Rogers Pain Part 3

Question 1

Uses of opioids

Answer 1

Acute and chronic pain

Question 2

Opioid side effects

Answer 2

-Antitussive
-Constipation
-Nausea and vomiting
-Itching
-Orthostatic hypotension
-Urinary retention
-Sedation
-Respiratory depression

Question 3

Opioid clinical pearls

Answer 3

-Consider starting stool softener and/or stimulant laxative
-Potential for tolerance, dependence and addiction
-Schedule 2 controlled substances besides tramadol and codeine

Question 4

Available formulation for codeine

Answer 4

-Tablet
-Cough syrup

Question 5

Codeine clinical pearls

Answer 5

-Schedule 5, 3, or 2 controlled substances
-Metabolized to morphine via CYP 2D6
-Not recommended in breastfeeding mothers or children less than 12

Question 6

Codeine brand name

Answer 6

Tylenol #3

Question 7

Tramadol available formulations

Answer 7

-Capsule ER 24hr
-Tablet - IR and ER 24hr
-Oral solution
-Combination products with acetaminophen and celecoxib available

Question 8

Tramadol clinical pearls

Answer 8

-Risk of serotonin syndrome when used with other serotonergic medications
-Renally dose adjusted
-US boxed warning: use of CYP 450 3A4 inducers, 3A4 inhibitors, and 2D6 inhibitors with tramadol requires careful consideration of the effects on the parent drug and metabolite
-Schedule 4 controlled substance

Question 9

Tramadol brand name

Answer 9

-Ultram-discontinued
-Conzip
-Qdolo

Question 10

Morphine available formulations

Answer 10

-Capsule ER 24hr
-Tablet - IR and 12hr ER (MS contin)
-Oral solution
-Solution for injection (IM, IV, subQ)
-Suppository

Question 11

Morphine clinical pearls

Answer 11

-Itching more prominent compared to other opioids
-Morphine and its metabolites are renally excreted and accumulate in renal dysfunction (avoid in patients with renal disease)
-US boxed warning: avoid alcohol while taking ER capsules - leads to increased morphine plasma levels and potentially fatal overdose

Question 12

Hydromorphone available formulations

Answer 12

-IR and ER tablets
-Oral solutions
-Solution for injection
-Suppository

Question 13

Hydromorphone clinical pearls

Answer 13

US boxed warning about dosing errors when prescribing, dispensing, and administering:
-Oral solution - do not confuse mg and mL
-IV solution - do not confuse high potency solution with other solutions

Question 14

Hydromorphone brand name

Answer 14

Dilaudid

Question 15

Hydrocodone +/- acetaminophen available formulations

Answer 15

-Oral solution
-ER tablet
-Tablet

Question 16

Hydrocodone +/- acetaminophen clinical pearls

Answer 16

-Counsel patients on acetaminophen use
-US boxed warning: Use with CYP 3A4 inhibitors may increase hydrocodone plasma concentrations

Question 17

Oxycodone +/- acetaminophen available formulations

Answer 17

-Tablet (IR and ER 12hr)
-Capsule (IR and ER 12hr)
-Oral solution

Question 18

Oxycodone +/- acetaminophen clinical pearls

Answer 18

-Counsel patients on acetaminophen use with combination product
-ER capsules/tablets are abuse-deterrent
-US boxed warning: use with CYP 3A4 inhibitors may increase oxycodone plasma concentrations

Question 19

Oxycodone brand names

Answer 19

-Oxycontin
-Xtampza

Question 20

Oxycodone + acetaminophen brand name

Answer 20

Percocet

Question 21

Fentanyl available formulations

Answer 21

-Buccal tablet
-Sublingual liquid
-Lozenge
-Injectable solution
-Patch

Question 22

Fentanyl clinical pearls

Answer 22

-US boxed warning: monitor patients receiving CYP 3A4 inhibitors or inducers
-Can be used in renal impairment
-Less hypotension than morphine or hydromorphone at similar doses
-Non-injectable forms are only indicated with patients who are opioid-tolerant
-Doses are not converted from one fentanyl product to another on a mcg-per-mcg basis

Question 23

What is opioid tolerance?

