pain policy update opioid update
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Pain Policy UpdateOpioid Update
Stuart Beatty, PharmD, BCPS
Opioids
• Tramadol (Ultram)– Not scheduled (still abused)– SNRI activity works for neuropathic pain– Risk of seizures– Interaction with SSRIs (serotonin syndrome)
Opioids
Schedule III-IV• Codeine, Propoxyphene, Hydrocodone• Can call Rx in; 5 refills
Schedule II• Oxycodone, Morphine, Methadone,
Fentanyl, Oxymorphone, Hydromorphone• Must have written Rx; No refills
All patient should receive Senna S or Peri-Colace
Opioids
• Codeine (Tylenol #3)– Low amount of APAP (300mg/tablet)– More constipation than others
• Propoxyphene (Darvocet)– High APAP dose (650mg/tablet)– Metabolite accumulates in renal dysfunction– DO NOT USE!!!
Opioids
• Hydrocodone (Lortab, Vicodin, Norco)– APAP ranges from 325-750mg/tablet (Norco
has lowest amount)– Street value, abuse
Opioids
• Oxycodone (Percocet, Oxycontin)– Immediate release available + APAP– Sustained release should be dose Q12H
• Can be crushed to remove time release
– Street value, abuse
Opioids
• Morphine (MS Contin, Avinza, Kadian)– Lots of dosage forms (immediate and time
release)– Active metabolite can accumulate in renal
dysfunction
• Hydromorphone (Dilaudid)– Short-acting only– Very potent
Opioids
• Fentanyl– Patch allows Q72H steady release– DO NOT USE IN CACHETIC PATIENTS
• Methadone– Long t½ makes it good long-acting option– May cause QT prolongation– Need to wait 3-5 days to adjust dose– Action at NMDA receptor treats neuropathic pain
Chronic Non-Malignant Pain Policy
• 2006– Pain Registry– 38% violations
• 2007– Move to Martha Morehouse / EMR
• 2008– Revised and reimplemented
• 2009– Current policy introduced
Current Policy
• NO NEW PATIENTS RECEVING CHRONIC NARCOTICS– Exceptions:
• Discharged from GIM service
Controlled Substance Agreement
Policy Requirements
• Signed agreement annually (chronic controlled substances = BZD & opioids)– JULY/AUGUST/SEPTEMBER – renew
everyone!!!– Review policy with patient – Signed by patient, resident, attending– Scanned into chart– Document under problem list date updated
Urine Toxicology
• Needs to be obtained annually when agreement is signed
• May be requested by prescriber during any office visit
• MUST BE OBTAINED IN CLINIC!!!
• Results will take up to 24 hours
• Failure to give urine when requested is considered a policy violation
OARXRS
Included in database– All controlled
substance (II-V) prescriptions
– Carisoprodol prescriptions
– Tramadol prescriptions
Excluded from database– Out-of-state pharmacy– Government pharmacy
(e.g., VA, IHS) – Physician dispensed– Inpatient, nursing
home, ED administered
– ED dispensed < 24 hr supply
– C-V OTC sales
Should be requested annually when agreement is signed. May be requested during any office visit.
