctio
ns
•2
0%
of
ind
ivid
ua
ls o
ve
r th
e a
ge
of
65
ye
ars
ta
ke
10
o
r m
ore
me
dic
atio
ns p
er
we
ek (
2)
•A
dve
rse
dru
g e
ve
nts
(A
ED
’s)
are
lin
ke
d t
o p
oly
- p
ha
rma
cy
•T
he
ou
tco
me
of
inc
rea
se
d d
rug
-dru
g e
xp
osu
re
(DD
E)
is d
rug
-dru
g in
tera
ctio
ns (
DD
I)
Site
s o
f D
DI’s
•D
DI’s
ca
n o
cc
ur
at
an
y p
ort
ion
of
the
dru
g p
ath
wa
y
tho
ug
h t
he
bo
dy a
nd
an
yw
he
re t
ho
se
dru
gs h
ave
an
a
ctio
n o
n t
he
bo
dy
•P
ha
rma
co
kin
etic
(a
bso
rptio
n,
dis
trib
utio
n,
me
tab
olis
m,
or
elim
ina
tio
n)
•P
ha
rma
co
dyn
am
ic (
mo
lec
ula
r m
ec
ha
nis
m o
f a
ctio
n)
Site
s o
f D
DI’s
Co
ntin
ue
d
•A
nyw
he
re a
lon
g t
he
GI
tra
ct,
blo
od
str
ea
m,
at
tra
nsp
ort
ers
(m
em
bra
ne
pro
tein
s in
vo
lve
d in
th
e in
flu
x
of
ne
ed
ed
su
bsta
nc
es a
nd
th
e e
fflu
x o
f to
xic
su
bsta
nc
es
•D
urin
g m
eta
bo
lism
-th
e m
ost
co
mm
on
me
ch
an
ism
of
DD
I’s
Ba
se
d o
n R
efe
ren
ce
s 5
,6
Op
ioid
-D
rug
In
tera
ctio
ns
•M
eta
bo
lic D
DI’s
ES
PE
CIA
LLY
th
ose
in
vo
lvin
g t
he
C
yto
ch
rom
e P
45
0 (
CY
P4
50
) p
ath
wa
y s
yste
ms a
re
•a
mo
ng
th
e m
ost
co
mm
on
•m
ost
clin
ica
lly r
ele
va
nt
•m
ost
po
ten
tia
lly a
vo
ida
ble
Based
on R
efe
rences 3
, 4
Wh
ere
do
es d
rug
me
tab
olis
m t
ake
pla
ce
?
•A
lmo
st
all
ce
lls in
th
e b
od
y c
an
me
tab
oliz
e d
rug
s t
o
so
me
exte
nt
(GI,
Lu
ng
s,
Kid
ne
ys,
Bra
in)
•T
he
Liv
er
is t
he
MA
JO
R s
ite
of
dru
g m
eta
bo
lism
in
h
um
an
s a
nd
co
nta
ins a
la
rge
nu
mb
er
of
“dru
g
me
tab
oliz
ing
” e
nzym
es (
Cyto
ch
rom
e P
45
0 p
ath
wa
y)
Me
tab
olis
m o
f M
ed
ica
tio
ns
•Tw
o m
ajo
r ty
pe
s o
f c
he
mic
al re
ac
tio
ns in
vo
lve
d in
th
e
me
tab
olis
m o
f d
rug
s:
“Ph
ase
1”
an
d “
Ph
ase
2”
•P
ha
se
2-
typ
e r
ea
ctio
ns in
vo
lve
co
nju
ga
tio
n o
f a
dru
g
to a
su
bsta
nc
e t
ha
t is
usu
ally
ava
ilab
le in
exc
ess in
w
ell-
no
urish
ed
ce
lls (
the
refo
re r
are
ly r
ate
-lim
itin
g
ste
ps in
th
e m
eta
bo
lic p
ath
wa
y a
nd
th
us r
are
ly
invo
lve
d in
DD
I’s)
Me
tab
olis
m o
f M
ed
ica
tio
ns
•P
ha
se
1 t
yp
e m
eta
bo
lic r
ea
ctio
ns in
vo
lve
CY
PP
45
0
en
zym
es
•T
he
CY
PP
45
0 s
up
erf
am
ily c
om
prise
s s
eve
ral
me
mb
ers
(is
oe
nzym
es),
ea
ch
with
se
ve
ral g
en
etic
p
oly
mo
rph
ism
s
•T
he
ma
jority
of
the
me
dia
tio
ns t
ha
t w
e u
se
are
su
bstr
ate
s f
or
on
e o
r m
ore
CY
PP
45
0 e
nzym
es
Op
ioid
s,
CY
PP
45
0 a
nd
DD
I’s
•M
ost
op
ioid
s a
re m
eta
bo
lize
d b
y o
ne
or
mo
re o
f th
e
CY
PP
45
0 iso
en
zym
es,
an
d t
his
re
su
lts in
th
e g
en
era
tio
n
of
mu
ltip
le m
eta
bo
lite
s.
