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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

Published in: Health & Medicine

Opioid review

  1. 1. Christian Sinclair, MD Kansas City Hospice & Palliative Care Opioids April 22, 2010
  2. 2. DISCLAIMER <ul><li>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. </li></ul><ul><li>Please contact your personal doctor regarding any personal health decisions. </li></ul>
  3. 3. Creative Commons <ul><li> </li></ul>
  5. 6. Individual
  6. 7. Assess Treat
  7. 8. Individual
  8. 9. Acheivable
  9. 10. Assess
  10. 11. Treat
  11. 16. Listen
  12. 18. Narcotic
  13. 20. Opioid Receptors <ul><li>Mu </li></ul><ul><li>Delta </li></ul><ul><li>Kappa </li></ul><ul><li>ORL-1 </li></ul><ul><li>All opioid receptors are inhibitory </li></ul><ul><li>Pre and post-synaptically </li></ul>
  14. 21. <ul><li>HPCF-USA 2 nd ed. </li></ul>
  15. 22. <ul><li>HPCF-USA 2 nd ed. </li></ul>
  16. 23. Chronic Opioid Use <ul><li>Affects hypothalamic-pituitary fxn </li></ul><ul><ul><li>Decreased testosterone/estrogen </li></ul></ul><ul><ul><li>Decreased cortisol release </li></ul></ul><ul><ul><li>Inhibition of growth hormone </li></ul></ul><ul><ul><li>Also impacts immune function </li></ul></ul><ul><li>As quickly as one week </li></ul>
  17. 24. Components of Opium
  18. 25. Name Your Opioids <ul><li>Name </li></ul><ul><li>Extended Release version? </li></ul><ul><li>Route </li></ul>
  19. 26. Codeine <ul><li>FDA Indications </li></ul><ul><ul><li>Mild-mod pain, cough, diarrhea </li></ul></ul><ul><li>AKA methylmorphine </li></ul><ul><li>‘ Weak’ opioid </li></ul><ul><li>More constipating than propoxyphene and tramadol </li></ul><ul><li>Must be metabolized by CYP2D6 </li></ul><ul><ul><li>Rapid (<10%) and slow metabolizers (40%) </li></ul></ul><ul><li>HPCF-USA, Wikipedia </li></ul>
  20. 27. Propoxyphene <ul><li>FDA Indications: </li></ul><ul><ul><li>Mild-moderate pain </li></ul></ul><ul><li>Synthetic derivative of methadone </li></ul><ul><li>Mu and NMDA effects </li></ul><ul><li>Effective? </li></ul><ul><li>Less drowsiness, dry mouth, n/v </li></ul><ul><li>Increases half-life with alprazolam </li></ul><ul><li>Increased overdose risk </li></ul><ul><li>HPCF USA, Wikipedia </li></ul>
  21. 28. Tramadol <ul><li>FDA indication: </li></ul><ul><ul><li>Mod-sever pain </li></ul></ul><ul><li>Synthetic opioid with serotonin and noepinepherine effects </li></ul><ul><li>Based off codeine so a pro-drug </li></ul><ul><ul><li>Converted to M1 (CYP2D6) </li></ul></ul><ul><li>NNT (n-pain) = 3.8 (TCA 2.3) </li></ul><ul><li>Equivalent to codeine for cough </li></ul>
  22. 29. Tramadol <ul><li>Onset: 30min-1hr </li></ul><ul><li>Time to Peak: 2h (SR 4-8hr) </li></ul><ul><li>Duration of action: 4-9h </li></ul><ul><li>Lowers seizure threshold </li></ul><ul><li>Reduced by ondansetron </li></ul><ul><ul><li>Because Zofran blocks….5HT3 </li></ul></ul><ul><li>$$$ </li></ul>
  23. 30. Hydrocodone <ul><li>FDA Indications: mod-sev pain, cough </li></ul><ul><li>Less histamine release </li></ul><ul><li>Active and prodrug (P450, CYP2D6) </li></ul><ul><ul><li>Hydromorphone </li></ul></ul><ul><li>HPCF-USA </li></ul>
  24. 31. <ul><li>HPCF-USA 2 nd ed </li></ul>
  25. 33. <ul><li>HPCF-USA 2 nd ed </li></ul>
  26. 34. Morphine
  27. 35. OMED
  28. 36. 3:1
  29. 37. 3:1 75mg: 25mcg/hr
  30. 41. 12 Or 12.5
  31. 42. Fentanyl Patch
  32. 44. Oxycodone <ul><li>Semi-synthetic opioid (thebaine) </li></ul><ul><li>Long acting formulation controversial </li></ul><ul><ul><li>And expensive </li></ul></ul><ul><li>Equianalgesic to morphine? </li></ul><ul><ul><li>MS 30 = Oxy 20 </li></ul></ul><ul><ul><li>MS 20 = Oxy 20 </li></ul></ul>
  33. 45. Methadone
  34. 47. Avoid Demerol
  35. 48. Christian Sinclair, MD [email_address]
  36. 49. References <ul><li>HPCF-USA 2 nd edition, </li></ul><ul><li>Dame Cicely Saunders </li></ul><ul><li>Eric Cassell, The Nature of Suffering and the Goals of Medicine. </li></ul><ul><li>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 </li></ul><ul><li>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) </li></ul>
  37. 50. References <ul><li>Opioid Conversion Tables, Adapted from Resident and Staff Physician </li></ul><ul><li>Hallenbeck J. Palliative Care Perspectives. Chapter 4. </li></ul><ul><li>Mercadante S. Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids. Clin J Pain. 2007 Nov-Dec;23(9):793-8. </li></ul>