Opioid use
Patient specific opioid selection is based on? Name 3...
Acute vs. Chronic pain, maintenance vs. breakthrough pain, route availability, substance abuse history, renal or hepatic dysfunction, cost, drug interactions.
Name 5 physical signs of opioid overdose
True or False? Constipation is the only opioid adverse effect that the body does not develop tolerance to and can occur after a single dose of opiods?
True.
This physiologic phenomenon occurs nearly universally among patients receiving repeated opioid doses for >7-10 days.
Dependence
If a patient has widespread pain (>3 areas) without objective signs and symptoms, what is their abuse risk? Low, medium or high?
High risk.
What are benefits of long acting opioids? Name 2.
More consistent pain control...WHY, improved adherence, lower risk for abuse but...?
Narcan intranasal dosing?
4mg/0.1ml intranasally.
Name 2 medications to give in opioid induced constipation with dosing and 1 alternate option if the first 2 medications are ineffective.
Methylnaltrexone, lubiprostone, naloxegol, naldemedine are all second line choices.
True or False? Tolerance is a physiologic phenomenon?
True.
True or False? Most standard immunoassays detect semisynthetic or synthetic opioids?
What is False. need to order confirmatory gas chromatography.
How much is the TDD increased for patients still having mild-moderate pain? How about severe pain? Answer both for full points.
mild to moderate: increase TDD by 25-50%
severe: increase by 50-100%
(any TDD increase 20% or less will no demonstrate clinical benefit).
What is the IM dosing for naloxone and how often should doses be repeated if the patient has a pulse but is not breathing effectively?
0.4mg IM may repeat dose every 4 minutes.
immediate discontinuation of opioids without tapering may be indicated when:
patient has aberrant behaviors, diversion, rx forgery, multisourcing, overdoses.
What are the 4 A's of monitoring?
Analgesia, ADLs, AEs and Aberrant drug taking behavior.
What are the total score sequences for opioid risk tool categories? Low, Medium and High?
Low: 0-3, Medium: 4-7, High: 8 or more.
Typical starting doses in opioid naïve patients? for hydrocodone, morphine, oxycodone and hydromorphone.
Norco: 5/325-10/650 Q6H PO PRN, no IV
Morphine: 2-4mg IV Q4H PRN, no PO
Oxycodone: IR 5-10mg PO Q6H PRN, no IV
Hydromorphone: 2-4mg PO Q6H PRN, 0.4-0.8mg Q4H PRN IV
What two medications are used to treat opioid use disorders?
Methadone and Buprenorphine
How much should an opioid dose be reduced by if a normal patient has an adequate pain control on their current regimen?
30%.
This psychologic phenomenon occurs with compulsive need to use an opioid despite known harms.
Addiction (opioid use disorder).
What is the purpose of a pain agreement form?
provide informed consent, limit opioid abuse potential, monitor adherence and improve efficiency of treatment program.
Calculate the OME for the following:
Oxycodone 10mg PO x 4 doses
Hydromorphone 1mg IV x 3 doses
Morphine 5 mg IV x 1 dose.
Please use OME sheet given on exam on slide: 115 of pain lecture.
135mg OME, 4.5 MMEs.
history of overdose patients, high opioid dose patients, history of substance disorder, concurrent benzo use, Respiratory conditions, poor mental health.
When should an opioid patient be rapid tapered? When should they be gradually tapered? What are the tapering instructions for each?
Rapid tapering: if non adherent to pain contract, experiencing major adverse effects. Reduce dose by 25% per day until daily dose is equivalent to 45-60mg OME then decrease by 25% every 3-5 days.
Gradual tapering: opioid induced hyperalgesia occurs, functional goals are not met/efficacy, persistent adverse effects occur despite rotation. Reduce TDD by 10-25% every 1-4 weeks.
What is patient controlled analgesia (PCA)? Advantages/disadvantages?
electrical pump that allows patient to deliver control doses of IV opiods to themselves. Advantage: faster pt access to pain meds, enhanced control. Disadvantages: pt must be at capacity to use, no friends and family pressing, pt must be able to recognize pain.
Breakthrough dosing are typically what % of TDD?
10-20%