The document discusses guidelines for prescribing opioid analgesics, including considerations for risk assessment, equianalgesic dosing, monitoring patients, guidelines for opioid rotation, and classes of opioids like partial agonists. It provides information on the public health issues surrounding opioid misuse and abuse as well as clinical best practices for safely prescribing opioids for pain management.
Pocket guide-medication-assisted-treatment-for-opioid-disorderMike Wilhelm
Medication-assisted treatment (MAT) is an effective response to opioid use disorder that combines medications with behavioral therapies. Nearly 80% of individuals with an opioid use disorder do not receive treatment. Screening, brief intervention, and referral to treatment (SBIRT) can help identify substance use disorders and refer individuals to appropriate care. There are three medications approved for treating opioid use disorder - extended release injectable naltrexone, methadone, and buprenorphine. These medications work through different mechanisms but must be combined with counseling and social support for effective treatment.
This document provides guidance on safely prescribing opioids in practice. It discusses considerations for new patients versus legacy patients already on chronic opioids. For new patients, it recommends avoiding opioids for conditions where evidence of use is weak, such as nonspecific musculoskeletal pain or headaches. It also discusses assessing risk and determining whether to initiate chronic opioid use. For legacy patients, it suggests applying criteria to determine if tapering is indicated. The document provides signs that indicate when to access addiction treatment and lists pharmacologic and non-pharmacologic alternatives to opioids. It also offers guidance on opioid use in special populations like older adults, pregnant women, and children.
1) This case discusses the challenges of managing acute pain in a hospitalized patient on chronic opioids who underwent foot amputation surgery.
2) The patient was prescribed escalating doses of opioids, including extended-release morphine up to 165mg 3 times daily as well as IV and oral hydromorphone. He developed somnolence and hypoxemia.
3) After holding the extended-release morphine, the patient's pain worsened and muscle spasms developed. He was prescribed diazepam which led to respiratory depression and an opioid/benzodiazepine overdose requiring naloxone and ICU admission.
The CDC guideline provides recommendations for prescribing opioids for chronic pain to improve safety and effectiveness. It advises that non-opioid therapy is preferred for chronic pain, and opioids should only be considered if benefits outweigh risks. For patients prescribed opioids, doctors should start with the lowest dose, evaluate risks and benefits regularly, and work to taper doses if risks are determined to outweigh benefits. The guideline aims to reduce risks like opioid use disorder and overdose.
This presentation discusses the opioid epidemic, guidelines for prescribing opioids, and strategies for managing postoperative pain with reduced opioid use. It provides objectives about understanding the societal costs of the opioid epidemic, complying with state prescribing laws, and following guidelines for different types of pain. The presentation reviews CDC guidelines for prescribing opioids, the Arizona prescription drug monitoring program, factors influencing opioid use, and results from a study showing most patients use fewer opioids than prescribed after surgery. It emphasizes multimodal analgesia, patient education, and tapering or discontinuing certain medications before surgery to reduce postoperative opioid needs.
This document outlines options for treating opioid use disorder and dependence. It defines opioid use disorder according to DSM-5 criteria. Treatment options discussed include medication assisted treatment with methadone, buprenorphine, or naltrexone as well as counseling. Regulations around prescribing opioids are more lax than those for treating opioid dependence. The presentation calls for improving access to evidence-based treatments, educating patients and providers, expanding treatment programs, and revising quality measures that may drive over-prescription of opioids.
This document discusses drug abuse, misuse, and control. It begins by defining drug use, misuse, and abuse. It then discusses the definition of rational drug use according to the WHO. Over 50% of drugs are prescribed or used inappropriately. The document outlines various types of drug misuse and their effects. It discusses why people use psychoactive drugs and factors that influence drug choice. Adverse impacts of drug misuse are outlined. The roles of industries, prescribers, patients, and communities in drug misuse are examined. Withdrawal effects and pharmaceutical care approaches are summarized.
In 2016, the Centers for Disease Control and Prevention (CDC)
introduced guidelines for prescribing opioids to chronic pain
patients. These guidelines apply to physicians treating patients
outside the context of cancer, palliative, and end-of-life care. The
goal of the guidelines was to reduce the number of people who
misuse or abuse opioids, while still ensuring that patients have
access to safe and effective treatment for chronic pain.
Pocket guide-medication-assisted-treatment-for-opioid-disorderMike Wilhelm
Medication-assisted treatment (MAT) is an effective response to opioid use disorder that combines medications with behavioral therapies. Nearly 80% of individuals with an opioid use disorder do not receive treatment. Screening, brief intervention, and referral to treatment (SBIRT) can help identify substance use disorders and refer individuals to appropriate care. There are three medications approved for treating opioid use disorder - extended release injectable naltrexone, methadone, and buprenorphine. These medications work through different mechanisms but must be combined with counseling and social support for effective treatment.
This document provides guidance on safely prescribing opioids in practice. It discusses considerations for new patients versus legacy patients already on chronic opioids. For new patients, it recommends avoiding opioids for conditions where evidence of use is weak, such as nonspecific musculoskeletal pain or headaches. It also discusses assessing risk and determining whether to initiate chronic opioid use. For legacy patients, it suggests applying criteria to determine if tapering is indicated. The document provides signs that indicate when to access addiction treatment and lists pharmacologic and non-pharmacologic alternatives to opioids. It also offers guidance on opioid use in special populations like older adults, pregnant women, and children.
1) This case discusses the challenges of managing acute pain in a hospitalized patient on chronic opioids who underwent foot amputation surgery.
2) The patient was prescribed escalating doses of opioids, including extended-release morphine up to 165mg 3 times daily as well as IV and oral hydromorphone. He developed somnolence and hypoxemia.
3) After holding the extended-release morphine, the patient's pain worsened and muscle spasms developed. He was prescribed diazepam which led to respiratory depression and an opioid/benzodiazepine overdose requiring naloxone and ICU admission.
The CDC guideline provides recommendations for prescribing opioids for chronic pain to improve safety and effectiveness. It advises that non-opioid therapy is preferred for chronic pain, and opioids should only be considered if benefits outweigh risks. For patients prescribed opioids, doctors should start with the lowest dose, evaluate risks and benefits regularly, and work to taper doses if risks are determined to outweigh benefits. The guideline aims to reduce risks like opioid use disorder and overdose.
This presentation discusses the opioid epidemic, guidelines for prescribing opioids, and strategies for managing postoperative pain with reduced opioid use. It provides objectives about understanding the societal costs of the opioid epidemic, complying with state prescribing laws, and following guidelines for different types of pain. The presentation reviews CDC guidelines for prescribing opioids, the Arizona prescription drug monitoring program, factors influencing opioid use, and results from a study showing most patients use fewer opioids than prescribed after surgery. It emphasizes multimodal analgesia, patient education, and tapering or discontinuing certain medications before surgery to reduce postoperative opioid needs.
This document outlines options for treating opioid use disorder and dependence. It defines opioid use disorder according to DSM-5 criteria. Treatment options discussed include medication assisted treatment with methadone, buprenorphine, or naltrexone as well as counseling. Regulations around prescribing opioids are more lax than those for treating opioid dependence. The presentation calls for improving access to evidence-based treatments, educating patients and providers, expanding treatment programs, and revising quality measures that may drive over-prescription of opioids.
This document discusses drug abuse, misuse, and control. It begins by defining drug use, misuse, and abuse. It then discusses the definition of rational drug use according to the WHO. Over 50% of drugs are prescribed or used inappropriately. The document outlines various types of drug misuse and their effects. It discusses why people use psychoactive drugs and factors that influence drug choice. Adverse impacts of drug misuse are outlined. The roles of industries, prescribers, patients, and communities in drug misuse are examined. Withdrawal effects and pharmaceutical care approaches are summarized.
In 2016, the Centers for Disease Control and Prevention (CDC)
introduced guidelines for prescribing opioids to chronic pain
patients. These guidelines apply to physicians treating patients
outside the context of cancer, palliative, and end-of-life care. The
goal of the guidelines was to reduce the number of people who
misuse or abuse opioids, while still ensuring that patients have
access to safe and effective treatment for chronic pain.
C. Give the patient Tylenol 650mg P.O as ordered and assist the patient with guided imagery.
This patient's pain level is relatively low at a 2/10 and is being well managed with scheduled Tylenol. Guided imagery could help further reduce the patient's perception of pain without unnecessary opioid exposure. Options A, B, and D would likely provide more pain relief than is needed and increase risks of opioid dependence, misuse or overdose.
The document discusses the importance of pharmacovigilance in health care. It defines pharmacovigilance as the science related to detecting, assessing, understanding, and preventing adverse effects of drugs. The main goals of pharmacovigilance are to improve patient safety, assess the risk-benefit profiles of medicines, and encourage their safe and effective use. Pharmacists can play important roles in pharmacovigilance by monitoring for and reporting adverse drug reactions. Pharmacovigilance programs in health systems should include ongoing surveillance, reporting, analysis, and education to prevent adverse drug events.
This document discusses guidelines for rational and appropriate pharmacotherapy in geriatric patients. It notes that older patients are more susceptible to adverse drug effects due to multiple illnesses, physiological changes, and reduced organ function. When prescribing for older adults, doctors should balance potential harms and benefits, regularly review prescriptions, use appropriate formulations, avoid symptomatic prescribing, consider non-prescribed medications, anticipate pharmacological differences in aging bodies, and be aware that adverse drug reactions may present atypically. The guidelines emphasize cautious, individualized prescribing tailored to each older patient's needs and risks.