•O
the
r p
resc
rip
tio
n m
ed
ica
tio
ns,
OT
C m
ed
ica
tio
ns,
“he
rba
ls”,
die
tary
su
pp
lem
en
ts,
etc
. c
an
in
hib
it o
r in
du
ce
th
e C
YP
P4
50
en
zym
e a
ctivity in
vo
lve
d in
op
ioid
m
eta
bo
lism
c
linic
ally
sig
nifi
ca
nt
DD
I
CY
PP
45
0 e
nzym
e I
nh
ibitio
n
•T
he
in
hib
itio
n o
f a
dru
g’s
me
tab
olis
m c
au
se
s a
n
inc
rea
se
in
th
e b
loo
d le
ve
l o
f th
e p
are
nt
dru
g a
nd
a
de
cre
ase
in
its
me
tab
olit
es.
•In
cre
asin
g a
pare
nt d
rug
incre
ases its
thera
peutic e
ffect and
p
ossib
le or
in A
DE
’s
•E
xcep
t if a
dru
g is a
pro
dru
g (
cod
ein
e),
inhib
itin
g the
meta
bolis
m o
f a p
rod
rug
dim
inis
hes its
thera
peutic e
ffect
CY
PP
45
0 e
nzym
e I
nd
uc
tio
n
•In
du
ctio
n o
f a
dru
g’s
me
tab
oliz
ing
en
zym
es d
ec
rea
se
s
the
blo
od
le
ve
l o
f th
e p
are
nt
dru
g a
nd
in
cre
ase
s its
m
eta
bo
lite
s,
de
cre
asin
g t
he
dru
g’s
th
era
pe
utic
effe
cts
(e
xc
ep
t in
th
e c
ase
of
a p
rod
rug
)
Ad
ve
rse
Dru
g E
ve
nts
•A
DE
will
either
incre
ase o
r d
ecre
ase d
ep
end
ing
on w
heth
er
they a
re c
aused
by the p
are
nt d
rug
or
the m
eta
bolit
es.
•If d
iffere
nt m
ed
ications a
re m
eta
boliz
ed
via
the s
am
e
CY
PP
450 p
ath
way,
com
petitive inhib
itio
n b
etw
een o
r am
ong
the d
rug
s c
an lead
to h
igher
than inte
nd
ed
levels
of
one o
r m
ore
of th
e d
rug
s.
•If a
med
ication is m
eta
boliz
ed
by a
sp
ecifi
c C
YP
P450
enzym
e a
nd
is c
o-a
dm
inis
tere
d w
ith a
n inhib
itor
or
ind
ucer
of th
e s
am
e e
nzym
e, an inte
raction is p
ossib
le.
•excep
t in
cases o
f a p
rod
rug
DR
UG
A
D
rug
B
Inh
ibits m
eta
bo
lism
EF
FE
CT
Dru
g A
Op
ioid
s
Th
eir C
PY
45
0 e
nzym
es
Ind
uc
er
me
dic
atio
ns
Inh
ibito
r m
ed
ica
tio
ns
OP
IOID
Tra
mad
ol
Hyd
roco
do
ne
Oxyco
do
ne
Fen
tan
yl
CY
PP
450 E
nzym
es
3A
4, 2B
6, 2D
63A
4, 2D
63A
4, 2D
63A
4
IND
UC
ER
S
Barb
itura
tes, carb
am
azep
ine,
cort
icoste
roid
s:
dexam
eth
asone, D
ulo
xetine,
Efa
virenz, P
henyto
in, R
ifam
pin
, Tr
og
litazone, G
inkg
o b
ilob
a, S
t Johns w
ort
, Vale
rian
Barb
itura
tes,
carb
am
azep
ine,
cort
icoste
roid
s:
dexam
eth
asone, E
favirenz,
Phenyto
in, R
ifam
pin
, Tr
og
litazone, G
inkg
o b
ilob
a,
St Johns w
ort
, Vale
rian
Barb
itura
tes, carb
am
azep
ine,
cort
icoste
roid
s:
dexam
eth
asone, E
favirenz,
Phenyto
in, R
ifam
pin
, Tr
og
litazone, G
inkg
o b
ilob
a, S
t Johns w
ort
, Vale
rian
Barb
itura
tes,
carb
am
azep
ine,
cort
icoste
roid
s:
dexam
eth
asone, E
favirenz,
Phenyto
in, R
