Pain Management Drug Therapy Workshop

1. Yale Interdisciplinary Palliative Care Educational Project Pain ManagementDrug Therapy Workshop

2. The Concept of Total Pain

3. World Health Organization (WHO) Step Ladder Approach Severe Pain 7-10/10 Potent opioids (e.g. morphine) +/- non-opioids Moderate Pain 4-6/10 Weak opioids +/- non- opioids (e.g. Tylenol #3®) Mild Pain 1-3/10 ASA, Tylenol, NSAIDS

4. Clinical Questions #1 Breakthrough pain dosing should be individualized, but a guide for determining the initial dose of bolus I.V. medication for a patient receiving a long acting oral form of morphine is that the initial breakthrough dose is what percentage of the total daily long-acting morphine dose? a. 10% b. 20% c. 50% d. 100%

5. Answer #1 a. 10% Rationale:10% would be the minimum dose, Titrated to effect. The range is 10-20%

6. Breakthrough Pain • Patients on long-acting med always need second, short-acting med, for breakthrough pain to take Q 4 hours or less. • Generally, dose of breakthrough opioid should be: • 10% of 24 hour dose of analgesics and made available Q 2-4 hours. • Example: MS Contin 60mg q12hrs breakthrough dose should be immediate release morphine (MSIR), 10-15 mg Q 2-4 hrs prn.

7. Clinical Question #2 What is the maximum number of tablets of hydrocodone/acetominophen 5 mg/500 mg (e.g., Vicodin ®) you can safely prescribe for a 24 hour period. a. 4 b. 6 c. 8 d. There is no ceiling dose/maximum

8. Answer #2 c. 8 Rationale: 4,000mg of acetominophen in 24 hours is safe for most patients, BUT ceiling dose may need to be modified significantly or the drug not used in patients with: • renal or liver disease • history of significant alcohol intake • consider starting at 50% of standard ceiling dose for elders.

9. Clinical Question #3 A 40 yr. old women with stage IV ovarian cancer reports mild to moderate burning pain in her hands and feet. Ibuprofen has not been effective. You suggest: a. A COX-2 inhibitor b. Topical capsaicin c. A steroid d. An adjuvant with activity in neuropathic pain

10. Answer #3 d. An Adjuvant with activity in neuropathic pain • Pain characterized by sharp, shooting, electric shocks, parethesias, dysesthesias, cold extremities • Neuropathic pain often responds poorly to NSAIDs and opioids

11. Drugs for Neuropathic Pain • opioids • antidepressants • anticonvulsants • local anesthetics • steroids • other

12. Antidepressants • Tricyclic antidepressants • Analgesic effects separate from anti-depressant effects. • Amitriptyline: most studied, but most side effects • Nortriptyline & desipramine: better tolerated, less well studied • SSRIs: little evidence of analgesic effect. • SNRI’s • inhibit both norepinephrine and serotonin reuptake • efficacy in neuropathic pain syndromes or pain associated with depression (duloxetine [Cymbalta®], venlafaxine [Effexor®])

13. Anticonvulsants • Agents for neuropathic pain • gabapentin (Neurontin®) • pregabalin (Lyrica®) • clonazepam (Klonopin®) • Other newer agents • Start low, go slow • Watch for side effects • Monitor serum levels, if available

14. Adjuvants to Opioid Therapy

15. Clinical Question #4 A 63 yr. old man with advanced prostate cancer has been stable on oral morphine 30 mg every 4 hours. He is now NPO and you are going to switch him to IV morphine. The correct IV dose is: a. 4 mg IV q 4 hours b. 6 mg IV q 4 hours c. 10 mg IV q 4 hours d. 30 mg IV q 4 hours

16. Answer #4 c. 10 mg IV q 4 hours Rationale: • Equianalgesic ratio for morphine is 1 mg IV = 3 mg PO. • When writing start time for the first dose, consider time of last oral dose.

17. Parenteral Opioids IV is the route of choice if access is available. • There is NO indication for IM opioids (painful, no benefit over SQ route) • All standard opioids can be given SQ, by either bolus dose or by continuous infusion. PCA (basal rate plus a patient initiated dose) is an effective and well accepted modality; either IV or SQ.

18. Parenteral Opioids (cont.) • IV or SQ bolus doses have a shorter duration of action than oral doses; typically 1-3 hours. • The peak effect from an IV bolus dose is 5-15 minutes. • Dose escalation of parenteral opioids is the same as with oral—always by a percentage of the starting dose.