Attendings should have access
Interpreting Urine ScreensDrug Drug Tox False Positive
Morphine Morphine; Hydrocodone (high dose); Hydromorphone (high dose)
Heroin
Codeine Codeine; Morphine; Hydrocodone (high dose); Hydromorphone (high dose)
Fentanyl Fentanyl Trazodone
Methadone Methadone Verapamil; diphenhydramine
Oxycodone Oxycodone; Oxymorphone
Oxymorphone Oxymorphone Oxycodone
Hydrocodone Hydrocodone; Hydromorphone
Hyrdromorphone Hydromorphone Hydrocodone
Mayo Clin Proc. 2008;83(1)66-76
Interpreting Urine Screens - Others
Drug Drug Tox False Positive
Alprazolam α-hydroxy-alprazolam Sertraline
Diazepam Nordiazepam; temazepam; oxazepam
Sertraline
Temazepam Temazepam; oxazepam Diazepam; Sertraline
Oxazepam Oxazepam Diazepam; Temazepam; Sertraline
Lorazepam Lorazepam Sertraline
Marijuana 9-carboxy-THC Pantoprazole; efavirenz; NSAIDs
Marinol is true positive
Cocaine Benzoylecgonine
Mayo Clin Proc. 2008;83(1)66-76
Interpreting Urine ScreensDrug Expected time in Urine
Opioids
Morphine
Hydromorphone
Oxycodone
Methadone
2-3 days
2-4 days
2-4 days
3-4 days
BZD
Short-acting (e.g., lorazepam)
Long-acting (e.g., diazepam)
3 days
30 days
Marijuana
Single use
Moderate (2-5x/wk)
Daily
3 days
5-7 days
10-30 days
Cocaine 2-4 days
Mayo Clin Proc. 2008;83(1)66-76
Opioid ConversionDetermine daily opioid use (LA only)
Opioid Agonist Parenteral Dose
Oral Dose
Morphine 10 mg 30 mg
Hydromorphone (Dilaudid) 1.5 mg 7.5 mg
Fentanyl (Duragesic)* 0.1 – 0.2 mg
Oxycodone (Oxycontin, Percocet) 20 mg
Codeine 200 mg
Hydrocodone (Vicodin, Lortab) 30 mg
*25 mcg patch = ~90 mg morphine per day
Opioid Conversion
Calculate the 24 hour morphine equivalent
Current Opioid 24 hr dose of current opioid(from conversion table)
Morphine Equivalent 24 hr dose of morphine* (X)(from conversion table)
*Use chart if converting to methadone
Opioid Conversion
Convert to daily methadone
Daily Oral Morphine Equivalents
Oral morphine: oral methadone conversion
ratio
< 100 mg 3:1
100 – 300 mg 5:1
300 – 600 mg 10:1
600 – 800 mg 12:1
800 – 1000 mg 15:1
> 1000 mg 20:1
Opioid Conversion
• Begin methadone at BID or TID (available in 5 mg and 10 mg tablets)
• 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days)
• When in doubt, go conservative!!!
• Follow-up appropriately and be prepared to titrate!!!
• Patient will still need short-acting– Likely require the same to more tablets while converting
Opioid Conversion ExamplePatient is taking Oxycontin 60mg TID and Percocet TID PRN daily.
Opioid Agonist Parenteral Dose
Oral Dose
Morphine 10 mg 30 mg
Hydromorphone (Dilaudid) 1.5 mg 7.5 mg
Fentanyl (Duragesic)* 0.1 – 0.2 mg
Oxycodone (Oxycontin, Percocet) 20 mg
Codeine 200 mg
Hydrocodone (Vicodin, Lortab) 30 mg
*25 mcg patch = ~90 mg morphine per day
Opioid Conversion
Calculate the 24 hour morphine equivalent
Current Opioid 24 hr dose of current opioid(from conversion table) Oxycodone – 20 mg Oxycodone – 180 mg
Morphine Equivalent 24 hr dose of morphine* (X)(from conversion table)Morphine – 30 mg Morp Eq. = x = 270 mg
*Use chart if converting to methadone
Opioid Conversion
Convert to daily methadone
Daily Oral Morphine Equivalents
Oral morphine: oral methadone conversion
ratio
< 100 mg 3:1
100 – 300 mg 5:1
300 – 600 mg 10:1
600 – 800 mg 12:1
800 – 1000 mg 15:1
> 1000 mg 20:1
270 mg Morph Eq. = 54 mg methadone
Opioid Conversion• Begin methadone at BID or TID (available in 5 mg and
10 mg tablets)
• 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days)
• When in doubt, go conservative!!!
• Follow-up appropriately and be prepared to titrate!!!
• Patient will still need short-acting– Likely require the same to more tablets while converting
Methadone 15mg TID + Percocet 5/325
QUESTIONS
???
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