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DOSING STRATEGIES

DOSING STRATEGIES. MELLAR DAVIS, WAEL LASHEEN, DECLAN WALSH. BACKGROUND. GUIDELINES BARRIERS HEALTHCARE PROFESSIONAL PATIENTS PAIN OPIOIDS. GUIDELINES. PAIN SEVERITY. STEP 3. POTENT OPIOID ANALGESICS ± NON-OPIOID ANALGESICS ± ADJUVANT. STEP 2. WEAK OPIOID ANALGESICS

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DOSING STRATEGIES

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  1. DOSING STRATEGIES MELLAR DAVIS, WAEL LASHEEN, DECLAN WALSH 1

  2. BACKGROUND • GUIDELINES • BARRIERS • HEALTHCARE PROFESSIONAL • PATIENTS • PAIN • OPIOIDS 2

  3. GUIDELINES PAIN SEVERITY STEP 3 POTENT OPIOID ANALGESICS ± NON-OPIOID ANALGESICS ± ADJUVANT STEP 2 WEAK OPIOID ANALGESICS ± NON-OPIOID ANALGESICS ± ADJUVANT STEP 1 NON-OPIOID ANALGESICS ± ADJUVANT WALSH ET AL SUPP. CANC. THER. 2004 3

  4. HEALTHCARE PROFESSIONAL • INADEQUATE ASSESSMENTS • FAILURE TO PRESCRIBE • INAPPROPRIATE OPIOID USE PATIENTS • UNDER-REPORT • COMPLIANCE 4

  5. PAIN HISTORY • LOCATION • TEMPORAL PATTERN (CP / IP) • INTENSITY • QUALITY • AGGREVAT / ALLEVIATING FACTORS • MEDICATION • IMPACT • ASSOCIATED FACTORS (ANXIETY / DEPRESSION) 5

  6. Continuous Pain Intermittent Pain (IP) Continuous Pain Alone (CP) Intermittent with Continuous Pain (BP) Intermittent Pain Alone (NBP) Incident Incident Non-Incident Non-Incident Mixed Mixed TEMPORAL PAIN PATTERN Cancer Pain EODF 6

  7. PAIN PATHOPHYSIOLOGY CANCER PAIN SOMATIC VISCERAL NEUROPATHIC MIXED 7

  8. OPIOID CHOICES • MORPHINE (MU AGONIST) • FENTANYL (MU AGONIST) • HYDROMORPHONE (MU AGONIST) • OXYCODONE (MU AND KAPPA AGONIST) • METHADONE (MU AND DELTA AGONIST) 8

  9. ADJUVANTS AND INTERVENTIONS 9

  10. SUMMARY • GUIDELINES (WHO LADDER) • BARRIERS • PAIN HISTORY • OPIOIDS 10

  11. PAIN EMERGENCY 11

  12. OPIOID LOADING • OPIOID LOADING (OPIOID NAÏVE / EXPER.) • FREQUENT • SMALL DOSES • SHORT ACTING OPIOID • GOALS • PAIN CONTROL • TOXICITY 12

  13. IV OPIOID LOADING

  14. IV OPIOID LOADING • DOSE • 1 MG MORPHINE • 0.2 MG HYDROMORPHONE • 20 MICGR FENTANYL • FREQUENCY • EVERY MINUTE X 10; RESPITE 5 MIN; REPEAT 14

  15. SC AND ORAL OPIOID LOADING IV 1MG/ 1 MIN SC 2 MG/ 5 MIN ORAL 5MG/ 30 MIN

  16. CARDIO-PULMONARY INSTABILITY • IV ROUTE IS PREFERRED • FIXED DOSE INTERVAL STRATEGY • 2-4 MG IV MORPHINE • EVERY 2 HOURS UNTIL PAIN IMPROVES WALSH ET AL SUPP. CANC. THER. 2004 16

  17. PATIENT ON CHRONIC OPIOID • ALTERNATIVE LOADING STRATEGY: ORAL • DOUBLE ORAL RESCUE DOSE (RD) • GIVE EVERY 30 MINS UNTIL PAIN CONTROL 2 X 5MG = 10 MG 17