ifam
pin
, Tr
og
litazone, S
t Johns w
ort
, Vale
rian
INH
IBIT
OR
S
Am
iod
ero
ne, A
zole
antifu
ng
als
, B
up
rop
rion, C
ele
coxib
, C
imetid
ine, C
itolo
pra
m,
Cla
rith
rom
ycin
, C
yclo
sp
orin,
Dia
zep
am
, D
iltia
zem
, D
iphenhyd
rmin
e, D
oxep
in,
Ery
thro
mycin
, E
scitalo
pra
m,
Flu
oro
quin
olo
nes, H
alo
perid
ol,
HIV
pro
tease inhib
itors
, H
yd
roxyzin
e, N
efa
zod
one,
Quin
idin
e, Q
uin
ine, S
ert
ralin
e,
SS
RI’s
, Ta
cro
limus, Venla
faxin
e,
Vera
pim
il, G
rap
efr
uit juic
e
Am
iod
ero
ne, A
zole
antifu
ng
als
, B
up
rop
rion,
Cele
coxib
, C
imetid
ine,
Citolo
pra
m, C
larith
rom
ycin
, C
yclo
sp
orin, D
iazep
am
, D
iltia
zem
, D
iphenhyd
rmin
e,
Doxep
in, D
ulo
xetine,
Ery
thro
mycin
, E
scitalo
pra
m,
Flu
oro
quin
olo
nes,
Halo
perid
ol, H
IV p
rote
ase
inhib
itors
, H
yd
roxyzin
e,
Nefa
zod
one, Q
uin
idin
e,
Quin
ine, S
ert
ralin
e, S
SR
I’s,
Tacro
limus, Venla
faxin
e,
Vera
pim
il,G
rap
efr
uit juic
e
Am
iod
ero
ne, A
zole
antifu
ng
als
, B
up
rop
rion,
Cele
coxib
, C
imetid
ine,
Citolo
pra
m, C
larith
rom
ycin
, C
yclo
sp
orin, D
iazep
am
, D
iltia
zem
, D
iphenhyd
rmin
e,
Doxep
in, D
ulo
xetine,
Ery
thro
mycin
, E
scitalo
pra
m,
Flu
oro
quin
olo
nes, H
alo
perid
ol,
HIV
pro
tease inhib
itors
, H
yd
roxyzin
e, N
efa
zod
one,
Quin
idin
e, Q
uin
ine, S
ert
ralin
e,
SS
RI’s
, Ta
cro
limus,
Venla
faxin
e, Vera
pim
il,
Gra
pefr
uit juic
e
Am
iod
ero
ne, A
zole
antifu
ng
als
, C
imetid
ine,
Cla
rith
rom
ycin
, C
yclo
sp
orin,
Dia
zep
am
, D
iltia
zem
, E
ryth
rom
ycin
, Flu
oro
quin
olo
nes, H
IV
pro
tease inhib
itors
, H
yd
roxyzin
e, N
efa
zod
one,
Quin
ine, S
SR
I’s, Ta
cro
limus,
Venla
faxin
e, Vera
pim
il,
Gra
pefr
uit juic
e
Op
ioid
Tap
en
tad
ol (N
ucen
ta)
Mo
rph
ine
Oxym
orp
ho
ne
Co
dein
eB
up
ren
orp
hin
e
CY
PP
450 e
nzym
es
Min
or-
meta
bolis
m v
ia
Phase 2
reaction
Min
or-
meta
bolis
m v
ia
Phase 2
reaction
Min
or-
meta
bolis
m v
ia
Phase 2
reaction
3A
4, 2D
63A
4, 2C
8, 3A
5, 3A
7, 2C
9, 2C
19,
2C
18
Ind
ucers
Barb
itura
tes, carb
am
azep
ine,
cort
icoste
roid
s: d
exam
eth
asone,
Efa
virenz, P
henyto
in, R
ifam
pin
, Tr
og
litazone
Gin
ko b
ilob
a, S
t Johns w
ort
, Vale
rian
Barb
itura
tes, carb
am
azep
ine,
cort
icoste
roid
s: d
exam
eth
asone,
Efa
virenz, P
henyto
in, R
ifam
pin
, Tr
og
litazone
St Johns w
ort
, Vale
rian
Inh
ibit
ors
Am
iod
ero
ne, A
zole
antifu
ng
als
, B
up
rop
rion,
Cele
coxib
, C
imetid
ine,
Citolo
pra
m, C
larith
rom
ycin
,
Cyclo
sp
orin, D
iazep