19. Clinical Question #5 Mrs. Jones has advanced cervical cancer. She has been taking Percocet-5 (2 tablets PRN) for pain with good effect. The patient is now NPO & is requiring something for pain. An appropriate starting dose of PRN IV morphine is approximately: a. 2 mg b. 3 mg c. 4 mg d. 5 mg e. 6 mg

20. Answer #5 c. 4 mg IV morphine Rationale: • Most equianalgesic tables use a ratio of 20 mg po oxycodone = 10 mg IV morphine. • Mathematically, answer is 5 mg IV morphine. Clinically, account for possible incomplete cross-tolerance, so reduce the dose by about 25%-50%. • 4 mg is a convenient dose of IV morphine. We might also have rounded down to 3 mg. 4 mg is almost certainly safe and analgesically appropriate for opioid non-naïve patient.

21. Incomplete cross-tolerance • If switching from one opioid to another, recommended to start the new opioid at ~50% of equianalgesic dose. • Why? :Because the tolerance a patient has towards one opioid, may not completely transfer (“incomplete cross-tolerance”) to the new opioid. to 50% of new Opioid from 100%

22. Clinical Question #6 A 69 yr. old patient with metastatic prostate cancer to the lumbar spine is taking OxyContin® (sustained release oxycodone) 100 mg every 8 hours. What should be the opioid for his breakthrough pain and at what dose and interval? a. Oxycodone 30 mg PO every 4 hours b. Oxycodone 30 mg PO every 8 hours c. Morphine 10 mg PO every 4 hours d. Morphine 10 mg IV every 8 hours

23. Answer #6 a. Oxyocodone 30 mg PO every 4 hours Rationale: • In general, keep PRN, short acting opioid the same drug as the long-acting opioid. • Starting dose for breakthrough pain is 10% of the total daily dose (and you can always titrate). • Here total daily dose = 300 mg, so 10% of this = 30 mg. The PRN interval should never be longer than the expected analgesic duration (~4 hours in this case), and can often be less.

24. Short Acting Opioids Oral dosing: • onset in 20-30 min • peak effect in 60-90 minutes • duration of effect 2-4 hours • Can be dose escalated or re-administered every 2-4 hours for poorly controlled pain • General guideline: • Moderate pain: increase 25-50% • Severe pain: increase by 50-100%

25. Parenteral or Oral: morphine hydromorphone (Dilaudid ®) Codeine Onset & duration of action depends on route administration Oral only: oxycodone (Percocet ® , Tylox ® ) hydrocodone (Vicodin ® Lortab ®, Lorcet ®) propoxyphene (Darvon ®, Wygesic ®) Note: hydrocodone is only available as a combination product. B.Short Acting Opioids

26. Clinical Question #7 Ms. Nguyen is reporting 7/10 pain now in her left leg. She had vomited after her last pain medication, morphine 10 mg IV. What is your next analgesic order? a. Dilaudid® (hydromorphone) 1.5 mg IV b. Fentanyl® Patch 25 mcg/hr q72 hours c. Dilaudid® 8 mg PO d. Percocet® 5/325 three tablets

27. Answer #7 a. Dilaudid® (hydropmorphone) 1.5 mg IV Rationale: • With severe pain we need rapid onset option. • Onset too slow with Fentanyl patch and orals. • IV morphine plus an antiemetic might be considered, but easier option - change to another opioid (different patients have different side effect responses to various opioids). • Hydromorphone 1.5 mg IV is approx. equianalgesic to 10 mg IV morphine. • As patient currently in severe pain, reducing dose for potential incomplete cross tolerance not necessary.

28. Opioid Dose Escalation Always increase by a percentage of the present dose based upon patient’s pain rating and current assessment 50-100% increase Severe pain 7-10/10 25-50% increase Moderate pain 4-6/10 25% increase Mild pain 1-3/10

29. Frequency of dose escalation The frequency of dose escalation (oral opioids) depends on the particular opioid … • Short acting oral: q 2-4 hours • Long acting oral, except methadone: q 24 hours • methadone: q 72 hours • transdermal fentanyl: q 72 hours.