  18. ALTERNATIVE STRATEGY: IV (SC) • TOTAL IV (SC) OPIOID PAST 24 HOURS • ATC • RD (FOR NON-INCIDENT PAIN) • CALCULATE THE HOURLY DOSE • LOADING • DOSE: 1ST 2 X HOURLY THEN HOURLY DOSE • FREQUENCY: EVERY 15 MINS PAIN CONTROL 24 MG 24 MG/ 24HRS = 1 MG 2 MG THEN 1 MG 18

  19. SUMMARY • ACUTE ONSET OF EXCRUCIATING PAIN OPIOID LOADING • IV • SC • ORAL • SEVERELY ILL • ALTERNATE STRATEGY 19

  20. OPIOID (OVERDOSE) EMERGENCY 20

  21. TREATMENT OF OPIOID OVERDOSE • INDICATIONS FOR NALOXONE: • PATIENT UN-RESPONSIVE • RR < 10 / MIN WITH EVIDENCE OF INADEQUATE VENTILATION (LOW OXYGEN SATURATION) 21

  22. PROTOCOL • STOP OPIOID ADMINISTRATION • PREPARE NALOXONE: NP VIAL OF NALOXONE (0.4MG/ML) + 9 ML SALINE = 40 MICG / ML NALOXONE • FLOW-CHART 22

  23. Opioids 1 ml NP (40MICG) Evaluate every 3 minutes: Responsive And RR > 10/min NO YES Naloxone Infusion: Sum of Doses Given / hour Observation for at least 4 hours Observation for at least 24 hours START OPIOIDS AT LOWER DOSE WITH ONSET OF PAIN 23

  24. STARTING ATC AND RD THERAPY 24

  25. OPIOID NAÏVE • RD = 5% - 15% OF 24 HR ATC DOSE 25

  26. FRAIL / ORGAN DYSFUNCTION • RD = 5% - 15% OF 24 HR ATC DOSE 26

  27. OPIOID TITRATION FOR CONTIUOUS PAIN (NO S/E) 27

  28. 28

  29. TITRATION FOR PAIN CONTROL • ASSESSMENT EVERY 24 HOURS • PAIN SEVERITY / RELIEF • DURATION OF RELIEF • INTERFERENCE WITH SLEEP AND ACTIVITY • SIDE EFFECTS 29

  30. ATC DOSE TITRATION • NEW ATC DOSE / 24 HRS = • PAST 24 HR OPIOID DOSE + (30% TO 50%) • ATC PAST 24 HOURS • RD (FOR NON-INCIDENT PAIN) PAST 24H 30

  31. EXAMPLE • PAST 24 HOURS • ATC M = 40MG • RD M = 5 MG (5MG X 6 = 30 MG) • TOTAL = ATC + RD = 40 + 30 = 70 MG NEW ATC DOSE • (30% TO 50%) = (21 TO 35) 30 MG • NEW ATC / 24HRS = 70 + 30 = 100MG / 24 31

  32. OPIOID TITRATIONINCIDENT AND NON-INCIDENT PAIN (NO S/E) 32

  33. MANIFESTATIONS • MILD SEDATION • NAUSEA • VOMITING • CONSTIPATION / DRY MOUTH / URINE RETENTION • VISUAL / TACTILE HALLUCINATIONS 33

  34. TITRATING RD • NEW RD • IF OLD RD < 50% RELIEF INCR. RD BY 100% • IF OLD RD = 50% - 75% INCR. RD BY 50% • IF 100% RELIEF BUT PAIN RETURN (0.5 HRS) INCR. RD BY 100% 34

  35. NON-INCIDENT PAIN • GOAL • < 4 • > 4 ADD THE RD TO THE ATC DOSE INCIDENT PAIN • NEVER ADD RD TO ATC • PRE-EMPTIVE DOSING 35

