Using Opioids in the Hospitalized Patient

Nicole Artz, MDAssistant Professor of MedicineUniversity of Chicago

No financial relationships to disclose

Outline

Rapid titration for rapid pain relief Dosing the PCA Converting between drug and route Special Populations

Renal/Liver Disease Opioid Tolerant/Dependent

Handling Side Effects What’s New

Mr. P

45 y/o man (100 kg) presenting to the ED with acute rib fracture after falling off a ladder.

Pain 9/10 Takes HCTZ for HTN; no other meds. You are evaluating him in the ED

Mr. P

What pain medication will you offer? What dose will you order?

Equianalgesic Opioid Table

Opioid Oral IV/SC/IM

Morphine 30 mg 10 mg

Hydromorphone 7.5 mg 1.5 mg

Meperidine 300 mg 100 mg

Fentanyl N/A 100 mcg

*For severe pain start with dose in chart. For moderate pain, start with 50% of dose and start with 25% of dose for mild pain. Start even lower in patients who are elderly, have renal or hepatic disease or weigh < 50 kg

American Pain Society;

Mr. P

You order 5 mg IV Morphine 15 minutes later Mr. P is still in 8/10

pain Can you redose yet? How much should you give?

Sedation ScaleSedation Scale

Action Required

S Sleeping, easily aroused None

1 Awake and Alert None

2 Occasionally drowsy, easy to arouse

None

3 Frequently drowsy, arousable, drifts off to sleep during conversation

Physically stimulate. Decrease or discontinue the opioid.

4 Somnolent, minimal or no response to stimuli

Discontinue opioid and consider naloxone; measure O2 saturation

*McCaffery, M. and Pasero, CL. Pain: Clinical Manual, 2nd ed.

General Principles for Rapid Titration

Redose with 50% of loading dose until adequate relief is achieved (usually <5/10)*

•American Pain Society. Fifth edition

•National Comprehensive Cancer Network, v.2.2005

*Variation exists among different guidelines.

Mr. P

You redose with 2.5 mg of Morphine and reassess 15 minutes later.

Mr. P reports his pain is now 6/10 You redose with an additional 2.5 mg 15 minutes later Mr. P is comfortable

with a pain score of 3-4/10.

Mr. P (Scenario 1)

What should his standing dose of Morphine be and at what interval?

10 mg Morphine IV Q3 hrs ATC You reassess later that day and he

reports adequate pain control immediately after the 10 mg dose but states the dose wears off after the first 90 minutes.

Options?

Consider changing to PCA Avoids peaks and valleys in pain control

from bolus dosing Increases patient self-efficacy Less burdensome for nurses Safe way to achieve excellent pain

control

Joshi and White, 1998; Ballantyne, 1993; Kerr, et al. 1988

Mr. P (Scenario 1)

How will you dose the PCA?

General Principles Avoid using a basal rate in an opioid naive

patient until opioid requirements are known To calculate an initial demand dose- use

30-50% of the effective bolus dose. *Goal is only 1-2 demands/hour needed to keep pain under control.

Titrate the demand dose to achieve good pain control

May add a basal once opioid requirements determined.

Mr. P (Scenario 1 Cont..)

Morphine PCA 3 mg demand dose 15 minute lockout No basal rate

Mr. P Scenario 1 cont…

Day 2- pain is well controlled with Morphine PCA 3 mg demand with 15 minute lockout.

Reports trouble sleeping due to pain Solution?

Add a basal infusion on the PCA

Mr. P (Scenario 1 cont…)

24 hour use = 120 mg IV Morphine

If still in severe pain could give full amount as basal

If pain improved but trouble sleeping, consider starting 30-50% 24 hr total as basal

Mr. P (Scenario 1 Cont…)

New PCA orders 60 mg/24 hrs = 2.5 mg/hr continuous

infusion Demand dose?

50-150% of basal 2.5 mg demand with 15 minute

lockout

Mr. P (Scenario 1)

Converting to orals for discharge Take 24 hr PCA requirements Give 50-100% as equianalgesic dose of

oral long-acting opioid Rescue with short-acting that is 10-15%

of 24 hr dose.

Mr. P (Scenario 1)

Pt used 90 mg IV Morphine past 24 hrs and currently has excellent pain control.

90 mg IV Morphine = 10 IV Morphine X mg po Morphine 30 mg po Morphine

X = 270 mg po Morphine/day

Mr. P (Scenario 1)

Start 50% as long-acting 270÷2 = 135 mg long-acting Morphine 135÷3 = 45 mg MS ER po Q 8 hrs

Calculate a breakthrough dose 10-15% of total daily dose Morphine Sulfate IR 15 mg po Q 2-4 hrs

prn breakthrough pain

Mr. P (Scenario 1)

How will you wean the morphine? Need to wean if >=5 days exposure 10-20% per day- more slowly if increased

pain or signs of withdrawal

Mr. P (Scenario 2) Pt just admitted from the ED You reassess later that day and he

reports worsening pain with relief only to 7/10 after each 10 mg IV morphine.

