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1. Using Opioids in the Hospitalized Patient Nicole Artz, MD
Assistant Professor of Medicine
University of Chicago
2. Outline Rapid titration for rapid pain relief
Dosing the PCA
Converting between drug and route
Handling Side Effects
3. Mr. P 45 y/o man (100 kg) presenting to the ED with acute rib fracture after falling off a ladder.
Takes HCTZ for HTN; no other meds.
You are evaluating him in the ED
4. Mr. P What pain medication will you offer?
What dose will you order?
5. Equianalgesic Opioid Table
6. Mr. P You order 5 mg IV Morphine
15 minutes later Mr. P is still in 8/10 pain
Can you redose yet?
How much should you give?
7. Sedation Scale
8. General Principles for Rapid Titration Redose with 50% of loading dose until adequate relief is achieved (usually <5/10)*
9. Mr. P You redose with 2.5 mg of Morphine and reassess 15 minutes later.
Mr. P reports his pain is now 6/10
You redose with an additional 2.5 mg
15 minutes later Mr. P is comfortable with a pain score of 3-4/10.
10. Mr. P (Scenario 1) What should his standing dose of Morphine be and at what interval?
10 mg Morphine IV Q3 hrs ATC
You reassess later that day and he reports adequate pain control immediately after the 10 mg dose but states the dose wears off after the first 90 minutes.
11. Options? Consider changing to PCA
Avoids peaks and valleys in pain control from bolus dosing
Increases patient self-efficacy
Less burdensome for nurses
Safe way to achieve excellent pain control
12. Mr. P (Scenario 1) How will you dose the PCA?
13. General Principles Avoid using a basal rate in an opioid naive patient until opioid requirements are known
To calculate an initial demand dose- use 30-50% of the effective bolus dose. *Goal is only 1-2 demands/hour needed to keep pain under control.
Titrate the demand dose to achieve good pain control
May add a basal once opioid requirements determined.
14. Mr. P (Scenario 1 Cont..) Morphine PCA 3 mg demand dose
15 minute lockout
No basal rate
15. Mr. P Scenario 1 cont Day 2- pain is well controlled with Morphine PCA 3 mg demand with 15 minute lockout.
Reports trouble sleeping due to pain
Add a basal infusion on the PCA
16. Mr. P (Scenario 1 cont) 24 hour use = 120 mg IV Morphine
If still in severe pain could give full amount as basal
If pain improved but trouble sleeping, consider starting 30-50% 24 hr total as basal
17. Mr. P (Scenario 1 Cont) New PCA orders
60 mg/24 hrs = 2.5 mg/hr continuous infusion
50-150% of basal
2.5 mg demand with 15 minute lockout
18. Mr. P (Scenario 1) Converting to orals for discharge
Take 24 hr PCA requirements
Give 50-100% as equianalgesic dose of oral long-acting opioid
Rescue with short-acting that is 10-15% of 24 hr dose.
19. Mr. P (Scenario 1) Pt used 90 mg IV Morphine past 24 hrs and currently has excellent pain control.
90 mg IV Morphine = 10 IV Morphine
X mg po Morphine 30 mg po Morphine
X = 270 mg po Morphine/day
20. Mr. P (Scenario 1) Start 50% as long-acting
2702 = 135 mg long-acting Morphine
1353 = 45 mg MS ER po Q 8 hrs
Calculate a breakthrough dose
10-15% of total daily dose
Morphine Sulfate IR 15 mg po Q 2-4 hrs prn breakthrough pain
21. Mr. P (Scenario 1) How will you wean the morphine?
Need to wean if >=5 days exposure
10-20% per day- more slowly if increased pain or signs of withdrawal
22. Mr. P (Scenario 2) Pt just admitted from the ED
You reassess later that day and he reports worsening pain with relief only to 7/10 after each 10 mg IV morphine.
A PCA is not available.
While evaluating causes for increased pain, how will you titrate the dose to achieve better control?