  36. END OF DOSE FAILURE • DEFINITION • STRATEGIES: • INCREASE ATC DOSE • INCREASE ATC FREQUENCY • INCREASE RD (50%) 36

  37. SIDE EFFECTS 37

  38. SIDE EFFECTS • TOLERANCE • PROPHYLAXIS • CHECK MEDICATION / HYDRATION • ATC VS. RD • S/E SHOULD BE TREATED • DOSE LIMITING S/E (GI , CNS) 38

  39. CONTROLLED PAIN • ATC = ↓ DOSE ( 30%) + SAME RD • RD = ↓ DOSE ( 50%) + ADJUVANT + SAME ATC UNCONTROLLED PAIN • OPIOID ROTATION • SYMPTOMATIC TREATMENT OF S/E • ADJUVANT + ↓ DOSE (30-50%) 39

  40. CHRONIC DOSING 40

  41. ORAL CONVERSION & CHRONIC DOSING • PARENTERAL ATC PAST 24 HOURS • MULTIPLY BY 3 (FOR MORPHINE) • ORAL ATC 24 HOUR DOSE • DIVIDED ACCORDING TO DOSING FREQUENCY • FOLLOW UP 48 HOURS 41

  42. EXAMPLE • PAST 24 HR ATC IV MORPHINE DOSE = 30MG • ORAL ATC = 30 X 3 = 90 MG / 24 HRS • IF SRM ( / 12 HRS) = 90 / 2 = 45 MG / 12 HRS • IF SRM ( / 8 HRS) = 90 / 3 = 30 MG / 8 HRS • IF IRM ( / 4 HRS ) = 90 / 6 = 15 MG / 4 HOURS 42

  43. SUMMARY • PAIN EMERGENCY • OPIOID OVERDOSE • START OPIOID THERAPY • TITRATE OPIOIDS (ATC & RD) • STARTING LONG TERM REGIMEN 43

  44. SPECIAL SITUATIONS 44

  45. PAIN CONTROL IN THE ACTIVELY DYING • ASSESS CAREFULLY / CONSULT CAREGIVER • ENSURE CONTINUOUS ANALGESIA EVEN IF PATIENT UNABLE TO COMMUNICATE • ALTERNATE ROUTES • GIVE SPECIFIC ORDERS NOT TO WITH HOLD OPIOIDS EVEN IN FALLING BP OR CHANGING BREATHING RATES 45

  46. SUBSTANCE ABUSE HISTORY • REQUIRED DOSAGE USUALLY HIGHER • MONITORING COMPLIANCE AND SUPERVISION • ONE PHYSICIAN / SHORT Rx / METHADONE • DRUG TESTING 46

  47. DIURNAL PAIN PATTERN • ATC PAIN WELL CONTROLLED DURING THE NIGHT BUT POORLY CONTROLLED BY DAY • INCREASE DAY TIME DOSE ONLY • RD FOR INCIDENT PAIN CONTROLLED BY DAY WAKE THE PATIENT BY NIGHT • A SINGLE LONG ACTING DOSE AT BED TIME • DOUBLE RD 47

  48. FRAIL / ELDERLY / ORGAN IMPAIRMENT • EXTEND DOSING INTERVAL • REDUCE DOSAGE OPIOID DOSE REDUCTION • DO NOT STOP OPIOID ABRUPTLY • ↓ DOSAGE BY 30-50 % EVERY DAY • MAINTAIN RD 48

  49. QUESTIONS 49

  50. CASE 1 • 52 YEAR OLD MALE WITH PANCREATIC CANCER AND SEVERE ABDOMINAL PAIN (10 NRS ) ON SR MORPHINE 30 MG TWICE DAILY • PHYSICAL EXAMINATION:EPIGASTRIC MASS, NO REBOUND TENDERNESS, NO ASCITES, NO JAUNDICE.HE IS DOUBLED OVER IN A FETAL POSITION WHICH RELIEVES HIS PAIN SLIGHTLY • KUB:UNREMARKABLE • CT SCAN ABDOMEN ; LARGE UPPER ABDOMINAL AND CELIAC LYMPH NODES COMPRESSING MESENTERIC VESSELS 50

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