PainMorning ReportRobin Staib, PharmDDecember 22, 2011

Equianalgesic Doses (100%)1) 4mg IV morphine ______ PO morphine

4mg IV M x 3 = 12mg PO morphine 2) 2mg IV dilaudid ______ PO dilaudid

2mg IV M x5 = 10mg PO dilaudid3) 50mcg IV fentanyl _______ IV morphine

0.05mg x 10/0.1= 5mg IV morphine4) 30mg PO morphine _______ PO

oxycodone30mg PO M x 20mg PO O/30mg PO M = 20mg PO oxy

5) 12mg PO dilaudid _______ PO morphine12mg PO D x 30mg PO M/7.5mg PO D = 48mg PO morphine

(7.5:30)

1:3

1:5

0.1:10

30:20

7.5:30

Patient 1

•69 y/o male with Multiple Myeloma (MM) and ESRD on PD who presents with a 2 wk hx of R sided pleuritic thoracic back pain ▫Thoracic x-ray shows compression fx at

T11, T12 and diffuse lytic lesions•Home Pain regimen

▫oxycodone IR 5mg #180 (30mg oxy/day)•Hospital regimen

▫oxycontin 10mg BID, oxycodone IR 5-10mg Q4 hrs prn, & hydromorphone IV 0.25mg Q 3 hrs prn

•Pt stating pain 10/10▫24 hr pain medication utilization:

Oxycontin (10mg bid) = 20mg Oxycodone IR (5-10mg Q 4hrs prn) = 50mg Hydromorphone IV (0.25mg Q 3hrs prn) = 0

•How would you adjust pt’s pain regimenA) Increase oxycodone 10-15mg Q 3 hrs prnB) Increase Hydromorphone IV dose 0.5mg Q

3hrs prn C) Increase Oxycontin to 20mg BID (20 to 40)D) Increase Oxycontin to 10mg TID (20 to 30)

Goal is to use orals

80-120mg

•After the increase to Oxycontin 20mg BID pt still complaining of 10/10 pain

•Do you feel patient would benefit from a fentanyl patch?

▫A) Yes▫B) No

Fentanyl Patch• Indicated for the management of persistent

mod-to-severe pain when around the clock pain control is needed

Criteria met?• Not for use in opioid-naïve patients

▫Pt should be tolerating a stable dose of at least 30mg oral morphine or its equivalent/day before placing 12mcg/hr patch Criteria Met? (70mg oxy = ______________)

• ~100x more potent than morphine ▫ (10mcg fentanyl ~ 1mg morphine)

68-105mg morphine

•So if wanted to start fentanyl patch, which dose would you start?

A) Fentanyl 12mcgB) Fentanyl 25mcgC) Fentanyl 50mcgD) Fentanyl 75mcg

70mg Oxy x 30mg Mor /20mg Oxy = 105mg Mor x 0.65

= 68-105mg po morphine

PO Morphine mg/24hrs

Fentanyl Patch

30-59 12 mcg/hr

60-134 25 mcg/hr

135-224 50 mcg/hr

225-314 75 mcg/hr

Patient 2

•20 yo male with right dental swelling; dental abscess

Current Pain RegimenHydromorphone 1-1.5mg IV Q 3hrs prnMorphine 2-4mg IV Q 3hrs prn

•Pt expected to go to surgery either later today or first thing tomorrow morning

How do you want to control pt’s acute pain?A) Continue IV pushesB) Start a PCA

PCA1) Which Opioid?

A) FentanylB) HydromorphoneC) Morphine

1.5mg IV Hydro = 10 mg IV morphine ** Hydromorphone should not be first line therapy- should

be reserved for pt’s unable to tolerate morphine/fentanyl or those who have failed therapy

2) Dose (Basal? Demand?)Basal? Demand ?