This document provides guidelines for tapering or discontinuing opioid and benzodiazepine medications. It outlines several situations that warrant tapering opioids, such as lack of pain relief, excessive dosing, side effects interfering with quality of life, or non-compliance. It recommends a slow opioid taper of 10-15% per week to minimize withdrawal symptoms. Benzodiazepine withdrawal poses seizure risks, so tapers must be even slower at 5-10% reductions every 1-2 weeks, or require inpatient detox. Adjuvant medications and psychosocial support are essential for managing taper discomfort and anxiety about reduced drug levels.
This document summarizes the key points from a conference on managing risk in the workplace by addressing substance abuse issues. The conference objectives are to identify signs of drug addiction, describe employer procedures for substance abuse, and explain potential liabilities. It discusses the opioid epidemic, prescription drug abuse trends, and provides statistics on prescription drug use. Guidelines are presented for screening employees, using urine drug testing, identifying aberrant behaviors, and establishing treatment plans when substance abuse is suspected.
The document discusses rational medication use and patient compliance. It defines rational use as prescribing the appropriate drug, dose, duration and cost to meet a patient's clinical needs. Irrational use can lead to ineffective treatment, prolonged illness and increased costs. The document outlines factors influencing rational use and strategies to improve it, including educational, managerial, economic and regulatory approaches. It also defines adherence versus compliance, discusses causes and measurements of non-compliance, and factors affecting a patient's ability to comply with medication instructions.
This document provides guidelines for pharmacological interventions in treating schizophrenia, including recommendations for initiating treatment with antipsychotic medication, how to use oral antipsychotic medication, recommendations for acute episodes, and promoting long-term recovery. It recommends choosing antipsychotics based on individual factors and monitoring for efficacy and side effects. It suggests considering depot/long-acting injectable antipsychotics or clozapine for non-responders and monitoring physical health in primary care.
This document discusses polypharmacy in the elderly, defined as using more than 5 medications. It notes that polypharmacy prevalence increases with age, reaching 50% in those over 65. Consequences can include adverse drug reactions, reduced quality of life, and increased healthcare costs. Pharmacokinetic changes in aging like decreased liver and kidney function must be considered. The Beers Criteria provide guidance on inappropriate medications in elders. Interventions to reduce polypharmacy risk include regular medication reviews, educating patients, and using a personal health record.
- Older patients are more likely to be prescribed multiple medications due to increased prevalence of chronic illnesses, which increases their risk of adverse drug reactions and interactions.
- A comprehensive geriatric assessment is important for designing effective management plans focused on broad functional outcomes and disease alleviation. It also helps assess medication risks and benefits in the context of comorbidities.
- Principles of prescribing for older adults include starting with low doses and slow titration, using fewer daily doses if possible, being aware of altered pharmacokinetics, and closely monitoring for adverse drug events.
- Polypharmacy can be appropriate if aimed at specific goals agreed upon with the patient, but becomes inappropriate if including unnecessary drugs, not achieving goals,
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
The clinic is instituting new opioid prescribing policies to respond to Oregon's prescription opioid epidemic. The policies include: limiting opioid prescriptions to a maximum of 30% pain relief and 90mg of morphine per day; requiring follow up appointments every 3 months for patients on long term opioids; and avoiding co-prescribing opioids with sedatives or benzodiazepines. The policies aim to reduce overdose risks and offer alternatives to opioids for chronic pain conditions.
This document discusses the opioid epidemic in the United States. It provides definitions of opioid dependence and abuse, and details the epidemiology and costs of the crisis. The neuropharmacology and clinical effects of opioids are described. Methadone and buprenorphine are discussed as treatments for opioid dependence, including their mechanisms of action, efficacy, administration, and safety profiles. Buprenorphine is presented as a promising alternative to methadone with a lower risk of respiratory depression.
clinical pharmacy and modern dispensing practice. ...docxPriyayannawar4
Clinical pharmacy involves providing care and advice to patients regarding their medication therapy to promote health and prevent disease. The clinical pharmacist plays an important role in various areas like making decisions about drug therapy, counseling patients, and ensuring compliance. Some key responsibilities of a clinical pharmacist include taking medication histories, educating patients, monitoring drug therapy, and participating in research. Proper patient counseling and compliance are important to achieve the desired outcomes of medication therapy.
This document discusses medication safety and errors. It defines key terms like adverse drug events, adverse drug reactions, and medication errors. It describes types of medication errors that can occur and factors that contribute to errors. Recommendations are provided to prevent errors, like adopting a systems approach, using technology, implementing policies on verbal orders, and reporting errors. Specific classes of high alert medications and look-alike/sound-alike medications that are prone to errors are also identified.
This document discusses the opioid epidemic in America and proposes actions to address it. It summarizes that:
1) Nearly 200,000 Americans have died from prescription opioid overdoses since 1999, and up to 40% of long-term opioid therapy patients may be addicted.
2) Keeping chronic opioid therapy doses low can help reduce overdose risk. Many overdose deaths occur at doses of 50 mg or more per day, while most patients receive lower doses.
3) Immediate actions are needed to curb new inappropriate long-term opioid prescriptions, including more selective initial prescribing, checking prescription monitoring programs, and limiting initial supplies. Policies and regulations also need to be updated to reflect risks of addiction
Medical care responding_to_us_opioid_epidemic_von_korff_franklin_4-22-2016 (3)Paul Coelho, MD
This document discusses the opioid epidemic in America and proposes actions to address it. The key points are:
1) America is experiencing an unprecedented epidemic of prescription opioid addiction and overdose, with almost 200,000 deaths since 1999 mostly affecting patients prescribed opioids.
2) Proposed actions to address the epidemic include avoiding unnecessary opioid prescriptions, changing policies to reflect risks of addiction/overdose, and enhancing surveillance of opioid prescribing and patient safety.
3) Additional actions proposed are increasing clinical monitoring of patients on long-term opioid therapy, consistently offering to taper doses or discontinue opioids as an option, and ensuring treatment for addicted patients.
The Highs And Lows Of Opiate Managementguest2e3167
This document summarizes guidelines for prescribing opioids to manage chronic pain. It discusses the high prevalence and economic impact of chronic pain, as well as barriers physicians face in treating it. While opioids can provide pain relief, they carry risks of adverse effects, addiction, and overdose. The guidelines recommend developing a comprehensive treatment plan, trying non-opioid options first, carefully selecting and titrating opioid doses, monitoring patients for signs of misuse, and using treatment agreements to promote safe prescribing. The goal is to improve patients' function and quality of life while minimizing risks from long-term opioid therapy.
This document discusses several key aspects of medication safety:
1. Medication errors are a major cause of preventable patient harm. Proper knowledge of pharmacology principles is important for safely administering and monitoring medications.
2. Several factors can contribute to medication errors, including lack of communication, assumptions, inadequate labeling, and lack of checking procedures. Errors can be prevented by developing safe habits like verifying medications and using memory aids.
3. Patients should be educated on their medication regimens and actively involved in their own care by maintaining accurate medication lists. Thorough medication histories are important to avoid unintended interactions or duplications.
The CDC published guidelines in 2016 for prescribing opioids for chronic pain that included 12 recommendations. The guidelines aimed to reduce risks of long-term opioid use, including overdose risk. They recommended non-opioid therapies as preferred for chronic pain. If opioids are used, immediate-release are preferred over extended-release/long-acting opioids. The guidelines also recommended starting low doses and slowly increasing if needed, establishing treatment goals, considering risk factors, reviewing prescription drug monitoring programs, using urine drug testing, avoiding concurrent benzodiazepines, and offering treatment for opioid use disorder. However, the guidelines received criticism from medical organizations for being too rigid and not accounting for specialist care of individual patients.
Responsible Opioid Prescribing for Chronic Non-Cancer PainPaul Coelho, MD
This document outlines new opioid prescribing policies for a clinic in response to Oregon's prescription opioid epidemic. The policies include: limiting opioid prescriptions to no more than 120mg of morphine per day; requiring follow up appointments every 3 months for long term opioid users; and promoting non-opioid alternatives for chronic pain conditions that typically do not respond to opioids. The policies aim to reduce overprescription while maintaining patient safety.
This document summarizes analgesics and their mechanisms of action. It discusses several classes of analgesics including opioids, NSAIDs, and triptans. It then focuses on the structure-activity relationships of various opioid drugs, including endogenous opioid peptides and their receptors. Several opioid drug classes are examined in depth, including morphinans, benzomorphans, piperidines, and diphenylheptanes. Specific drugs within each class such as morphine, codeine, fentanyl, methadone, and tramadol are discussed. The metabolic pathways and SARs that determine the potency and properties of each drug are outlined.
The document discusses solubility and solubility product (Ksp). It defines solubility and Ksp, which is a measurement of how soluble a substance is. The greater the Ksp value, the more soluble the substance. It provides an example of calculating Ksp using the solubility of Pb3(PO4)2. The document also discusses how the common ion effect can decrease the solubility of a salt by increasing the concentration of one of its ions. It explains how to determine if a precipitate will form by comparing the ion product (Q) to the Ksp value - if Q > Ksp, a precipitate will form.
C. Give the patient Tylenol 650mg P.O as ordered and assist the patient with guided imagery.
This patient's pain level is relatively low at a 2/10 and is being well managed with scheduled Tylenol. Guided imagery could help further reduce the patient's perception of pain without unnecessary opioid exposure. Options A, B, and D would likely provide more pain relief than is needed and increase risks of opioid dependence, misuse or overdose.