Answer 23

Taking morphine 60mg per day (or equivalent) for at least 1 week

Question 24

Fentanyl brand name

Answer 24

Duragesic

Question 25

Fentanyl patch counseling

Answer 25

-Apply one patch every 72 hours (3 days) -Apply the patch to the chest, back, flank, or upper arm -Do not cut patches or use a patch that is torn or damaged (could cause an overdose) -Do not use the patch over broken skin -Do not let the patch get too warm while wearing (body will absorb too much)

Question 25

Methadone available formulations

Answer 25

-Oral solution -Injectable solution -Tablet

Question 26

Methadone brand name

Answer 26

Methadose

Question 26

Meperidine available formulations

Answer 26

-Injectable solution -Oral solution -Tablet

Question 26

Methadone uses

Answer 26

-Last line treatment for chronic pain -Opioid detoxification

Question 26

Methadone clinical pearls

Answer 26

-US boxed warning: QTc prolongation (check baseline ECG before initiation) -US boxed warning: monitor patients receiving CYP #A4 inhibitors or inducers -Long half life (8-59 hours)

Question 27

Meperidine clinical pearls

Answer 27

-Avoid in the elderly, avoid in renal impairment, caution use in hepatic impairment -US boxed warning: monitor patients receiving CYP 3A4 inhibitors or inducers -US boxed warning: do not use within 14 days of monoamine oxidase inhibitors (MAOIs) -Metabolized by the liver into an active metabolite (accumulation of this metabolite can cause delirium and seizures) -Not commonly used due to adverse effects

Question 28

Which opioid has serotonergic activity?

Answer 28

Tramadol

Question 29

What do opioids with serotonergic activity have the risk to do?

Answer 29

-Lower seizure threshold -Cause serotonin syndrome when used with other agents with serotonergic activity

Question 30

Initial dosing of codeine in opioid naive patients

Answer 30

15-60mg PO Q4H PRN

Question 31

Initial dosing of tramadol in opioid naive patients

Answer 31

25-50mg PO Q4-6H PRN

Question 32

Initial dosing of morphine in opioid naive patients

Answer 32

-5-10mg PO Q4H PRN -2.5-5mg IV Q3-4H PRN

Question 33

Initial dosing of hydromorphone in opioid naive patients

Answer 33

-2.4mg PO Q4-6H PRN -0.2-1mg IV Q2-3H PRN

Question 34

Initial dosing of hydrocodone in opioid naive patients

Answer 34

2.5-10mg PO Q4-6H PRN

Question 35

Initial dosing of oxycodone in opioid naive patients

Answer 35

5-15mg PO Q4-6H PRN

Question 36

Initial dosing of fentanyl in opioid naive patients

Answer 36

25-50mcg Q30-60min PRN

Question 37

Which opiates are natural opiates?

Answer 37

-Morphine -Codeine

Question 38

Which opiates are semi synthetic opioids?

Answer 38

-Hydromorphone -Oxycodone -Oxymorphone -Hydrocodone -Buprenorphine

Question 39

Which opiates are synthetic opioids?

Answer 39

-Fentanyl -Methadone -Meperidine -Tramadol

Question 40

Is there allergic cross reaction for natural opiates with other opioids?

Answer 40

Yes, avoid in patients with allergy to other natural opiates and semi synthetic opioids

Question 41

Is there allergic cross reaction for semi synthetic opioids with other opioids?

Answer 41

Yes, avoid in patients with allergy to other natural opiates and semi synthetic opioids

Question 42

Is there allergic cross reaction for synthetic opioids with other opioids?

Answer 42

No, can be used if patient has an allergy to another synthetic opioid, semi synthetic opioid or natural opiate

Question 43

How do you switch between opioids?

Answer 43

-Calculate daily consumption for each opioid -Convert each opioid to oral morphine -Add morphine doses together to get total daily oral morphine dose -Due to cross-tolerance, reduce the equal analgesic dose by 25-30% -Split total daily dose into appropriate dosing interval based on opioid selected (duration of action)