NO

(1.5mg Q 3hrs prn)

(4mg Q 3hrs prn)

Concentration Morphine Hydromorphone Fentanyl

Infusion Rate(Continuous Rate):

________mg/hr0-2mg/hr *(1mg/hr)

________mg/hr0-0.3mg/hr *(0.2mg/hr)

________mcg/hr0-25mcg/hr *(10mcg/hr)

Demand Dose ________mg1-2.5 mg *(1mg)

________mg0.2-0.4mg *(0.2mg)

________mcg10-25mcg *(10mcg)

Lockout Interval _________min8-12 min *(12min)

_________min6-12 min *(8min)

_________min4-8 min *(6min)

4 Hr Lockout ________mg30-50 mg

________mg6-10 mg

________mcg200-400 mcg

2mg

12min

•Recommend Demand dose of 2mg Q 12min with a bolus of 2mg Q 2hrs prn

•Following day, POD1- after extraoral and intraoral I&D R submandibular, sublingual and lateral pharyngeal odontogenic abscess with extraction of #32▫Pt used 21 doses (1700-0700) over past

10hrs 21 x 2mg = IV = Oral

morphine•Plan to convert to oral pain regimen in

preparation for discharge

42mg 126mg

Oral Pain Regimen? (126mg po morphine/10hrs)

A) MS Contin and MSIRB) Fentanyl PatchC) Lortab ElixerD) Percocet

Plan:Lortab Elixer 7.5mg hydrocodone/15ml

(501mg APAP) Q 4hrs prn painMorphine IV 2-4mg Q 2hr prn

Patient 3

•35 yo male with necrotizing pancreatitis complaining of severe pain

•No opioid history•Started on Fentanyl IV pushesFentanyl 50mcg Q2hrs prn

▫50mcg @ 0244▫50mcg @ 0439▫50mcg @ 0620

Fentanyl 200mcg Q 1hr prn▫200mcg @0757▫200mcg @ 0912▫200mcg @ 1129

200mcg Fentanyl = ____mg IV morphine0.1mg Fentanyl = 10mg IV morphine So 0.2mg = morphine 20mg IV morphine = dilaudid

20 mg IV 3 mg IV

•PCAConcentration Fentanyl

Infusion Rate(Continuous Rate)

____mcg/hr0-25mcg/hr(*10mcg/h)

Demand Dose _____mcg0-25mcg (*10mcg)

Lockout Interval ____min4-8 min (*6min)

4 Hr Lockout _____mcg200-400mcg

Basal Rate: 0

Demand Dose: 25mcg Q 20min

4Hr Lockout: 225mcg/4hr (56mcg/hr)Over 18hrs used 35doses out of 61 attempts 35 x 25mcg = 875mcg (48mcg/hr)

How do you want to adjust pt’s PCA?

a) Add basal rateb) Increase demand dosec) Decrease intervald) Change to morphine

Patient 4

26 yo female admitted 0300 with a new DVT and history of heroin abuse

•Pt reports being maintained on methadone 100mg daily for heroin withdrawal avoidance

What do you do?A) Start Methadone 100mg dailyB) Nothing, wait and see if pt actually withdrawals C) Start Methadone 10mg BID and use prn methadone if pt starts having withdrawal sxmsD) Add prn IV morphine and call clinic in morning to verify methadone dose

•Started methadone 10mg BID •Pharmacy called SW behavioral health and was

told that pt had not been seen for >30days•At 36hrs, pt evaluated and was lying in bed

calm and without diaphoresis or other obvious signs of withdrawal

•Discharge occurred within 48hrs and ▫Sparred 80mg/day of methadone administration▫Avoided potential harm to pt with high dose

methadone (>30days)▫Didn’t increase maintenance demand with our

dosing ▫Successfully controlled sxms of withdrawal

Patient 5

26yo female on oxycontin 80mg TID and dilaudid 8mg Q 3hrs prn

•Admitted and made NPO including meds for surgery

•Plan to start dilaudid PCAWould you start a basal rate? And if so

what rate? A) 1mg/hrB) 0.25mg/hrC) 0.5mg/hrD) 0.75mg/hr240mg oxycodone x 7.5mg po dilaudid x 1.5mg IV dilaudid

--------------------- ------------------- -------------------- = 12-18mg 20mg oxycodone 7.5mg po dilaudid

12/24hrs =0.5 mg/hr18/24hr = 0.75 mg/hr

Thank you and Happy Holidays