The document discusses the importance of pharmacovigilance in health care. It defines pharmacovigilance as the science related to detecting, assessing, understanding, and preventing adverse effects of drugs. The main goals of pharmacovigilance are to improve patient safety, assess the risk-benefit profiles of medicines, and encourage their safe and effective use. Pharmacists can play important roles in pharmacovigilance by monitoring for and reporting adverse drug reactions. Pharmacovigilance programs in health systems should include ongoing surveillance, reporting, analysis, and education to prevent adverse drug events.
This document discusses guidelines for rational and appropriate pharmacotherapy in geriatric patients. It notes that older patients are more susceptible to adverse drug effects due to multiple illnesses, physiological changes, and reduced organ function. When prescribing for older adults, doctors should balance potential harms and benefits, regularly review prescriptions, use appropriate formulations, avoid symptomatic prescribing, consider non-prescribed medications, anticipate pharmacological differences in aging bodies, and be aware that adverse drug reactions may present atypically. The guidelines emphasize cautious, individualized prescribing tailored to each older patient's needs and risks.
This document provides guidelines for tapering or discontinuing opioid and benzodiazepine medications. It outlines several situations that warrant tapering opioids, such as lack of pain relief, excessive dosing, side effects interfering with quality of life, or non-compliance. It recommends a slow opioid taper of 10-15% per week to minimize withdrawal symptoms. Benzodiazepine withdrawal poses seizure risks, so tapers must be even slower at 5-10% reductions every 1-2 weeks, or require inpatient detox. Adjuvant medications and psychosocial support are essential for managing taper discomfort and anxiety about reduced drug levels.
This document summarizes the key points from a conference on managing risk in the workplace by addressing substance abuse issues. The conference objectives are to identify signs of drug addiction, describe employer procedures for substance abuse, and explain potential liabilities. It discusses the opioid epidemic, prescription drug abuse trends, and provides statistics on prescription drug use. Guidelines are presented for screening employees, using urine drug testing, identifying aberrant behaviors, and establishing treatment plans when substance abuse is suspected.
The document discusses rational medication use and patient compliance. It defines rational use as prescribing the appropriate drug, dose, duration and cost to meet a patient's clinical needs. Irrational use can lead to ineffective treatment, prolonged illness and increased costs. The document outlines factors influencing rational use and strategies to improve it, including educational, managerial, economic and regulatory approaches. It also defines adherence versus compliance, discusses causes and measurements of non-compliance, and factors affecting a patient's ability to comply with medication instructions.
This document provides guidelines for pharmacological interventions in treating schizophrenia, including recommendations for initiating treatment with antipsychotic medication, how to use oral antipsychotic medication, recommendations for acute episodes, and promoting long-term recovery. It recommends choosing antipsychotics based on individual factors and monitoring for efficacy and side effects. It suggests considering depot/long-acting injectable antipsychotics or clozapine for non-responders and monitoring physical health in primary care.
This document discusses polypharmacy in the elderly, defined as using more than 5 medications. It notes that polypharmacy prevalence increases with age, reaching 50% in those over 65. Consequences can include adverse drug reactions, reduced quality of life, and increased healthcare costs. Pharmacokinetic changes in aging like decreased liver and kidney function must be considered. The Beers Criteria provide guidance on inappropriate medications in elders. Interventions to reduce polypharmacy risk include regular medication reviews, educating patients, and using a personal health record.
- Older patients are more likely to be prescribed multiple medications due to increased prevalence of chronic illnesses, which increases their risk of adverse drug reactions and interactions.
- A comprehensive geriatric assessment is important for designing effective management plans focused on broad functional outcomes and disease alleviation. It also helps assess medication risks and benefits in the context of comorbidities.
- Principles of prescribing for older adults include starting with low doses and slow titration, using fewer daily doses if possible, being aware of altered pharmacokinetics, and closely monitoring for adverse drug events.
- Polypharmacy can be appropriate if aimed at specific goals agreed upon with the patient, but becomes inappropriate if including unnecessary drugs, not achieving goals,
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
The clinic is instituting new opioid prescribing policies to respond to Oregon's prescription opioid epidemic. The policies include: limiting opioid prescriptions to a maximum of 30% pain relief and 90mg of morphine per day; requiring follow up appointments every 3 months for patients on long term opioids; and avoiding co-prescribing opioids with sedatives or benzodiazepines. The policies aim to reduce overdose risks and offer alternatives to opioids for chronic pain conditions.
This document discusses the opioid epidemic in the United States. It provides definitions of opioid dependence and abuse, and details the epidemiology and costs of the crisis. The neuropharmacology and clinical effects of opioids are described. Methadone and buprenorphine are discussed as treatments for opioid dependence, including their mechanisms of action, efficacy, administration, and safety profiles. Buprenorphine is presented as a promising alternative to methadone with a lower risk of respiratory depression.
clinical pharmacy and modern dispensing practice. ...docxPriyayannawar4
Clinical pharmacy involves providing care and advice to patients regarding their medication therapy to promote health and prevent disease. The clinical pharmacist plays an important role in various areas like making decisions about drug therapy, counseling patients, and ensuring compliance. Some key responsibilities of a clinical pharmacist include taking medication histories, educating patients, monitoring drug therapy, and participating in research. Proper patient counseling and compliance are important to achieve the desired outcomes of medication therapy.
This document discusses medication safety and errors. It defines key terms like adverse drug events, adverse drug reactions, and medication errors. It describes types of medication errors that can occur and factors that contribute to errors. Recommendations are provided to prevent errors, like adopting a systems approach, using technology, implementing policies on verbal orders, and reporting errors. Specific classes of high alert medications and look-alike/sound-alike medications that are prone to errors are also identified.
This document discusses the opioid epidemic in America and proposes actions to address it. It summarizes that:
1) Nearly 200,000 Americans have died from prescription opioid overdoses since 1999, and up to 40% of long-term opioid therapy patients may be addicted.
2) Keeping chronic opioid therapy doses low can help reduce overdose risk. Many overdose deaths occur at doses of 50 mg or more per day, while most patients receive lower doses.
3) Immediate actions are needed to curb new inappropriate long-term opioid prescriptions, including more selective initial prescribing, checking prescription monitoring programs, and limiting initial supplies. Policies and regulations also need to be updated to reflect risks of addiction
Medical care responding_to_us_opioid_epidemic_von_korff_franklin_4-22-2016 (3)Paul Coelho, MD
This document discusses the opioid epidemic in America and proposes actions to address it. The key points are:
1) America is experiencing an unprecedented epidemic of prescription opioid addiction and overdose, with almost 200,000 deaths since 1999 mostly affecting patients prescribed opioids.
2) Proposed actions to address the epidemic include avoiding unnecessary opioid prescriptions, changing policies to reflect risks of addiction/overdose, and enhancing surveillance of opioid prescribing and patient safety.
3) Additional actions proposed are increasing clinical monitoring of patients on long-term opioid therapy, consistently offering to taper doses or discontinue opioids as an option, and ensuring treatment for addicted patients.
The Highs And Lows Of Opiate Managementguest2e3167
This document summarizes guidelines for prescribing opioids to manage chronic pain. It discusses the high prevalence and economic impact of chronic pain, as well as barriers physicians face in treating it. While opioids can provide pain relief, they carry risks of adverse effects, addiction, and overdose. The guidelines recommend developing a comprehensive treatment plan, trying non-opioid options first, carefully selecting and titrating opioid doses, monitoring patients for signs of misuse, and using treatment agreements to promote safe prescribing. The goal is to improve patients' function and quality of life while minimizing risks from long-term opioid therapy.
This document discusses several key aspects of medication safety:
1. Medication errors are a major cause of preventable patient harm. Proper knowledge of pharmacology principles is important for safely administering and monitoring medications.
2. Several factors can contribute to medication errors, including lack of communication, assumptions, inadequate labeling, and lack of checking procedures. Errors can be prevented by developing safe habits like verifying medications and using memory aids.
3. Patients should be educated on their medication regimens and actively involved in their own care by maintaining accurate medication lists. Thorough medication histories are important to avoid unintended interactions or duplications.
The CDC published guidelines in 2016 for prescribing opioids for chronic pain that included 12 recommendations. The guidelines aimed to reduce risks of long-term opioid use, including overdose risk. They recommended non-opioid therapies as preferred for chronic pain. If opioids are used, immediate-release are preferred over extended-release/long-acting opioids. The guidelines also recommended starting low doses and slowly increasing if needed, establishing treatment goals, considering risk factors, reviewing prescription drug monitoring programs, using urine drug testing, avoiding concurrent benzodiazepines, and offering treatment for opioid use disorder. However, the guidelines received criticism from medical organizations for being too rigid and not accounting for specialist care of individual patients.
Responsible Opioid Prescribing for Chronic Non-Cancer PainPaul Coelho, MD
This document outlines new opioid prescribing policies for a clinic in response to Oregon's prescription opioid epidemic. The policies include: limiting opioid prescriptions to no more than 120mg of morphine per day; requiring follow up appointments every 3 months for long term opioid users; and promoting non-opioid alternatives for chronic pain conditions that typically do not respond to opioids. The policies aim to reduce overprescription while maintaining patient safety.
This document summarizes analgesics and their mechanisms of action. It discusses several classes of analgesics including opioids, NSAIDs, and triptans. It then focuses on the structure-activity relationships of various opioid drugs, including endogenous opioid peptides and their receptors. Several opioid drug classes are examined in depth, including morphinans, benzomorphans, piperidines, and diphenylheptanes. Specific drugs within each class such as morphine, codeine, fentanyl, methadone, and tramadol are discussed. The metabolic pathways and SARs that determine the potency and properties of each drug are outlined.
