Opioids Flashcards
(44 cards)
Should a patient ‘tough out’ acute pain?
-probably not
-can lead to higher risk of chronic pain(delayed ambulation, long-term use of opioids)
Numerical Rating Scale
0-10 scale based on the work of Clevland and Brief Pain Inventory
NSAIDS vs Opioids
-there is no statistical significance is in opioids being more effective than NSAIDs
-both equally effective after 30 minutes
non drug therapies for Lower Back pain
-gentle exercise
-rehab
-local heat pack
-mindfulness stress reduction
non drug therapies for lower back pain with little evidence
-spinal manipulation
-acupuncture
-massage
Drug treatment for lower back pain
-Acetaminophen
-NSAIDS(better)
-muscle relaxants(little evidence in chronic back pain)
-tramadol and strong opioids
Non-malignant chronic pain
-studies are typically short
-opioids are commonly no better than NSAIDs and other drugs
Cancer related pain
-More likely to respond to opioids
-caution still needed in initiation and titration
-adjuvants are still appropriate
FDA tolerance definition
-patients who are taking, for 1 week or longer, at least:
-60 mg morphine/day
-30 mg oxycodone
-8 mg hydromorphone
-25 mcg transdermal fentanyl
How long does it take to become dependent on opioids?
-dependences can be presumed to occur when one has developed tolerance
-faster onset with shorter half life
Pros of Urine testing
-confirm use of opioids
-identify use of unprescribed opioids or drugs of abuse
Cons of Urine screening
-increase cost for patient
-test may be misinterpreted
-test may be adulterated
What is opioid misuse?
defined as use in
any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more
often, or longer than told; or use in any other way not
directed by a doctor.
When choosing an opioid, what should you typically avoid?
-Codeine +/- APAP: bc it’s a prodrug and it has varied metabolism throughout the population
-Tramadol: increased seizure risk, serotonin syndrome, drug interactions, hypoglycemia
-Meperidine: seizures
Meperidine
-short acting, cause seizures due to metabolite build up
-not reversed by naloxone
-COMMONLY used IV as a single dose for the treatment of severe rigors
Pros of morphine oral formulations
-least expensive
-multiple ER and IR formulations, including liquids
-few drug interactions
Cons of morphine oral formulation
-15 mg size of IR tablet is an awkward starting dose
-accumulation of neurotoxic morphine-3-glucuronide metabolite in high doses and/or renal dysfunction often leads to adverse effects
morphine characteristics
-peak concentration after IR dose is within 1 hour
-glucuronidated by the liver: Morphine-6-G 5x more potent, M3G: neurotoxicity (delirium, dysphoria, hallucinations, myoclonic jerking)
-glucuronides are renal excreted: avoid morphine for GFR < 30 mL/min
Oxycodone as an alternative to morphine
-less dependent on kidneys for elimination
-slightly more potent than morphine
-use 2 mg oxycodone:3 mg morphine
-use 1:1 when converting from oxy TO morphine
Hydrocodone with APAP
-less dependence on kidneys for elimination
-NOT commonly used in cancer pain and palliative care because of combination with APAP
Fentanyl as a alternative to morphine
-metabolized to inactive metabolites: good for patient’s with renal inpairment
-Tansdermal patch 1:1 to IV infusion
What patients can use transdermal fentanyl patches?
-have established opioids needs AND
-who are already tolerant to opioids
-same with ER oral dosage of other opioids
Morphine in renal insufficiency
-not completely contraindicated for GFR < 60 with monitoring
Oxycodone and hydromorphone in renal insufficiency
-can be used in moderate renal impairment
-initial dose must be lower than usual, and the size and frequency of dose smaller