am
,
Dilt
iazem
, D
iphenhyd
rmin
e,
Doxep
in, D
ulo
xetine,
Ery
thro
mycin
, E
scitalo
pra
m,
Flu
oro
quin
olo
nes,
Halo
perid
ol, H
IV p
rote
ase
inhib
itors
, H
yd
roxyzin
e,
Nefa
zod
one, Q
uin
idin
e,
Quin
ine, S
ert
ralin
e, S
SR
I’s,
Tacro
limus, Venla
faxin
e,
Vera
pim
il,
Gra
pefr
uit juic
e,
Am
iod
ero
ne, A
zole
antifu
ng
als
,
Chlo
ram
phenic
ol, C
imetid
ine,
Cla
rith
rom
ycin
, C
yclo
sp
orin,
Dia
zep
am
, D
iltia
zem
,
Ery
thro
mycin
, Flu
oro
quin
olo
nes,
HIV
pro
tease inhib
itors
,
Isonia
zid
, N
efa
zod
one,
Om
ep
razole
, Q
uin
ine, S
SR
I’s,
Tacro
limus, Venla
faxin
e,
Vera
pim
il, Z
afirlukast,
Gra
pefr
uit juic
e
Op
ioid
Hyd
rom
orp
ho
ne
Meth
ad
on
e
CY
P450 E
nzym
es
Min
or-
meta
bolis
m v
ia P
hase 2
reaction
3A
4, 2B
6,
2D
6
Ind
uces
Barb
itura
tes, carb
am
azep
ine, cort
icoste
roid
s:
dexam
eth
asone, D
ulo
xetine, E
favirenz, P
henyto
in,
Rifam
pin
, Tr
og
litazone
Gin
ko b
ilob
a, S
t Johns w
ort
, Vale
rian
Inh
ibit
ors
Am
iod
ero
ne, A
zole
antifu
ng
als
, B
up
rop
rion,
Cele
coxib
, C
imetid
ine, C
itolo
pra
m,
Cla
rith
rom
ycin
, C
yclo
sp
orin, D
iazep
am
,
Dilt
iazem
, D
iphenhyd
rmin
e, D
oxep
in,
Dulo
xetine, E
ryth
rom
ycin
, E
scitalo
pra
m,
Flu
oro
quin
olo
nes, H
alo
perid
ol, H
IV p
rote
ase
inhib
itors
, H
yd
roxyzin
e, N
efa
zod
one,
Quin
idin
e, Q
uin
ine, S
ert
ralin
e, S
SR
I’s,
Tacro
limus, Venla
faxin
e, Vera
pim
il,
Gra
pefr
uit juic
e,
Com
mon C
YP
Ind
ucers
CY
PIn
du
cers
1A
2b
arb
itura
tes, carb
am
azep
ine, om
ep
razole
, p
henyto
in, rifa
mp
in, to
bacco
sm
oke
2B
6b
arb
itura
tes, carb
am
azep
ine, p
henyto
in, rifa
mp
in,
efa
viren
z, nevirap
ine
2C
9b
arb
itura
tes, p
henyto
in, rifa
mp
in, S
t Jo
hn
’s w
ort
2C
19
barb
itura
tes, carb
am
azep
ine, p
henyto
in, rifa
mp
in, S
t John’s
wort
, lo
pin
avir/r
itonavir
2E
+01
Eth
anol, isonia
zin
d
3A
4B
arb
itura
tes, carb
am
azep
ine, cort
icoste
roid
s, efa
virenz, m
od
afinil,
nevirap
ine, oxcarb
azep
ine, p
henyto
in, rifa
butin, rifa
mp
in, S
t. J
ohn
s w
ort
, tr
og
litazone
Ba
se
d o
n r
efe
ren
ce
s 7
,8,9
,10
Com
mon C
YP
Ind
ucers
Com
mon C
YP
Inhib
itors
CY
PIn
hib
ito
rs
1A
2C
imetid
ine, fluoro
quin
olo
nes, Flu
voxam
ine,
gra
pefr
uit ju
ice,
isonia
zid
2B
6C
lop
idro
gel, thio
tep
a, ticlo
pid
ine, vorico
nazole
,
2C
9A
mio
daro
ne, chlo
ram
phenic
ol, c
imetid
ine, azole
antifu
ng
als
, is
onia
zid
, m
etr
onid
azole
, S
SR
I’s, p
rob
enecid
, zafirlukast
2C
19
Cim
etid
ine, in
dom
eth