The document discusses solubility and solubility product (Ksp). It defines solubility and Ksp, which is a measurement of how soluble a substance is. The greater the Ksp value, the more soluble the substance. It provides an example of calculating Ksp using the solubility of Pb3(PO4)2. The document also discusses how the common ion effect can decrease the solubility of a salt by increasing the concentration of one of its ions. It explains how to determine if a precipitate will form by comparing the ion product (Q) to the Ksp value - if Q > Ksp, a precipitate will form.
This document defines and provides examples of adjective clauses and adverb clauses. Adjective clauses modify nouns and usually contain a relative pronoun like who, which, that. Adverb clauses are used like adverbs to describe when, where, why, or how something occurred. Examples of adjective clauses include "Emma Willard was the one who founded the first women's college in the United States" and "The team's mascot, which is a horse, is called Renegade." Examples of adverb clauses include "After I finish painting my bookcases, I will call you" and "I paint where there is plenty of fresh air."
This document defines and provides examples of different types of adverb clauses and adverbial phrases. It begins by explaining that adverb clauses are dependent clauses that function as adverbs, modifying verbs by describing manner, time, place, cause, or condition. It then provides examples and explanations of different categories of adverb clauses, including time, place, manner, degree, condition, concession, and reason. The document also discusses adverbial phrases, which are multi-word adverb constructions that function similar to adverb clauses. It provides examples of time, place, manner, and cause/effect adverbial phrases. Finally, it includes some exercises testing understanding of different adverb clauses and phrases.
This document provides information about different types of dependent clauses that can be used in sentences, including adverbial clauses, nominal clauses, and relative clauses. It discusses how to punctuate sentences containing these clauses, explaining that adverbial clauses at the beginning of a sentence should be separated by a comma, while other types of clauses are not usually separated by commas. Examples are provided to illustrate the different clause types and proper punctuation. Exercises at the end ask the reader to insert commas in sentences containing various clauses.
The document provides guidance on teaching fronted adverbials to Year 4 students. It includes definitions of fronted adverbials and notes on punctuation. Examples are given to help students identify fronted adverbials in sentences and add correct punctuation. The resource also provides exercises for students to write sentences using fronted adverbials and rewrite sentences to include fronted adverbials.
Diamond is an exceptionally hard material with many superior properties including high thermal conductivity, strength, and hardness. It was long valued as a gemstone before its crystalline structure of carbon was discovered in the 18th century. While graphite is slightly more stable than diamond under standard conditions, diamond forms under extreme heat and pressure deep in the earth and is kinetically stable at the surface. Synthetic diamond can be produced through high-pressure high-temperature processes or chemical vapor deposition, but remains expensive to produce at large scales needed for many industrial applications.
This document defines and provides examples of adverb clauses. It explains that an adverb clause is a group of words that contains a subject and verb and describes or adds meaning to a verb, adjective, or other adverb. It then lists and provides examples of the 8 types of adverb clauses: time, reason, concession, contrast, result, purpose, place, and manner. Adverb clauses are introduced by words like when, because, although, whereas, so that, where, and as depending on the specific type of adverb clause.
The document discusses different types of adverb clauses. It provides examples of clauses that use conjunctions like "as", "as though/if", "as...as", and "so...as" to compare amounts or degrees. These clauses answer questions like "how much?" or "how little?". The document also gives examples of clauses introduced by "as", "as if", and "as though" that use the subjunctive verb form. Finally, it asks the reader to identify the adverb clauses in three example sentences and state their meanings.
This document discusses narcissism and some potential causes of rising narcissism in culture. It defines narcissism as having an inflated sense of self-importance and lack of empathy. Some factors that may contribute to rising narcissism include excessive praise from a young age, lack of natural consequences for misbehavior, and decreased opportunities for free play which teaches empathy. Narcissists are prone to bullying, lack of accountability, and relationship issues due to inability to consider others. Treatment focuses on regulating emotions and gaining a realistic self-view through compassion for others.
The document discusses robotic nursing and healthcare assistants. It describes several robots that are being developed to assist nurses and care for patients, including Robot nurse that can recognize faces and speak multiple languages, RIBA which can lift and move patients, and Cody which can assist with bathing. The benefits of robotic assistants are also summarized, such as helping with heavy lifting, monitoring patients, and preserving dignity. Concerns about costs, privacy, and not replacing humans are also mentioned.
This document discusses different ways to modify adverb clauses into modifying adverbial phrases through various techniques such as omitting subjects and verbs, changing verbs to -ing forms, and using upon + -ing. It provides examples of modifying time clauses, expressing simultaneous events and cause-effect relationships. Exercises are included for students to practice modifying adverb clauses according to the rules discussed.
The document discusses active and passive voice in grammar. It defines voice as the form of the verb that indicates whether the subject performs or receives the action. The active voice is used when the subject performs the action, while the passive voice is used when the subject receives the action. Some general rules for changing between active and passive voice are provided, along with examples of changing common phrases and sentences to passive voice.
This document discusses strategies for hospital partnerships and care coordination. It describes approaches to more effectively serve populations outside hospitals, including bringing together treatment providers, community groups, and others. One model mentioned is Health Enterprise Zones (HEZs). The document outlines characteristics of today's healthcare system and drivers transforming it, including new models of coordinated and population-based care. It provides examples of partnerships and programs at Carroll Hospital and Access Carroll, a community health center, to integrate services and coordinate care for low-income populations.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
Beyond Degrees - Empowering the Workforce in the Context of Skills-First.pptxEduSkills OECD
Iván Bornacelly, Policy Analyst at the OECD Centre for Skills, OECD, presents at the webinar 'Tackling job market gaps with a skills-first approach' on 12 June 2024
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
2. Opioid Misuse/ Abuse is a Major Public Health Problem
Improper use of opiates can result in serious adverse
events including overdose and death
The risk of death is increased in patients on extended
release formulations
In 2010, over 425,000 emergency room visits
involved non medical uses of opioids
Methadone is involved in 30% of prescription opiate
deaths
3. In 2009, 14,800 People Died in the US from a
Prescription Drug Overdose
4. When Prescribing Opiates for Pain, Always Consider
Risk Vs. Benefit Ratio
Potential Benefits
- Pain Control
- Improved Function
Potential Risks
- Overdose
- Abuse
- Misuse
- Addiction
- Physical Dependence
- Tolerance
- Interactions with other drugs
& substances
- Inadvertent exposure to
household contacts,
including children
5. Clinical Considerations when History Taking
Before Prescribing Opiates
Pulmonary Disease
Renal Disease
Hepatic Disease
Constipation
Cognitive
Impairment
Nausea
Illnesses Possibly
Linked to Substance
Abuse :
- Hepatitis
- HIV
- TB
- Cellulitis
- STIs
- Trauma, Burns
6. Clinical Interview
What causes or increases the pain ?
(pain generator)
What relieves the pain?
Effect of pain on physical, emotional,
and psychosocial function
Patient’s pain & functional goals
7. Physical Examination of the Pain Patient
Conduct a physical examination and
document vital signs, appearance,
posture, gait and pain behaviors
Conduct a neurological examination
Conduct a thorough musculoskeletal
examination, including inspection,
palpation, and provocative testing
8. Assessment of the Pain Patient
Seek objective confirmatory data – including xrays, MRI, CT, or
EMG as indicated
Order appropriate tests, including urine toxicology and ethyl
glucuronide levels
Query the state Prescription Drug Monitoring Program (PDMP)
Contact past providers and obtain old medical records
Document non pharmacological strategies which have been or
can be employed to relieve the patient’s pain and document the
effectiveness of these interventions (epidurals, acupuncture,
spinal manipulation)
For those patients already on opioids, document the opiate
used, the dose, regimen and duration to determine if the patient
is opiate tolerant
9. Assessment Risk of Abuse, Including
Substance Abuse & Psychiatric History
Obtain a history of current &
past substance abuse :
- Prescription Drugs
- Illicit substances
- Alcohol Use
- Tobacco Use
Social History is also
relevant :
- Employment
- Cultural Background
- Social Network
- Marital History
- Legal History
- Behavioral Problems
10. Always Perform a Risk Assessment for
Abuse & Diversion
Patients who are more likely to abuse
opiates are :
- Younger
- Have a personal history of substance
abuse
- Have a family history of substance abuse
- Have a psychiatric diagnosis of depression
11. Always Perform A Risk Assessment – For Risk of Respiratory
Arrest
Many deaths of patients receiving opiates are due to
concomitant ingestion of opiates with alcohol or
benzodiazepines.