30. Clinical Question #8 Mr. MacLean comes to your floor in excruciating pain (10/10). He receives morphine 4 mg IV, but reports no relief at all after 15 minutes. The intern or fellow then orders morphine 6 mg IV. After another 20 minutes the patient reports that she still has no relief. You note that the patient is wide awake (no sedation) with continued 10/10 pain. What would you recommend? a. Tell the patient that the interval between doses is 4 hours and they will have to wait b. Administer another dose of morphine 6 mg IV in one hour c. Administer another dose of morphine 9-12 mg now d. Call for a pain or palliative care consult

31. Answer #8 c. Administer another dose of morphine 9-12 mg now. Rationale: • Patient has no unacceptable side effects, so no immediate reason to change to another drug. • Patient is in a pain crisis. We should titrate aggressively (i.e., 50-100% increase in each dose at approximately 15 minute intervals) until a response is observed. • Note:some protocols for pain crisis in cancer patients suggest that 1-2 doses of ketorolac (Toradol®) 30 mg IV be considered (if not otherwise contraindicated) in addition to the opioid.

32. Clinical Question #9 Ms. Santini, a 45 yr. old woman with colon cancer metastatic to the liver, had been admitted for uncontrolled pain. Her pain is now controlled and stable on PCA morphine of 10 mg/hr. The boluses are 5 mg q15 minutes PRN and work very well but she rarely needs to use the bolus doses for breakthrough pain. She is to be discharged home on oral opioids. What opioid/formulation and what dose would you recommend? a. MS Contin 120 mg PO Q 12 hours b. MS Contin 240 mg PO Q 12 hours c. MS Contin 360 mg PO Q 12 hours d. Fentanyl patch 50 mcg Q 72 hours e. Dilaudid 8 mg PO Q 8 hours

33. Equianalgesic Doses: Opioid Analgesics

34. Answer #9 c. MS Contin 360 mg PO every 12 hours Rationale: • Patient already on morphine, so use same opioid. • Using long-acting formulation is the oral equivalent of a continuous infusion. • Total daily dose of morphine IV is 240 mg and the oral equivalent is 720 mg of morphine, can be given as 360 mg of MS Contin PO every 12 hours.

35. Oral morphine: MS Contin® Kadian® Oramorph SR oxycodone Oxycontin® Oxycodone SR oxymorphone Opana SR methadone Transdermal Fentanyl Patch (Duragesic®) – Dosing Q 72 hours C. Long Acting Opioids

36. Clinical Question #10 What breakthrough pain opioid/formulation would you recommend for Ms. Santini if she takes MS Contin 360 Mg Q 12 hours? a. Morphine elixir 20 mg PO every 2-4 hours PRN b. Morphine immediate release tablets 40 mg PO Q 2-4 hours PRN c. Morphine immediate release tablets 60 mg PO Q 2-4 hours PRN d. Morphine immediate release tablets 70 mg PO Q 2-4 hours PRN

37. Answer #10 d. Morphine immediate release tablets 70 mg PO every 2-4 hours PRN. Rationale: • Breakthrough pain requires a short-acting formulation. • Preferable to use same opioid as long-acting. • PRN initially 10% of the total daily dose = 10% of 720mg = 72mg. • Dosing interval is q2-3h PRN. We don’t expect that pts will need to take 12 doses in 24hr (our pain regimen would be really off). • If patient requires >5 PRN doses/day, either the PRN dose needs adjusting or the basal dose or both.

38. Name one new fact you learned about the use of narcotics from this presentation and how you might use it clinically as a Sub- I

39. References Portions of this presentation were originally developed by David E. Weissman, MD, Drew Rosielle, MD, Kathy Biernat, MS and Judi Rehmfor: EPERC End of Life/Palliative Education Resource Center And: Yale Cancer Center Supportive Oncology ProgramConnecticut Challenge Survivorship ClinicKenneth Miller, MD & Thomas Quinn, APRN

40. References con’t Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service, 1992. Backonja M, Beydoun, A, Edwards KR, et al. Gabapentin for symptomatic treatment of painful neuropthy in patients with diabetes mellitus. JAMA 1998;280:1831-1836. Breitbart W, Chandler S, Eagle B, et al. An alternative algorithm for dosing transdermal fentanyl for cancer pain. Oncology 2000:14:695-702. Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, 1994. Portenoy, RK. Chronic Opioid Therapy in Nonmalignant Pain. J Pain Symptom Manage 1990; 5: S46-S62. Portenoy, RK. Continuous Infusion of Opioid Drugs in the Treatment of Cancer: Guidelines for Use. J Pain Symptom Manage 1986;1: 223-228. Storey P, Hill HH, Jr., St. Louis RH, Tarver EE. Subcutaneous infusions for control of cancer symptoms. J of Pain Symptom Manage 1990; 5:33-41.