acin
, fluconazole
, fluvoxam
ine
, keto
conazo
le, la
nsop
razole
, m
ep
razole
, m
od
afinil,
pro
benecid
, S
SR
I’s, to
piram
ate
2D
6A
mio
daro
ne, chlo
ram
phenic
ol, c
imetid
ine, cin
aca
lcet, d
iph
enhyd
ram
ine,
ha
lop
erid
ol,
meth
ad
one, m
ibefr
ad
il, q
uin
idin
e, fluoro
quin
olo
nes, S
SR
I’s, te
rbin
afine, th
iorid
azin
e
3A
4A
mio
dero
ne, azole
antifu
ng
als
, cim
etid
ine, cla
rith
rom
ycin
, d
iltia
zem
, ery
thro
mycin
, fluoro
quin
olo
nes, g
rap
efr
uit juic
e, H
IV p
rote
ase in
hib
itors
, q
uin
ine,
SS
RI’s
Ba
se
d o
n r
efe
ren
ce
s 7
, 8
,9,1
0
Testin
g f
or
CY
PP
45
0 a
bn
orm
alit
ies
•In
patients
who a
re r
eq
uirin
g a
bnorm
ally
hig
h d
oses o
f op
ioid
med
ications, are
havin
g a
bnorm
al re
sp
onses to the
op
ioid
, or
who h
ave a
bnorm
al urine d
rug
monitoring
-
consid
er
CY
PP
450 g
enetic testing
• C
YP
2D
6, C
YP
2C
9 a
nd
2C
19 C
onsid
er
usin
g
hyd
rom
orp
hone, oxym
orp
hone a
nd
tap
enta
dol (u
se
phase 2
glu
curo
nid
ation for
meta
bolis
m)
inste
ad
of
cod
ein
e, hyd
rocod
one, oxycod
one, tr
am
ad
ol,
fenta
nyl,and
meth
ad
one w
hic
h a
re m
eta
boliz
ed
by the
CY
PP
450 s
yste
m
Wh
o s
ho
uld
un
de
rgo
ge
ne
tic
te
stin
g f
or
CY
PP
45
0 a
bn
orm
alit
ies?
•N
o p
ub
lish
ed
gu
ide
line
s c
urr
en
tly e
xis
t
•To
id
en
tify
pa
in p
atie
nts
wh
o le
gitim
ate
ly r
eq
uire
a h
igh
d
ose
, o
r u
nu
su
al o
pio
id r
eg
ime
•P
atie
nts
re
qu
irin
g m
ore
th
an
15
0 m
g o
f m
orp
hin
e a
da
y
eq
uiv
ale
nt
do
sa
ge
sh
ou
ld b
e t
este
d t
o h
elp
va
lida
te
tha
t a
hig
h o
pio
id d
osa
ge
is n
ee
de
d (
the
se
pa
tie
nts
are
o
fte
n e
rro
ne
ou
sly
la
be
led
as d
rug
se
eke
rs o
r a
dd
ict
Wh
o s
ho
uld
un
de
rgo
ge
ne
tic
te
stin
g f
or
CY
PP
45
0 a
bn
orm
alit
ies?
•To
decre
ase the risk o
f D
DI’s
- m
ost D
DI’s
in o
pio
id m
ed
ications
involv
e C
YP
P450 inhib
itors
, w
hic
h lead
to a
n incre
ase level of
op
ioid
s in the p
atient’s
syste
m-
pla
cin
g the p
atient at risk o
f sed
ation, re
sp
irato
ry d
ep
ressio
n a
nd
possib
le toxic
effects
•To
help
guid
e the p
ractitioner
in the s
ele
ction o
f op
ioid
that are
com
para
ble
with a
patient’s
genetic s
tatu
s (
EX
: p
atient w
ith
CY
P-2
D6 d
efe
ct m
ay n
ot re
sp
ond
to c
od
ein
e, w
hic
h is
consid
ere
d a
pro
dru
g w
ith the a
ctive m
eta
bolit
e m
orp
hin
e, B
UT
the r
isk o
f m
orp
hin
e toxic
ity follo
win
g c
od
ein
e a
dm
inis
tration is
hig
her
in u
ltra
-meta
boliz
ers
)
Wh
at
tests
do
I o
rde
r?