Use only minimal doses of opiates in patients already on
benzodiazepines
Use minimal doses of opiates in patients with a history of sleep
apnea
Never start a patient who is using alcohol on opiates – order
urine ethyl glucuronide levels prior to starting opiates, inquire
about alcohol use when taking the history
Respiratory arrest is more likely to occur in patients who are
elderly, cachexic, or debilitated
- Altered opiate pharmacokinetics are seen in patients with
poor fat stores, muscle wasting, or altered clearance
12. Opiate Induced Respiratory Arrest
Patients are at increased risk of a respiratory arrest
within the first 24-72 hours of initiating opiate therapy
or within 24-72 hrs. of a dose increase
Respiratory arrest is more common in patients who
chew, crush, or dissolve extended release
medications rather than swallowing the tablets whole
Do not overestimate dosing when switching (rotating)
one opiate to another as this can result in fatal
overdose with the first dose
Extended release opiates are intended for opiate
tolerant patients only
13. Opiate Tolerance
Extended release opiates are only for opiate tolerant patients
Opiate tolerant patients are those who have been on any of the
following agents for one week or longer :
- 60 mg oral IR Morphine Sulfate
- 25 mcg transdermal fentanyl
- 30 mg oral oxycodone / day
- 8 mg hydromorphone / day
- 25 mg oral oxymorphone / day
- Or an equianalgesic dose of any other opioid
These patients still require close attention when rotating from
one long acting opioid to another opioid
14. Opioid Rotation
Definition : Change from an existing opiate regimen to another
opioid with the goal of improving therapeutic outcomes or avoid
adverse events / side effects of attributed to the drug the patient
is currently using
Rationale: Differences in pharmacologic or other effects make it
likely that a switch (rotation) will improve outcomes
Effectiveness and side effects of different mu opioids vary
among patients
Patients show incomplete cross tolerance to new opiates
Patients tolerant to the first opioid can have improved analgesia
from second opioid at a dose lower than calculated from an
equianalgesic dosing table.
15. Equianalgesic Dosing
Opioid rotation entails the calculation of an
approximate equianalgesic dose
It is a construct derived from relative opioid potency
estimates
There are many different versions of equianalgesic
dosing tables (EDTs):
- Published
- Online interactive
- Online
- Smart phone apps
17. Calculating the Equianalgesic Dose
Incomplete cross tolerance and inter – patient
variability require use of conservative dosing when
converting from one opiate to another
Equianalgesic dose is the starting point for
calculation of dose for an opiate rotation
The calculated dose of the new drug based on EDT
must be reduced, then titrate the new opioid as
needed.
Closely follow patients during periods of dose
adjustment
18. Guidelines for Opiate Rotation
Calculate the equianalgesic dose of the new opioid
from the EDT
Reduce the calculated equianalgesic dose by 25-
50%
- Choose 50% dose reduction if patient is receiving a relatively
high dose of the current opioid regimen or if the patient is
elderly or medically frail
- Choose 25% dose reduction if you are only switching to an
alternate route of administration of the same drug, or if
patient is on a low dose of opiates, or if the patient is young
and otherwise healthy
19. Guidelines for Opiate Rotation to Methadone
If switching to methadone, reduce the
calculated equianalgesic dose by 75% -
90%
For patients on a very high opiate dose
>1000 mg morphine, be cautious when
converting to methadone > 100 mg /
day
Consider serial EKG monitoring in this
situation
20. Breakthrough Pain
Immediate release drug is administered at 5-15% of the total
daily opiate dose
If dose required to reduce breakthrough pain is greater than
15%, the dose of the extended release medication must be
increased
Do not use extended release medication for breakthrough pain
Consider adding non opioid pharmacological agents to reduce
pain, called adjuvant analgesics
Adjuvant analgesics : anti spasticity agents, anticonvulsants,
NSAIDs
Non pharmacological treatments can be ordered to reduce
breakthru pain, including exercise, interventional procedures,
acupuncture , spinal manipulation.
21. Monitoring Programs are Based Upon Risk
Assessment
High risk patients must be placed on
intensive monitoring programs if opiates
are used
Low risk patients receive standard
monitoring programs
We monitor for aberrant drug behaviors
22. Aberrant Drug Behaviors
Examples of Aberrant Behaviors Include :
- Unsanctioned dose escalations
- Non compliance with therapy
- Unapproved use of the drug to treat symptoms than pain i.e..
anxiety, depression, sleep disorder
- Acquiring opioids from other clinicians
- Prescription forgery
- Obtaining prescription drugs from non medical sources
- Urine toxicology study contains drugs not prescribed
- Urine toxicology positive for illicit substances
- Urine toxicology negative for the prescribed drug
- Loss or “theft” of prescribed medications
- Medication reconciliation (pill count) reveals missing tablets
suggesting abuse or possible diversion
23. Always Have a PPA
PPA= a patient – prescriber agreement
Should be signed by both the patient
and the provider
Clarifies the treatment plan & goals of
treatment
Informs patients of the risks & benefits
of treatment
Document patient and provider rights &
responsibilities
24. Always Counsel Patients To :
Refrain from sharing, selling, or trading opiates with someone
else
Store the opiates in locked cabinet or safe in your home taking
only one day supply on your person
Keep opiates away from children and pets
Dispose of opiates when they are no longer needed – you may
flush extra pills and dispose of medication vials in the trash after
identifiers have been scratched off the vial- there are also
prescription drug disposal centers and drop boxes
Transdermal medications should be removed and adhesive
surfaces folded against each other and flushed down the toilet –
a patch that has been used for 3 days still has enough
medication in it to kill a child
Do not abruptly stop opiate use as this can trigger withdrawal
25. Prescription Drug Monitoring Programs
(PDMP)
49 states & 1 territory have
legislation authorizing a
PDMP
43 states have an operational
PDMP
Individual State Laws
Determine :
• Who has access to PDMP information
• Which drug schedules are monitored
• Which agency administers the PDMP
• Whether prescribers are required to
register w/ the PDMP
• Whether prescribers are required to
access PDMP information in certain
circumstances
• Whether unsolicited PDMP reports are
sent to prescribers
26. Always Be Sure to Check the PDMP Website
Prior to Prescribing Opiates !
Checking the NYS PDMP is required :
- Within 24 hours of admission if ordering narcotics
- Prior to writing a prescription for opiates at time of
discharge
- Prior to writing a prescription for an outpatient
- Not required to check for a hospice patient
- ER may give up to a 5 day supply of opiates
without checking the PDMP in NY State
27. When to Consider a Trial of an Opioid
When pain is moderate – severe
Failure of the patient to respond to non opiate, non
drug interventions, i.e. epidurals, exercise, PT,
acupuncture, spinal manipulation
Potential benefits outweigh risks – consider referral to
an interventional pain specialist or addiction medicine
specialist when risks outweigh benefits
When continuous around the clock analgesics are
needed around the clock for an extended period of
time
No alternative therapy is likely to provide as favorable
a balance of benefits to harms
28. Opium Poppies – Source of The Naturally
Occurring Opiates, Morphine & Codeine
30. Locations of Opiate Receptors
Found at both pre and post
synaptic sites in the ascending
pain transmission system in the
dorsal horn of the spinal cord,
the brain stem, thalamus, and
cortex
Opioid receptors are also found
in the descending inhibitory
modulating pathways of the
midbrain periaqueductal gray
matter, nucleus raphe magnus,
the rostral ventral medulla –
these modulate spinal pain
transmission.
31. Opiate Receptors
Receptor
Type
Endogenous
Opiate Agonist
Exogenous Agonists Exogenous
Antagonist
Mu *Beta Endorphin* Morphine Naloxone
Delta *Enkephalin* TAN - 67 Naltrindole
Kappa *Dynorphin* TRK – 820, opiate
agonists – antagonists act
at this receptor, including
butorphanol & pentazocine
Norbinaltorphimine
32. 3 Kinds of Opiate Receptors
Mu receptors influence responses to mechanical,
chemical and thermal nociception at a supraspinal
level
- Mu receptors also mediate the undesirable side
effects of opiate analgesics, including respiratory
depression, constipation, and physical
dependence
Kappa opiate receptors modulate spinally mediated
thermal nociception and chemical visceral pain
Delta receptors may modulate mechanical
nociception & inflammatory pain
33. How Opiate Receptors Work
Endogenous or exogenous opioid peptides bind to
opioid receptors to modulate mechanical nociception
and control pain sensitivity
Opioid receptors have extracellular transmembrane
regions that provide receptor specificity and
intracellular regions that link to G proteins
Activation of the opiate receptor sends a signal via
potassium ion channels and protein kinase C enzyme
systems located in the cytosol and cell membrane
resulting in both reduction of the action potential
duration and neurotransmitter release
34.
35. Opiate Agonist – Antagonists
Includes butorphanol, nalbuphine,
pentazocine
They act as agonists at the kappa
receptor, and antagonists at the mu
receptor
36. Opiate Partial Agonist Analgesics – Buprenorphine
Opioid partial agonist analgesics bind to an opiate receptor producing a
fraction of the full opiate response
Buprenorphine is an example of a partial agonist at the mu receptor
Used to help patients overcome opiate addiction
In order to use Suboxone in the state of NY, you must take a special
course
Subutex, the buprenorphine-only formulation, is available as 2 mg and
8 mg sublingual tablets
Suboxone, the buprenorphine and naloxone combination product, is
available as sublingual tablets in doses of 2 mg buprenorphine/0.5 mg
naloxone, and 8 mg buprenorphine/2 mg naloxone.
Naloxone is added to buprenorphine to decrease the potential for
abuse by the parenteral route.
The use of a partial agonist can offer some analgesia with a ceiling
effect
Later administration of full agonists can result in partial antagonist
effects
37. Buprenorphine Transdermal
System (BuTrans)
Transdermal system changed every 7 days
Initial dose in opioid tolerant patients on < 30 mg
morphine equivalents & in mild – moderate hepatic
impairment is 5 mcg/hour
When switching from an oral agent, first taper 30-80
morphine equivalents down to 30 mg morphine
equivalent, then initiate BuTrans at 10 mcg/hr.
May titrate dose up after patient has been on
BuTrans for a minimum of 72 hrs.
