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Opioid review
 

Opioid review

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Slidedeck for Opioid review presentation for Hospice and palliative medicine fellowship series for University of Kansas. PLEASE SEE DISCLAIMER

Slidedeck for Opioid review presentation for Hospice and palliative medicine fellowship series for University of Kansas. PLEASE SEE DISCLAIMER

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  • Address multidisciplinary approach to pain management Understand the assessment of pain and identify causes of pain Identify effective pain symptom management and various treatment modalities
  • Dame Cicely Saunders Physical Social Psychological Spiritual
  • Genetic variation and response to morphine in cancer patients multidrug resistance-1 gene ( MDR-1 and COMT) Journal Cancer
  • Assess the pain Treat the underlying cause Individualize therapy Reassess the pain and the treatment 24 hour pain control is achievable Work with long-acting and short-acting meds
  • Assess the pain Treat the underlying cause Individualize therapy Reassess the pain and the treatment 24 hour pain control is achievable Work with long-acting and short-acting meds
  • Assess the pain Treat the underlying cause Individualize therapy Reassess the pain and the treatment 24 hour pain control is achievable Work with long-acting and short-acting meds
  • When using scales Simple, flexible, consistent, patient completed Location Type/Quality Bone, Soft Tissue, Neuropathic, Visceral Consider ‘Total Pain’ Concept
  • Assess the pain Treat the underlying cause Individualize therapy Reassess the pain and the treatment 24 hour pain control is achievable Work with long-acting and short-acting meds
  • Heat/Cold Massage Turning Physical/Occupation Therapy Music/Art Therapy Listening Meditation/guided imagery Cognitive behavioral therapy/biofeedback TENS
  • http://flickr.com/photos/trevormorgan/393489807/
  • http://flickr.com/photos/wisdoc/113675789/sizes/l/
  • http://flickr.com/photos/limando/2085166716/sizes/o/
  • Communication Interventions Validate presence and severity of pain Demonstrate pain can be adequately relieved Explain the origin of pain Find meanings in pain
  • Paroxetine inhibits CYP2D6
  • Paroxetine inhibits CYP2D6
  • PO Morphine to IV Morphine PO Morphine to Fent Patch
  • PO Morphine to IV Morphine PO Morphine to Fent Patch
  • PO Morphine to IV Morphine PO Morphine to Fent Patch
  • PO Morphine to IV Morphine PO Morphine to Fent Patch
  • PO Morphine to IV Morphine PO Morphine to Fent Patch
  • Address multidisciplinary approach to pain management Understand the assessment of pain and identify causes of pain Identify effective pain symptom management and various treatment modalities

Opioid review Opioid review Presentation Transcript

  • Christian Sinclair, MD Kansas City Hospice & Palliative Care Opioids April 22, 2010
  • DISCLAIMER
    • The information included in this slidedeck is for informational purposes only and should NOT be used to guide individual medical decisions and is NOT a marker of a doctor-patient relationship.
    • Please contact your personal doctor regarding any personal health decisions.
  • Creative Commons
    • http://creativecommons.org/licenses/by-nc-sa/3.0/us/
  •  
  • PAIN SUFFERING
  • Individual
  • Assess Treat
  • Individual
  • Acheivable
  • Assess
  • Treat
  •  
  •  
  •  
  •  
  • Listen
  •  
  • Narcotic
  •  
  • Opioid Receptors
    • Mu
    • Delta
    • Kappa
    • ORL-1
    • All opioid receptors are inhibitory
    • Pre and post-synaptically
    • HPCF-USA 2 nd ed.
    • HPCF-USA 2 nd ed.
  • Chronic Opioid Use
    • Affects hypothalamic-pituitary fxn
      • Decreased testosterone/estrogen
      • Decreased cortisol release
      • Inhibition of growth hormone
      • Also impacts immune function
    • As quickly as one week
  • Components of Opium
  • Name Your Opioids
    • Name
    • Extended Release version?
    • Route
  • Codeine
    • FDA Indications
      • Mild-mod pain, cough, diarrhea
    • AKA methylmorphine
    • ‘ Weak’ opioid
    • More constipating than propoxyphene and tramadol
    • Must be metabolized by CYP2D6
      • Rapid (<10%) and slow metabolizers (40%)
    • HPCF-USA, Wikipedia
  • Propoxyphene
    • FDA Indications:
      • Mild-moderate pain
    • Synthetic derivative of methadone
    • Mu and NMDA effects
    • Effective?
    • Less drowsiness, dry mouth, n/v
    • Increases half-life with alprazolam
    • Increased overdose risk
    • HPCF USA, Wikipedia
  • Tramadol
    • FDA indication:
      • Mod-sever pain
    • Synthetic opioid with serotonin and noepinepherine effects
    • Based off codeine so a pro-drug
      • Converted to M1 (CYP2D6)
    • NNT (n-pain) = 3.8 (TCA 2.3)
    • Equivalent to codeine for cough
  • Tramadol
    • Onset: 30min-1hr
    • Time to Peak: 2h (SR 4-8hr)
    • Duration of action: 4-9h
    • Lowers seizure threshold
    • Reduced by ondansetron
      • Because Zofran blocks….5HT3
    • $$$
  • Hydrocodone
    • FDA Indications: mod-sev pain, cough
    • Less histamine release
    • Active and prodrug (P450, CYP2D6)
      • Hydromorphone
    • HPCF-USA
    • HPCF-USA 2 nd ed
  •  
    • HPCF-USA 2 nd ed
  • Morphine
  • OMED
  • 3:1
  • 3:1 75mg: 25mcg/hr
  •  
  •  
  •  
  • 12 Or 12.5
  • Fentanyl Patch
  •  
  • Oxycodone
    • Semi-synthetic opioid (thebaine)
    • Long acting formulation controversial
      • And expensive
    • Equianalgesic to morphine?
      • MS 30 = Oxy 20
      • MS 20 = Oxy 20
  • Methadone
  •  
  • Avoid Demerol
  • Christian Sinclair, MD [email_address]
  • References
    • HPCF-USA 2 nd edition, www.palliativedrugs.com
    • Dame Cicely Saunders
    • Eric Cassell, The Nature of Suffering and the Goals of Medicine.
    • Ross, J.R., Riley, J., Taegetmeyer, A.B., Sato, H., Gretton, S., du Bois, R.M., Welsh, K.I. (2008). Genetic variation and response to morphine in cancer patients. Cancer DOI: 10.1002/cncr.23292
    • Nadler et al. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician. 2004 Jul;7(3):395-9. (free pdf online)
  • References
    • Opioid Conversion Tables, Adapted from Resident and Staff Physician
    • Hallenbeck J. Palliative Care Perspectives. Chapter 4. http://www.mywhatever.com/cifwriter/library/70/4932.html
    • Mercadante S. Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids. Clin J Pain. 2007 Nov-Dec;23(9):793-8.