•Te
st
for
de
fic
its in
th
e C
YP
2D
6,
2C
9 a
nd
2C
19
•T
he
se
th
ree
en
zym
es a
cc
ou
nt
for
a s
ign
ific
an
t a
mo
un
t o
f o
pio
id m
eta
bo
lism
•In
ten
siv
ely
stu
die
d d
ata
is a
va
ilab
le d
eta
ilin
g t
he
ir
inte
rac
tio
ns w
ith
nu
me
rou
s d
rug
s
•L
ab
te
stin
g t
ec
hn
olo
gy is r
elia
ble
Wh
at
tests
do
I o
rde
r?
C
ontinu
ed
•T
hird
pa
rty p
aye
rs,
inc
lud
ing
Me
dic
are
, n
ow
pa
y f
or
the
se
te
st
•S
am
ple
s c
an
be
ob
tain
ed
fro
m s
aliv
a,
blo
od
or
bu
cc
al sw
ab
•O
the
r C
YP
en
zym
es s
uc
h a
s 3
A4
are
be
gin
nin
g t
o b
e
co
mm
erc
ially
ava
ilab
le
La
b r
esu
lt in
terp
reta
tio
n
En
zym
e V
ari
ati
on
Lab
ora
tory
Term
ino
log
yO
pio
id D
osag
e
No
rmal
Exte
nsiv
e M
eta
bolis
er
Norm
al
Overa
cti
ve
Rap
id o
r ultra
rap
id m
eta
boliz
er
Hig
h o
r u
ltra
- hig
h d
osag
e r
eq
uired
because
the e
nzym
e c
ontinuously
deactivate
s the
op
ioid
, w
hic
h low
ers
seru
m le
vels
(excep
t in
a
pro
dru
g)
Un
dera
cti
ve
Inte
rmed
iate
meta
boliz
er
(50%
or
less
function)
CY
P e
nzym
es a
re s
low
or
“la
zy”
need
ing
exa
op
ioid
to “
forc
e”
meta
bolis
m
Min
imally a
cti
ve o
r
inacti
ve
Poor
meta
boliz
er
(90%
-100%
less
function)
Wo
n’t
effi
cie
ntly p
roce
ss a
n o
pio
id, so o
pio
id
dosag
e m
ay h
ave
to
decre
ase. A
n inac
tive
enzym
e m
ay c
ause
seru
m le
vels
to r
ise a
nd
p
rod
uc
e t
oxic
ity (
excep
t in
a p
rod
rug
)
Co
mm
on
Sp
ina
l S
tero
id I
nje
ctio
ns
•C
ort
ico
ste
roid
in
jec
tio
ns h
ave
be
co
me
an
in
teg
ral p
art
o
f p
ain
ma
na
ge
me
nt
for
pa
tie
nts
with
sp
ine
pa
in
Co
mm
on
Sp
ina
l In
jec
tio
ns C
on
tin
ue
d
•E
pid
ura
l ste
roid
in
jec
tio
ns
•Tr
an
sfo
ram
ina
l/S
ele
ctive
Ne
rve
Ro
ot
ep
idu
ral ste
roid
in
jec
tio
ns
•F
ac
et
Jo
int
Inje
ctio
ns/M
ed
ial B
ran
ch
Ne
rve
Blo
cks
Ep
idu
ral S
tero
id I
nje
ctio
ns
•G
oa
l is
to
pu
t c
ort
ico
ste
roid
s a
s c
lose
as p
ossib
le t
o t
he
in
fla
me
d n
erv
e r
oo
t to
he
lp r
elie
ve
pa
in
•C
an
be
do
ne
fo
r b
oth
th
era
pe
utic
an
d d
iag
no
stic
p
urp
ose
s (
to h
elp
dia
gn
ose
th
e s
ite
of
pa
in o
f p
ain
)
Ep
idu
ral S
tero
id I
nje
ctio
ns C
on
tin
ue
d
•In
dic
atio
ns:
rad
icu
lop
ath
y, s
pin
e p
ain
, sp
ina
l ste
no
sis
, p
ost
lam
ine
cto
my s
urg
ery
syn
dro
me
, p
ha
nto
m lim
b
pa
in,
PH
N,
ve