Maximum dose is 20 mcg./hr due to risk of QTc
prolongation
38. BuTrans
Apply topically to non irritated, intact skin
Prep site by clipping hair, wash site with water only,
then dry
Rotate application sites – wait a minimum of three
weeks prior to re-using an application site
Do not cut or damage the system
Avoid exposure to heat
Disposal : fold adhesive sides together and flush
down the toilet or use disposal kit included with the
drug
39. BuTrans
CYP3A4 inhibitors may increase
buprenorphine levels
CYP3A4 inducers may decrease
buprenorphine levels
Concomitant use of benzodiazepines
increases the risk of respiratory
depression
10 mcg and 20 mcg patches are only for
opiate tolerant patients
40. BuTrans
Use of this drug along with Class 1 A
and III anti-arrhythmics increases the
risk of prolonged QTc intervals
prolongation & torsade de pointes
It is hepatotoxic so you must check
LFTs and hepatitis serologies before
prescribing this drug
Equipotency to morphine has not been
determined.
41. Opioid Antagonists
Bind to opiate receptors producing no or low
antagonist activity that may reverse or inhibit
effects of opioid agonists by preventing
receptor access
Naloxone, naltrexone, nalfmefene are useful
for reversing opiate induced sedation and
respiratory depression
Naltrexone is used in the treatment of both
opiate and alcohol addiction
42. Federal Controlled Substances Schedules
Description of Criteria Examples
Schedule 1
C - I
High Potential for Abuse
Lack of Accepted Safety Data
No accepted medical use
Heroin, LSD, mescaline,
methaqualone
Schedule 2
C – II
High Potential for Abuse
Severe psychological &
physical dependence liability
accepted medical use
Morphine, hydromorphone,
oxycodone, cocaine,
amphetamine, methadone,
methylphenidate
Schedule 3
C-III
Less abuse potential than 1 or
2
Moderate or low physical
dependence or high
psychological dependence
Accepted medical use
Opioids combined with non
narcotic drugs :
percocet, dronabinol, anabolic
steroids, benzphetamine,
proposed move of
hydrocodone containing
combination drugs to
Schedule 2
Schedule 4
C-IV
Less potential for abuse than
C I- CIII
Limited physical /
psychological dependence
Accepted medical use
Benzodiazepines, chloral
hydrate, dextropropxyphene,
phenobarbital, fenfluramine,
tramadol
Schedule 5
C – V
Low Abuse Potential
Limited physical /
psychological dependence
Accepted medical use
Dephenoxylate / Atropine
antidiarrheal meds, Anti-
Tussives with small amnt.
codeine
43.
44. Morphine
The prototypical mu opiate receptor
agonist against which all other opiates
are compared for equianalgesic potency
Can be administered by IV, epidural,
intrathecal, rectal and oral routes
45. Morphine : Equivalence Between
IV/IM Vs. Oral Dosing
**Remember : 10 mg IV or IM Morphine
Sulfate is equivalent to 30 mg po**
46. Oral Morphine
Available as sustained release and
immediate release preparations
May be used in sustained release form
for chronic pain, and in immediate
release form for post op pain &
breakthru pain
Sustained release formulations : MS
Contin, Kadian, Avinza, Embeda
47. Morphine : Pharmacology
Morphine has an oral bioavailability of 35 – 75%
Due to its relative hydrophilicity, it is a less than ideal analgesic
Its transport across the blood brain barrier is frequently delayed,
and therefore it has a slower onset of action compared to the
other opioids
Morphine has a relatively longer duration of analgesic effect of 4
– 5 hours relative to its plasma half life ( 2 - 3.5 hrs) thereby
minimizing its accumulation & contributing to its safety
The disproportionate duration of analgesia vs. plasma half life is
due to its low solubility & slower elimination from the brain
relative to the plasma concentration
IR form is administered 10 – 30 mg po q 4 hours
48. Morphine Metabolites
Morphine’s effect as an analgesic is
primarily due to the parent compound,
however its efficacious & toxic effects
are also seen as a result of 2 of its
major metabolites, morphine 3
glucuronide (M3G)& morphine 6
glucuronide (M6G)
49. M3G
Lacks any mu or delta opiate receptor activity
– its mechanism of action is unknown
Accounts for 50% of morphine’s metabolites
Demonstrated to cause hyperalgesia, CNS
irritability, seizures, myoclonus, and opiate
tolerance in animals
Believed to cause neuroexcitatory side effects
in humans as well
50. M6G
A mu and delta receptor agonist
Accounts for 5 – 15 % of morphine
metabolites
It has intrinsic opioid agonist effects and
it sustains analgesia
51. Metabolites & Modes of Morphine
Administration
IV & rectal administration of morphine
avoids hepatic metabolism and
glucuronide concentrations are less
than with oral administration
52. Glucuronides
Chronic administration of morphine
sulfate orally results in higher
concentrations of glucuronides than the
concentration of the parent compound
Mean rations of M3G : M6G are
approximately 5:1
Patients experiencing side effects from
the metabolites are candidates for
rotation to an alternative opiate
53. Precautions For Morphine Usage
MSO4 elimination is dependent on hepatic
metabolism
Use it with caution in cirrhotic patients
Morphine metabolites are also renally
excreted, thus the dose should be reduced in
renal failure
Patients with renal failure develop
encephalopathy and myoclonus due to the
accumulation of morphine metabolites, in
particular, M3G
54.
55. MS Contin
Dosed every 8-12 hours
Titrate dose up at a minimum of 2 day
intervals between dose increases
Swallow tablets whole, do not crush or
chew
PGP inhibitors (ie quinidine) may
increase absorption of morphine by a
factor of 2
57. Morphine Sulfate ER
Capsules (Kadian)
Dosed once a day or Q12 hours
Package insert recommends against using this as
first opioid
Titrate dose up at a minimum of Q2 day intervals
Swallow capsule, whole, but you may open the
capsule and sprinkle the pellets on applesauce for
patients who cannot reliably swallow without chewing
Do not use with alcohol as this can result in rapid
release and absorption of the drug
PGP inhibitors like quinidine may increase absorption
of the drug 2 fold
58. Morphine Sulfate ER Capsules (Avinza)
Once daily dosing only
Titrate up at 3 day intervals
Initial dose in opiate tolerant patients is 30 mg / day
Maximum daily dose is 1600 mg due to renal toxicity of excipient
fumaric acid
Swallow capsule whole, may open capsule and sprinkle pellets
on applesauce for patients who cannot swallow
Concomitant use of alcohol may result in rapid release and
absorption of drug resulting in potentially fatal overdose
PGP inhibitors like quinidine may increase drug absorption by a
factor of 2
59. Morphine Sulfate ER - Naltrexone Tablets (Embeda)
Dosed once per day or Q 12 hours
Initial dose as a first opioid : 20 mg MSO4/0.8 mg naltrexone
Titrate up at 3 day or more intervals
Do not chew, crush, or dissolve
Crushing or chewing will release morphine rapidly, possibly
resulting in an overdose, naltrexone will also be released
possibly resulting in a withdrawal syndrome
Do not use with alcohol due to concerns about rapid release and
potentially fatal overdose
Don’t use with PGP inhibitors
100 mg / 4 mg capsule is for use in opiate tolerant patients only
60. Codeine (Methylmorphine)
One of the two naturally occurring opiates (morphine & codeine)
Is a derivative of opium, just as morphine is
Short acting
Available PO / IV / IM
Frequently administered with APAP, as Tylenol #2, Tylenol #3,
Tylenol #4
Commonly used as an anti – tussive
Administered every 4 – 6 hrs.
Metabolized in the body to codeine, (70%) norcodeine,
(10%),morphine (10%), normorphine, (4%) and hydrocodone
(1%)
Essentially it is a pro – drug. Conversion in the body to its
metabolite, morphine, is responsible for its analgesic properties
61. Codeine
Codeine has a poor affinity for opioid receptors in the brain.
As a pain medication, its effect occurs because of partial (approximately 10%)
metabolism to morphine in the liver.
The active enzyme in the liver responsible for conversion to morphine is the
P450 2D6 enzyme.
The 2D6 enzyme is also active in the metabolism of many medications,
including paroxetine, sertraline, and others.
Approximately 10% of the Caucasian population lacks 2D6 enzyme metabolic
activity.
It would be expected that those with limited 2D6 activity would get little or no
analgesic effect from codeine
Of interest, codeine is effective on the cough reflex regardless of the conversion
to morphine
62.
63. Oxycodone
Is the semi – synthetic cogener of morphine which
has been used as an analgesic for over 80 yrs.
