OPIOIDS

T H E 10 DAY

D I R E C T I V E

MORPHINE

MEDICAL HEROIN

HARRISON ACT OF 1914

OPIOIDS

UNDER-TREATMENT

ADDICTION TO NARCOTICS - RARE

1996 – PURDUE PHARMA

PARRALEL RISE IN OPIOID PRECRIBING,ADDICTION AND OVERDOSE

RATES OF OPIOID PAIN RELIEVER (OPR) DEATH;

OPR RELATED HOSPITAL ADMISSIONS;

AND KG OF OPR SOLD IN THE U.S. FROM 1999 - 2010

OPIOID CRISIS

TRUE CRISIS

0

5,000

10,000

15,000

20,000

25,000

30,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Opioid Crisis Emerged in 3 Waves

Precriptions Heroin Synthetics

Overd

ose

Death

s

Originally And Consistently a Crisis

of Prescription

OpioidsHeroin becomes

a major factor

Synthetic Opioid Associated Death

Totals Explode

FENTANYL

SIGNIFICANT DATES

AUGUST 1, 2016 CDC ESTABLISHES MME GUIDELINES FOR OPIOID THERAPY

JUNE 1, 2019 NEW TEXAS TRIPLICATE C-II PRESCIPTION FORMS

SEPTEMBER 1, 2019 OPIOID RX LIMITED TO 10 DAY SUPPLY

MARCH 1, 2020 REQUIRED USE OF TEXAS PMP

JANUARY 1, 2021 REQUIRED E-PRESCRIBING

Morphine Milligram Equivalents

A) Norco 5/325 Tablets Take one tablet q 6 hours prn pain.

B) Tylenol # 3 Tablets Take one tablet q 4 - 6 hours prn pain.

C) Dilaudid 2 mg Tablets Take one tablet q 8 hours prn pain.

D) Tramadol 100mg Tablets Take 1 tablet every 6 hours prn pain.

E) Fentanyl Nasal Spray Spray 100 mcg in one nostril.

MORPHINE MILLIGRAM EQUIVALENTS< 50 MME

50-90 MME

> 90 MME

/ DAY

/ DAY

/ DAY

NON-OPIOID PHARMACOLOGIC ALTERNATIVES

Class Drug Dose Considerations

Alpha-2-agonists Dexmedetomidine IV loading dose: 0.5-1 mcg/kg over 10 min

Infusion: 0.2-1.4 mcg/kg/hr

Bradycardia, hypotension

Clonidine PO: 0.2 mg BID

Epidural: 30-40 mcg/hr

Hypotension, withdrawal, epidural- sever cancer pain

Gabapentanoid* Gabapentin PO: 300-1200 mg TID Give pre-op; dizziness, drowsiness

Pregabalin PO: 150-600 mg per day

in 2-3 divided doses

NMDA

Antagonist

Ketamine IV bolus: 0.3-0.5 mg/kg

Infusion: 0.1-0.2 mg/kg/hr

Intensive monitoring for bolus doses > 0.3 mg/kg or

infusions > 1 mg/kg/hr; dysphoric reactions; excessive

salivation

Local

anesthetics

Lidocaine IV bolus: 1.5 mg/kg

Infusion: 1-2 mg/kg/hr

Can cause conduction block, dizziness, seizures,

bradycardia

Acetaminophen PO: 325-650 mg q4-6 hr

IV: 1000 mg q6h if > 50 kg or

15 mg/kg if < 50 kg

Do not exceed 4 g/day, 2 g/day in chronic alcohol use,

cirrhosis, elderly; potentiates warfarin

NSAIDS Diclofenac PO: 100-200 mg per day in 2-3 divided doses Dose dependent anti-inflammatory and relief;

use lowest possible dose;

prolonged use predisposes to GI, CV and renal

dysfunction;

Limit ketorolac to 5 days

Ibuprofen IV: 400 mg first dose, followed by 100-200 mg q4-6hrs

PO: 1200-3200 mg per day in 3-4 divided doses

Ketorolac IM or IV: 15-30 mg every 4-6 hrs

PO: 10 mg q4-6hrs

Meloxicam PO: 7.5-15 mg daily

Celecoxib PO: 50-200 mg daily in 1-2 divided doses

OPIOID NAÏVE VS TOLERANT

Opioid Tolerant are Patients receiving , for ONE WEEK OR LONGER:

60 mg ORAL MORPHINE PER DAY;

25 mcg TRANSDERMAL FENTANYL PER HOUR;

30 mg ORAL OXYCODONE PER DAY;

8 mg ORAL HYDROMORPHONE PER DAY;

25 mg ORAL OXYMORPHONE PER DAY;

OR EQUIANALGESIC DOSE OF ANOTHER OPIOID

10 DAY SUPPLY LIMIT

Opioid Prescription Quantity Limit for Acute Pain

House Bill 2174 requires that, for the treatment of acute (not chronic) pain, apractitioner may not issue a prescription for an opioid in an amount thatexceeds a 10-day supply, nor provide for a refill of an opioid for acute pain.

Exceptions are provided for cancer care, hospice or other end-of-life care, palliative care, and opioids prescribedfor the treatment of substance addiction. (Provisions of this law requiring electronic prescribing of controlledsubstances do not take effect until January 1, 2021.)

10 DAY SUPPLY LIMIT

“The Texas Medical Board interprets this section to mean a

practitioner may write an opioid prescription for up to 10 days without

a refill. However, the patient may see the practitioner in a follow up

appointment and receive another opioid prescription for up to 10

days. The law does not limit how many times this may occur,” TMB’s

statement said. “The Texas Medical Board does not interpret this

section to limit patients to a maximum of 10 days of opioids for acute

pain without the possibility of any further opioids for that specific

issue or ‘episode of care.’”

10 DAY QUESTIONS

CAN SUBSEQUENT PRESCRIPTIONS BE WRITTEN AT THE INITIAL FILL?

DOES TELEMEDICINE QUALIFY TO “SEE” A PATIENT IN ORDER

TO WRITE SUBSEQUENT PRESCRIPTION

WHAT IF THE PATIENT IS ALLERGIC, HAS NO PAIN RELIEF, EXPERIENCES

INTOLERABLE SIDE EFFECTS, NEED THE DRUG IN A DIFFERENT FORMAT,

NEEDS A DOSE ADJUSTMENT, ETC.

CAN AN RX BE WRITTEN DURING A VISIT PRIOR TO 10 DAYS? (AT

WHAT DAY ?)

RELEVANT PHARMACY LAW

TSBP: TAC Title 22, Part 15 Chapter 315 Rule 315.5

(4) A schedule II prescription must be dispensed no later than 21days after the date of issuance.

(d) Controlled substance prescriptions may not be postdated.

CONCLUSION

NALOXONE

QUESTIONS