rte
bra
l c
om
pre
ssio
n f
rac
ture
s,
DP
N,
ch
em
oth
era
py r
ela
ted
pe
rip
he
ral n
eu
rop
ath
y, C
RP
S,
orc
ha
lgia
, p
roc
talg
ia,
pe
lvic
pa
in s
yn
dro
me
, C
erv
ico
ge
nic
he
ad
ac
he
, d
isc
og
en
ic p
ain
, sp
on
dylo
sis
Ep
idu
ral S
tero
id I
nje
ctio
ns C
on
tin
ue
d
•C
on
tra
ind
ica
tio
ns:
•A
bso
lute
: u
nw
illin
g p
atie
nt,
pre
gn
an
cy (
un
de
r flu
oro
),
an
ap
hyla
ctic
re
ac
tio
n/a
llerg
y t
o t
he
me
dic
atio
ns,
ca
ud
a e
qu
ina
syn
dro
me
, a
ntic
oa
gu
latio
n,
co
ag
ulo
pa
thy,
su
sp
ec
ted
lo
ca
l o
f syste
m in
fec
tio
n
•R
ela
tive
: h
yp
ovo
lem
ia,
DM
, G
lau
co
ma
Ep
idu
ral
Ste
roid
In
ject
ion
Tra
nsfo
ram
ina
l/S
ele
ctive
Ne
rve
Ro
ot
Inje
ctio
ns
•T
he
diff
ere
nc
e b
etw
ee
n s
ele
ctive
ne
rve
ro
ot
inje
ctio
n
an
d t
ran
sfo
rma
tio
na
l e
pid
ura
l ste
roid
in
jec
tio
n is
qu
estio
na
ble
an
d b
oth
are
pe
rfo
rme
d u
sin
g s
imila
r te
ch
niq
ue
s
•G
oa
l is
to
pu
t c
ort
ico
ste
roid
s a
s c
lose
as p
ossib
le t
o t
he
in
fla
me
d n
erv
e r
oo
t to
he
lp r
elie
ve
pa
in
•C
an
be
do
ne
fo
r b
oth
th
era
pe
utic
an
d d
iag
no
stic
p
urp
ose
s (
to h
elp
dia
gn
ose
th
e s
ite
of
pa
in o
f p
ain
)
Tra
nsfo
ram
ina
l/S
ele
ctive
Ne
rve
Ro
ot
Inje
ctio
ns
Co
ntin
ue
d
•In
dic
atio
ns a
nd
co
ntr
ain
dic
atio
ns a
re b
asic
ally
th
e s
am
e
as e
pid
ura
l ste
roid
in
jec
tio
ns
Transfo
ram
inal/S
ele
ctive N
erv
e R
oot In
jection
Fa
ce
t Jo
int
Inje
ctio
ns
•G
oa
l is
to
pu
t c
ort
ico
ste
roid
s in
to t
he
fa
ce
t jo
int
to h
elp
re
lieve
pa
in
•C
an
be
do
ne
fo
r b
oth
th
era
pe
utic
(fo
r p
ain
re
lief)
an
d
dia
gn
ostic
pu
rpo
se
s (
to h
elp
dia
gn
ose
th
e s
ite
of
pa
in)
Fa
ce
t Jo
int
Inje
ctio
ns C
on
tin
ue
d
•In
dic
atio
ns:
No
n-r
ad
icu
lar
sp
ina
l p
ain
, sp
ina
l p
ain
with
re
ferr
ed
pa
in t
o t
he
extr
em
ity,
•C
on
tra
ind
ica
tio
ns:
pa
tie
nt
refu
sa
l, a
llerg
ies t
o in
jec
ted
m
ed
ica
tio
ns,
infe
ctio
n a
t th
e s
ite
of
inje
ctio
ns,
an
tic
oa
gu
lan
ts (
pra
ctic
e v
arie
s w
ith
th
is-
we
on
ly h
old
a
ntic
oa
gu
lan
ts f
or
ce
rvic
al fa
ce
t in
jec
tio
ns)
Fa
ce
t Jo
int
Inje
ctio
ns C
on
tin
ue
d
•W
he
n p
atie
nts
ha
ve
go
od
re
lief
bu
t o
f sh
ort
du
ratio
n
with
fa
ce
t jo
int
inje
ctio
ns,
we
ca
n d
o d
iag
no
stic
me
dia
l b
ran
ch
blo
cks.