Available as a short acting or long acting opiate
It is available as a short acting opiate in immediate
release preparations as oxycodone IR or roxicodone
The short acting preparation is also compounded with
aspirin (called endodan or percodan) or
acetaminophen (called percocet, endocet, or roxicet)
Short acting compound comes as 5 and 10 mg
tablets every 4 – 6 hrs
64. Long Acting Oxycodone
Is available as the drug oxycontin in the US
Q12 hr dosing schedule
More potent than morphine
Shorter onset of analgesia than morphine
Less variation in plasma levels than morphine
Associated with fewer side effects than morphine
(less confusion, sedation, hallucinations, dizziness,
and pruritis)
Oxycodone itself has some intrinsic opiate agonist
activity thru activation of kappa receptors, but it
basically is a pro – drug
65. Oxycodone ER (Oxycontin)
Dosed every 12 hours
Opioid naïve patients : Starting dose is 10 mg po Q12 hours
Titrate at a minimum of 1-2 day intervals
Hepatic impairment: start with ⅓-½ usual dosage
Renal impairment (creatinine clearance <60 mL/min): start with
½ usual dosage
CYP3A4 inhibitors may increase oxycodone levels
CYP3A4 inducers may decrease oxycodone levels
Approximately 2:1 oral morphine to oxycodone oral dose ratio
Dosing greater than 40 mg for patients who are opioid tolerant only
Cannot be used in patients who have swallowing dysfunction
66. Metabolism of Oxycodone
Oxycodone is a pro-drug
It undergoes hepatic metabolism via the
cytochrome P4502D6 where it is
converted to the mu opiate agonist,
oxymorphone & the inactive
noroxycodone
- Oxymorphone is an active metabolite with
mu opioid agonist which is 14X more
potent than the parent compound
- Noroxycodone is an inactive metabolite
67. Oxycodone & Cytochrome P450 2D6
About 10% of the population has genetically low
levels of cytochrome P450 2D6 enzyme
These individuals may need higher doses of
oxycodone to achieve analgesia than the average
individual
Analgesic efficacy may also be decreased in those
patients who are concurrently taking medications
which competitively inhibit the P450 enzyme
Careful dose titration must be made in those who
concurrently take SSRIs, TCAs, or neuroleptics
The kidneys excrete oxycodone, therefore, the dose
should be adjusted in renal dysfunction
68.
69. Hydrocodone
semi-synthetic opioid derived from two of the naturally occurring
opiates, codeine and thebaine
Most frequently prescribed opiate in the US, and one of the most
frequently abused drugs
Known in the US as Vicodin, Lorcet, Lortab, Norco.
Most popular formulation : as a tablet in combination with APAP, called
Vicodin
Also is available in a combination tablet with ibuprofen, called
Vicoprofen
Standard Vicodin Tab : 5.0 mg with APAP
Vicodin ES : 7.5 mg with APAP
Reaches peak effect in 0.5 – 1 hr.
Duration of analgesia is 3 – 4 hrs
Typically dosed every 4 – 6 hrs.
No significant interaction with adjuvant analgesics
70. Hydromorphone
Marked in the US as Dilaudid
Hydrogenated ketone analog of
morphine that can be formed by n-
demethylation of hydrocodone
Can be administered via IV, IM, SQ,
epidural, intrathecal, rectal, or PO
routes of administration
71. Hydromorphone Immediate Release
(Dilaudid)
Oral short acting drug marketed in the US as 4 and 8 mg tablets,
and 3 mg rectal suppositories
A hydrophilic compound which has strong mu opiate receptor
agonist activity
5 – 7 x more potent than morphine
Time to Onset of Analgesia : 30 minutes if administered orally, 5
minutes to onset if administered parenterally
Duration of analgesic effect : 3 - 4 hours
Side effects of nausea, pruritis, sedation, and vomiting occur
less frequently with Dilaudid
Typically dosed every 4 – 6 hrs.
72. Hydromorphone Extended Release Tablets
(Exalgo)
Dosed once per day
Titrate up at 3-4 day intervals
Swallow tabs whole, do not crush or chew
Start the patient with moderate hepatic impairment on
25% of the recommended dose
Start the patient with moderate renal failure on 50%
of the recommended dose, patients with severe renal
failure on 25% of the recommended dose
Do not use in patients with sulfite allergy as it
contains sodium metabisulfite
~ 5 : 1 oral morphine to hydromorphone dose ratio
73.
74. Tapentadol ER (Nucynta)
An opiate agonist
Dosed Q 12 hours
50 mg po Q12 hours is the initial dose in non opioid tolerant patients
Swallow tablets whole one at a time with water – do not chew or crush
Do not take this medication with alcohol
Titrate up by 50 mg increments at a minimum of three day intervals
between dose increases
Maximum daily recommended dose is 500 mg / day
Maximum dose is 100 mg /day in moderate hepatic impairment
Avoid use in severe hepatic and renal impairment
Cannot use with MAO inhibitors
Risk of serotonin syndrome when used with SSRI and SNRI
Risk of angioedema
Equipotency with morphine has not been established
75. Methadone
Originally called Adolfine, after Adolf Hitler
Then name was changed to Dolofine
Now called methadone which is an acronym for : 6
dimethylamino 4,4 diphenyl 3 heptanone
Highly lipophilic & basic (pka = 9.2)
Totally synthetic
Administered by oral, rectal or parenteral administration
Delayed clearance from the body and long half life permit this
drug to be given once daily for opiate maintenance programs for
prevention of withdrawal symptoms for up to 24 hrs.
Dispensed as 5, 10, 20 mg tablets
Initial dose for non opiate tolerant patients : 2.5 – 5 mg
Dosed every 8-12 hours
76. Methadone for Analgesia
Not administered once daily for analgesia unlike methadone
maintenance for drug addiction
Duration of analgesia following each dose : 6 – 8 hrs.
Onset of analgesia : 2 hrs post administration
Has no known metabolites
Undergoes hepatic metabolism by cytochrome P450 system,
specifically CYP3A4
Peak absorption is dependent upon gastric pH, patients who are willing
to take omeprazole will absorb more methadone
CYP 450 inducers may decrease methadone levels
CYP 450 inhibitors may increase methadone levels
Antiretroviral drugs have mixed effects on methadone levels and it
is advised not to use methadone in HIV patients on these drugs
Coadministration with benzodiazepines is not recommended due to risk
of respiratory depression
Coadministration with other agents which prolong the QT interval is
contraindicated
77. Methadone
Usually exists in a racemic mixture of
two isomers, d methadone and l
methadone, both of which have
separate modes of action
The d isomer antagonizes the NMDA
receptor & inhibits 5 hydroxytryptamine
& norepinephrine reuptake
The l isomer possesses opioid receptor
agonist properties
78. Methadone
Methadone has a lower affinity than morphine
for the mu opioid receptor
This explains why methadone has fewer mu
opioid related side effects
Methadone has a higher affinity for the delta
opiate receptor than morphine
Its action at the delta receptor prevents opiate
induced tolerance and dependence
Its action at the NMDA receptor also prevents
the development of tolerance
79. Methadone
Advantages :
- Low Cost
- Long acting
- High Bioavailability
- Multiple receptor affinities
- No known metabolites with
neurotoxicity
- Does not accumulate in
renal failure patients
- Not significantly removed by
dialysis
- The tablets may be broken
in half and chewed
- Available as an elixir for use
in gastrostomy tubes
Disadvantages :
- Unpredictable bioavailability
- High inter-individual
variability in steady state
serum levels with half lives
varying from 75 -175 hrs. /
half life
- Auto – induces activity of
the cytochrome P450
subtype CYP3A4 which is
responsible for its
metabolism, so methadone
metabolism may increase
with time, and dose required
for analgesia may increase
with time.
80. Cardiotoxicity of Methadone
Methadone increases the duration of
the QT interval
Bradycardia has been described as a
result of methadone administration
Torsade de Pointes can result from QT
interval prolongation
Obtain serial EKGs on patients who
require methadone when titrating the
drug
83. Methadone in Pregnancy &
Lactation
Safe for use in pregnancy
Clearance may increase in pregnancy
Safe for use in lactation at doses < 20
mg / day
84.
85. Fentanyl
A mu opioid receptor agonist
Faster onset of action than morphine
75 -125 times more potent than morphine
High lipophilic – due to its lipophilicity, it is available
in transdermal and transmucosal forms
This lipophilicity also leads to limited spread when
infused epidurally or intrathecally
May be administered via IV, epidural, intrathecal,
transdermal, and transmucosal routes
Patch comes in 25 mcg, 50 mcg, and 100 mcg
strength
86. Precautions : Transdermal
Fentanyl
CYP3A4 inhibitors may increase
fentanyl serum levels
CYP3A4 inducers may decrease serum
fentanyl levels
Bradycardia has been described as a
side effect
Not to be used in opiate naïve patients
87. Fentanyl Patch
Use 50% of the regular dose in the
setting of mild - moderate hepatic or
renal impairment
Avoid use of this drug in severe hepatic
or renal impairment
88. Fentanyl Transdermal Patch
Recommended for chronic pain or cancer pain – not
recommended for opiate naïve subjects
20% incidence of hypoventilation when used for acute
postoperative pain management in opiate naïve subjects
Consists of 4 layers :
- Polyester backing layer which is impermeable to drug loss
or moisture penetration
- Drug reservoir contains fentanyl gelled with
hydroxymethylcellulose & ethanol – the ethanol facilitates
transdermal absorption
- Rate controlling membrane controls rate of release of the
drug by 50%, 50% of rate control is affected by the inherent
resistance of the skin
- A silicone adhesive layer keeps the patch affixed to the
skin
89. Transdermal Fentanyl
Should be placed on the upper body on clean, intact
skin with clipped, (not shaved), hair
Clean skin with water and allow to dry before patch is
placed
Rotate application sites
Permits 3 day dosing
Avoids the first pass effect in the liver
Because it is absorbed thru the skin, it can be given
to patients who cannot take medications orally
Can take 1 – 30 hrs (average : 13 hrs.) to achieve
therapeutic serum levels
Takes 16 hrs after patch removal to clear 50% of the
drug
90. Precautions for Patients – Fentanyl Patch
Do not place a heating pad over the patch
Do not use a tanning bed or a heat lamp with the
patch in place
Cannot be used in a patient with a fever
Do not wear the patch in a jacuzzi, or direct the
stream of hot shower water on it.