A PCA is not available. While evaluating causes for increased

pain, how will you titrate the dose to achieve better control?

Mr. P (Scenario 2 Cont…)

Severe Pain (7-10)- Increase by 100%

Moderate Pain (4-6)- Increase by 50%

Mild Pain (0-3)- Increase by 25%

Mr. P (Scenario 2)

New Morphine dose = 15 mg IV Q 3hrs OR 20 mg IV Q 3hrs

Avoid writing a range for dose or interval

Consider dosing ATC patient may refuse instead of prn

Renal/Liver Insufficiency Start with Lower Dose, Longer Interval

Avoid Meperidine (even for pts w/o renal insuff) Avoid scheduled doses of Morphine in renal

insufficiency Preferred opioids in renal insufficiency:

Fentanyl, Hydromorphone, Methadone

The Opioid Tolerant Patient

What is tolerance? What is physical dependence? Difference between physical

dependence and psychological dependence/(addiction)?

Mrs. G

60 y/o woman with metastatic breast cancer admitted with intractable pain

Home regimen: Two 100 mcg Fentanyl patches Hydromorphone 12 mg po Q 3 hrs prn

breakthrough pain Reports severe nausea with morphine

Mrs. G Calculate a basal rate for a Hydromorphone

PCA Convert Fentanyl to Morphine using 1:2 ratio 200 mcg Fentanyl patch equiv to 400 mg po

Morphine/day 400 mg po Morphine/day = 30 X mg IV Hydromorphone/day 1.5

X = 20 mg IV Hydromorphone/day Consider reducing dose by 25%-50% due to

incomplete cross-tolerance

Mrs. G Add in breakthrough pain medication

Hydromorphone 12 mg Q 3 hrs = 96 mg/day po Hydromorphone

96 mg po hydromorphone/day = 7.5 X mg IV hydromorphone/day 1.5

X = 19 mg IV Hydromorphone/day

20 mg + 19 mg = 39 mg IV Hydromorphone/24 hrs

Mrs. G cont.. Given intractable pain, would give

total amount as basal and add demand dose 39mg/24hrs = 1.6 mg/hr basal infusion Demand dose?

50-150% of basal 1.5 mg demand available every 10

minutes* In addition to this, you add ketoralac and

Dexamethasone

Mrs. G Later that day, the patient is more

comfortable, with pain 5/10 and decreased to 3/10 after using the demand dose on PCA.

Reports no bowel movement for 2 weeks at home and increased abd bloating;

Abd series reveals constipation but no obstruction

Opioid Side Effects Nausea

Metoclopramide, haloperidol, prochlorperazine Constipation

Prophylactic bowel regimen with stimulants (Senokot, Bisacodyl)

Pruritis Diphenhydramine,

Sedation Decrease opioid dose, caffeine, methylphenidate

Dysphoria,Visual/tactile hallucinations, Delirium Adjust dose or change opioid; haloperidol

Myoclonus Adjust dose or change opioid

Allodynia/Hyperalgesia Wean opioid, change opioids

What’s new…

• Methylnaltrexone• Peripheral opioid receptor antagonist• Does not cross the blood-brain barrier• Effective for treatment of opioid induced

constipation and nausea• Subcutaneously administered• Recently approved by the FDA for treatment of

opioid-induced constipation in palliative care pts with inadequate response to laxatives.

Take Home Points Rapid Titration:

reassess every 15 minutes and redose with 50% of loading dose until adequate relief achieved.

Add up total mg required to achieve relief during rapid titration- this is your scheduled bolus dose.

Titrate opioids by 25%, 50%, or 100% for mild, moderate, or severe pain

When transitioning to po make sure to calculate an equianalgesic dose using the opioid conversion tables.

Take Home Points

Use PCA’s when available In opioid naive- set demand at 30-50% of

loading or bolus dose In opioid tolerant- convert current

opioids to equianalgesic basal rate on pca; set starting demand dose the same as the basal rate

References Principles of Analgesic Use in the

Treatment of Acute Pain and Cancer Pain, American Pain Society, Fifth edition, 2003.

Education for Physicians on End-of-Life Care (EPEC), Pain Management Module, RWJF, 1999.

National Comprehensive Cancer Network: Practice Guidelines in Oncology- v.2.2005

Resources

Hopkins Opioid Program Fast Facts, National Residency End-

of-Life Curriculum ProjectDownload at

www.eperc.mcw.edu