23. Mr. P (Scenario 2 Cont) Severe Pain (7-10)- Increase by 100%
Moderate Pain (4-6)- Increase by 50%
Mild Pain (0-3)- Increase by 25%
24. Mr. P (Scenario 2) New Morphine dose = 15 mg IV Q 3hrs OR 20 mg IV Q 3hrs
Avoid writing a range for dose or interval
Consider dosing ATC patient may refuse instead of prn
25. Renal/Liver Insufficiency Start with Lower Dose, Longer Interval
Avoid Meperidine (even for pts w/o renal insuff)
Avoid scheduled doses of Morphine in renal insufficiency
Preferred opioids in renal insufficiency: Fentanyl, Hydromorphone, Methadone
26. The Opioid Tolerant Patient What is tolerance?
What is physical dependence?
Difference between physical dependence and psychological dependence/(addiction)?
27. Mrs. G 60 y/o woman with metastatic breast cancer admitted with intractable pain
Two 100 mcg Fentanyl patches
Hydromorphone 12 mg po Q 3 hrs prn breakthrough pain
Reports severe nausea with morphine
28. Mrs. G Calculate a basal rate for a Hydromorphone PCA
Convert Fentanyl to Morphine using 1:2 ratio
200 mcg Fentanyl patch equiv to 400 mg po Morphine/day
400 mg po Morphine/day = 30
X mg IV Hydromorphone/day 1.5
X = 20 mg IV Hydromorphone/day
Consider reducing dose by 25%-50% due to incomplete cross-tolerance
29. Mrs. G Add in breakthrough pain medication
Hydromorphone 12 mg Q 3 hrs = 96 mg/day po Hydromorphone
96 mg po hydromorphone/day = 7.5
X mg IV hydromorphone/day 1.5
X = 19 mg IV Hydromorphone/day
20 mg + 19 mg = 39 mg IV Hydromorphone/24 hrs
30. Mrs. G cont.. Given intractable pain, would give total amount as basal and add demand dose
39mg/24hrs = 1.6 mg/hr basal infusion
50-150% of basal
1.5 mg demand available every 10 minutes
* In addition to this, you add ketoralac and Dexamethasone
31. Mrs. G Later that day, the patient is more comfortable, with pain 5/10 and decreased to 3/10 after using the demand dose on PCA.
Reports no bowel movement for 2 weeks at home and increased abd bloating;
Abd series reveals constipation but no obstruction
32. Opioid Side Effects Nausea
Metoclopramide, haloperidol, prochlorperazine
Prophylactic bowel regimen with stimulants (Senokot, Bisacodyl)
Decrease opioid dose, caffeine, methylphenidate
Dysphoria,Visual/tactile hallucinations, Delirium
Adjust dose or change opioid; haloperidol
Adjust dose or change opioid
Wean opioid, change opioids
33. Whats new Methylnaltrexone
Peripheral opioid receptor antagonist
Does not cross the blood-brain barrier
Effective for treatment of opioid induced constipation and nausea
Recently approved by the FDA for treatment of opioid-induced constipation in palliative care pts with inadequate response to laxatives.
34. Take Home Points Rapid Titration:
reassess every 15 minutes and redose with 50% of loading dose until adequate relief achieved.
Add up total mg required to achieve relief during rapid titration- this is your scheduled bolus dose.
Titrate opioids by 25%, 50%, or 100% for mild, moderate, or severe pain
When transitioning to po make sure to calculate an equianalgesic dose using the opioid conversion tables.
35. Take Home Points Use PCAs when available
In opioid naive- set demand at 30-50% of loading or bolus dose
In opioid tolerant- convert current opioids to equianalgesic basal rate on pca; set starting demand dose the same as the basal rate
36. References Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, American Pain Society, Fifth edition, 2003.
Education for Physicians on End-of-Life Care (EPEC), Pain Management Module, RWJF, 1999.
National Comprehensive Cancer Network: Practice Guidelines in Oncology- v.2.2005
37. Resources Hopkins Opioid Program
Fast Facts, National Residency End-of-Life Curriculum Project
Download at www.eperc.mcw.edu