•If
pa
tie
nts
ha
ve
“g
oo
d”
(th
e p
erc
en
tag
e o
f re
lief
req
uire
d is in
su
ran
ce
sp
ec
ific
) re
lief
with
th
e m
ed
ial
bra
nc
h b
loc
ks t
he
n a
n R
ad
io F
req
ue
nc
y A
bla
tio
n M
AY
b
e in
dic
ate
d
Ce
rvic
al F
ac
et
Re
ferr
ed
Pa
in
Th
ora
cic
Fa
ce
t
Re
ferr
ed
Pa
in
Lum
bar
Refe
rred
Pain
An
ato
my o
f th
e F
ac
et
Jo
int
Cerv
ical A
nato
my
Ce
rvic
al F
ac
et
M
ed
ial B
ran
ch
Ne
rve
Thora
cic
Med
ial B
ranch N
erv
es
Thora
cic
Med
ial B
ranch N
erv
es
Lu
mb
ar
Fa
ce
t Jo
int
an
d M
ed
ial B
ran
ch
Ne
rve
!an
k yo
u fo
r yo
ur a"
en#
on
Questions?
Refe
rences
•1
. w
ww
.cd
c.g
ov/d
rug
ove
rdo
se/p
df/
co
mm
on_e
lem
en
ts_in
_g
uid
line
s_fo
r_p
resc
rib
ing
•2
. C
ho
u, R
, F
an
ciu
llo G
J,
et
all:
Clin
ica
l G
uid
elin
es f
or
the
Use
of
Chro
nic
Op
ioid
Th
era
py in
Ch
ron
ic N
on
ca
nc
er
Pa
in.
Th
e J
ou
rna
l o
f P
ain
, 2
00
9:
pp
1
13
-13
0
•3
. N
atio
na
l D
ise
ase
an
d T
he
rap
eu
tic
In
de
x. h
ttp
s://w
eb
01
.im
sh
ea
lth.c
om
/nd
ti/n
dtilo
gin
.asp
x
•4
. M
itc
hell
AA
, K
au
fma
n D
W,
Ro
se
nb
erg
L. P
att
ern
s o
f m
ed
ica
tio
n u
se
in
th
e U
nite
d S
tate
s 2
00
6:
a r
ep
ort
fro
m t
he
So
ne
Su
rve
y. h
ttp
://w
ww
.bu
.ed
u/
slo
ne/S
lon
eS
urv
ey/A
nn
ua
lRp
t/S
lon
eS
urv
eyW
eb
Re
po
rt2
00
6.p
df
•5
. F
loc
kha
rt D
A.
Ind
ian
a U
niv
ers
ity S
ch
oo
l of
Me
dic
ine
. D
rug
in
tera
ctio
ns:c
yto
ch
rom
e P
45
0 d
rug
in
tera
ctio
ns t
ab
le.
htt
p://m
ed
icin
e.iu
pu
i.e
du//
clin
ph
arm
/dd
is/t
ab
le.a
sp
x
•6
. G
urw
itz J
H,
Fie
ld T
S,
Ha
rro
ld L
R,
et
al. I
nc
ide
nc
e a
nd
pre
ve
nta
bili
ty o
f a
dve
rse
dru
g e
ve
nts
am
on
g o
lde
r p
ers
on
s in
th
e a
mb
ula
tory
se
ttin
g.
JA
MA
2
00
3;2
89
(9):
11
07
-111
6
•7
. F
loc
kha
rt,
DA
, In
dia
na
Un
ive
rsity S
ch
oo
l o
f M
ed
icin
e.
Dru
g in
tera
ctio
ns:
cyto
ch
rom
e P
45
0 d
rug
in
tera
ctio
ns t
ab
le.
htt
p://m
ed
ica
ine
.iu
pu
i.e
du/
clin
ica
lph
arm
/dd
is/t
ab
le.a
sp
x
•8
. P
ola
sek T
M,
Lin
FP
Y,
Min
ers
JO
, D
oo
gu
e M
P.
Pe
rpe
tra
tors
of
pha
rma
co
kin
etic
dru
g-d
rug
in
tera
ctio
ns a
risin
g f
rom
alte
red
cyto
ch
rom
e P
45
0 a
ctivity:
a
crite
ria
-ba
se
d a
sse
ssm
en
t. B
r J C
lin P
ha
rma
cy.
20
11
;71
(5):
72
7-7
36
Refe
rences
•9. O
verh
ols
er
BR
, Foste
r D
R. O
pio
id p
harm
acokin
etic d
rug
-dru
g inte
ractions. A
M J
Manag
Care
. 2011;1
7(s
up
pl):S
276-S
287
•10. Lynch T
. M
anag
em
ent of d
rug
-dru
g inte
ractions:c
onsid
era
tions for
sp
ecia
l p
op
ula
tions-
a focus o
n o
pio
id u
se in the
eld
erly a
nd
long
term
care
. A
M J
Mana C
are
. 2011;1
7(s
up
pl):S
293-S
298