Do not place the patch over broken skin, as this will
speed absorption
Take care when holding children or animals while
wearing the patch to avoid the child or animal from
experiencing accidental exposure to the drug
Dispose of by folding adhesive sides together and
flushing down the toilet
91. Transmucosal Fentanyl
Marketed in the US as Actiq
Rapid onset of analgesia ( 5 – 10 min)
Short duration of action
Buccal absorption avoids the first pass effect
Peak serum concentrations are achieved in
22 minutes, similar onset time as IV morphine
Good for breakthru pain in patients who are
unable to swallow
92. Fentanyl Derivatives
Sufentanil (Sufenta) :
- Used in the operative setting as an IV or neuroaxial
anesthetic, it has a rapid onset with short duration of effect.
- 5 – 7 x as potent as Fentanyl
Alfentanil (Alfenta) :
- Used in the operative setting as an IV or neuroaxial
anesthetic agent
Remifentanil (Ultiva) :
- The most potent mu opioid receptor agonist of all
- Administered IV in the operative setting for rapid induction
and maintenance of anesthesia
- More lipophilic than fentanyl or any of the above derivatives
- More rapid onset, distribution, and metabolism than other
fentanyl derivatives, briskly cleared and rapidly metabolized,
has no hepatic metabolism / renal metabolism
93.
94. Propoxyphene
Formerly Marketed in the US as Darvon or Darvocet – oral
administration only
Removed from the market in fall of 2010 due to QT interval
prolongation seen in normal subjects on the drug
Peak plasma concentrations are achieved within 2 – 2.5 hrs
post administration
Metabolized by the liver to norpropoxyphene, an active
metabolite with a propensity to accumulate
This metabolite causes dizziness, sedation, nausea, vomiting
If this drug is consumed in excess by accident or purposefully,
seizures, cardiac arrhythmias, heart block may result
95. Was Propoxyphene Safe & Effective ?
Proven to be no stronger than taking 3
tylenol or aspirin tablets
Increases risk of falls in the elderly
population
Not recommended for chronic use due
to concerns about accumulation of toxic
metabolite
96.
97. Tramadol
Has action at multiple receptors
Acts at the mu opiate receptor
Also inhibits the reuptake of norepinephrine & serotonin
Tramadol is metabolized in the liver to its active metabolite which is
excreted by the kidneys
Has an elimination half life of 5 hrs.
Contrary to assertions of Big Pharma, it is a drug of abuse
Useful in mild – moderate pain associated with osteoarthritis,
fibromyalgia, low back pain, diabetic neuropathy
Available in the US as Ultram, or as Ultracet tabs (combination with
APAP)
Dispensed as 50 mg tablets
50 – 100 mg po Q 4 – 6H
Maximum Daily Dose : 400 mg / day
Not regulated by the Controlled Substances Act in most states, only
two states control this drug under Schedule 4
98. Tramadol – Side Effects
Nausea
Dizziness
Somnolence
Headache
**Seizure activity seen in < 1% of users**
- Risk of seizure activity is increased in patients with alcohol
abuse, stroke, head injury, or renal insufficiency,
- When combined with SSRIs, SNRIs, tricyclic
antidepressants, or in patients with epilepsy, the seizure
threshold is further decreased
**Do not prescribe for patients on SSRI or SNRI anti-depressant
medications – this would place the patient at increased risk of
developing the serotonin syndrome**
99.
100. Oxymorphone
Marketed in the US in immediate release and
sustained release forms as Opana (IR) and Opana
ER
Semi – synthetic opioid analgesic
Immediate release : Half life of 7 – 8 hrs.
Metabolized in the liver
Naturally produced in the body as a by product of the
hepatic metabolism of oxycodone
Duration of Analgesia for Oxymorphone IR : 6 – 8
hrs.
Starting dose for opiate naïve patients of Opana IR :
5 – 10 mg po Q 6 hrs.
101. Oxymorphone ER (Opana ER)
Dosed every 12 hours
Use 5 mg po Q 12 hours as the initial dose in opiate
non tolerant patients & in patients with mild hepatic
impairment and renal impairment (creatinine
clearance < 50 and in patients > 65 yrs old
Titrate dose at a minimum of 2 day intervals
Do not crush or chew, do not ingest alcohol while on
this drug
Contraindicated in moderate and severe hepatic
impairment
Approximately an oral morphine : oxymorphone ER
ratio of 3:1
102. Pentazocine
An opiate agonist – antagonist : agonist at the kappa
receptor, antagonist at the mu receptor
IM or IV Administration : 30 mg q 3 - 4 hours (not to
exceed 60 mg/dose I.M., or 30 mg/dose I.V.).
Maximum daily dosage is 360 mg.
Oral Tablets: 50 mg pentazocine and 0.5 mg
naloxone (Talwin NX); 25 mg pentazocine and 650
mg acetaminophen (Talacen)
- Oral Dosing of Talwin Nx : q 3 to 4 hours, increased to two
tablets p.r.n., up to a maximum of 12 tablets daily
- One tablet (Talacen) P.O. q 4 hours; up to a maximum of six
tablets daily
103. Pentazocine
Also known as Talwin, Fortral, Talacen (with APAP)
or Talwin NX (combination with naloxone) , Fortwin
(IM or IV injectable)
Synthetic
Opiate agonist – antagonist of the benzomorphan
class
This compound exists as two enantiomers, named
(d)pentazocine and (l)-pentazocine. (l)-pentazocine is
a kappa-opioid receptor agonist, while (d)-
pentazocine is not, instead displaying a ten-fold
greater affinity for the NMDA receptor
104. Benefits of Talwin
Some evidence suggests that
pentazocine may differ from other
marketed narcotics in one respect - it
causes little or no elevation in biliary
tract pressures
105. Pentazocine Drug Interactions
Concomitant use of monoamine oxidase
inhibitors (MAOIs) with pentazocine may
cause CNS excitation and hypertension
through their respective effects on
catecholamines.
Caution should therefore be observed in
administering pentazocine to patients who
are currently receiving MAOIs or who have
received them within the preceding 14 days.
106.
107. Levorphanol
Also known as Levo-Dromoran
Has affinity for mu, kappa, and delta opiate receptors,
as well as NMDA receptor antagonist properties
Reaches its peak effect in 0.5 – 1.5 hrs
Duration of Analgesia 4 – 6 hrs.
Has a long half life and can accumulate rapidly
Typically dosed 2 mg IV or 4 mg po every 6 – 8 hrs.
Drug Interactions : Although no interaction between
MAO inhibitors and Levo-Dromoran has been
observed, it is not recommended for use with MAO
inhibitors.
108. A Drug Which You Should Not Use :
Meperidine
It is a synthetic opiate which is weaker than morphine
with relatively weak mu opiate receptor agonist
properties which was initially designed in Nazi
Germany
1/10 as potential as morphine
Has a neurotoxic metabolite, normeperidine, which
causes seizures – accumulates when used for more
than three days, particularly in patients with renal
insufficiency
Is cardiotoxic ( causes myocardial depression)
Interacts with MAOI drugs with a fatal outcome
Interacts with SSRI, SNRI, tramadol, and methadone
No longer on most hospital formularies !!
113. Equianalgesic Values of Short Acting Opioids - Equivalence to
Morphine Sulfate 10 mg IV or 30 mg PO
Generic Name Equianalgesic Amount
Codeine 200 mg oral, 130 mg IM
Hydrocodone 30 mg oral, no IM formulation available
Hydromorphone 1.5 mg IM or IV, 8 mg po, 3 mg rectal suppository
Meperidine 75 mg IM or IV, 300 mg po
Tramadol 120 mg po, no IV or IM formulations available
Oxycodone IM : 15 mg, 30 mg po
Methadone IM : 10mg, PO : 20 mg
Pentazocine IM : 30 mg PO : 167 mg
Levorphanol IM : Acute Pain : 2 mg
PO : Acute Pain : 4 mg
Oxymorphone 1 mg IM, Oral : 10 mg, Rectal : 5 – 10 mg suppository
114. Online Tools for Opiate Equianalgesic Dose
Conversion
http://www.globalrph.com/narcoticonv.htm
http://endoflife.stanford.edu/M11_pain_control/doses_m01.html
http://www.ohsu.edu/ahec/pain/part2sect6.pdf
http://www.acpinternist.org/archives/2008/01/extra/pa
in_charts.pdf
Download Free Opioid Converter apps for your
Iphone or Android phone via your APP store or
Google Play
115. Tips for Equianalgesic Dose Conversion
When rotating/changing to an alternative opiate
medication, consider the following guidelines:
Calculate the total daily dose of the
original opioid (add long acting and breakthru doses)
Convert to the equinalgesic dose of the alternative
opiate medication
Adjust the dose of the alternative opiate medication
for incomplete cross tolerance by reducing dose by
25% - 50%.
116. General Warnings Regarding
Prescribing Opiates
Concurrent use of any opiate with all central nervous
system depressants such as alcohol, sedatives,
hypnotics, benzodiazepines, barbiturates, and
tranquilizers may result in additive central nervous
system depressant effects.
Respiratory depression, hypotension, and profound
sedation or coma may occur.
When such combined therapy is contemplated, the
dose of one or both agents should be reduced.
Be cautious, particularly in patients with sleep apnea
117. Pre – Prescription Patient
Assessment
Assess all patients for risk of abuse and diversion of
opiate medications with a standardized tool, such as
SOAPP or ORT and tailor your monitoring program
based on the risk assessment of the patient
Assess all patients for risk of sleep apnea as well
This is mandated by the Federal Government as part
of the Opiate REMS program (Risk Evaluation &
Mitigation Strategies)