Cory Taylor, MD
January 15, 2016
56 year-old veteran with obstructive sleep
apnea presents with subacute abdominal
pain. CT findings are concerning for
gastric adenocarcinoma. The patient is
complaining of 10/10 pain and the nurse
wants to know what you would like to give
him…
 Understand
practical pharmacology behind
selecting dose amounts and frequencies
 Appreciate
the different ways of making
opioids available to patients
 Bring
balance to the Force and order to your
opioid selection
 Prepare
for the possible respiratory side
effects of opioid administration

Onset: informs the dose amount
 IV speed of onset (fastest-slowest)
 Fentanyl ≈ Heroin : Dilaudid : Morphine
 PO speed of onset (fastest-slowest)
 Oxycodone ≈ Dilaudid : Morphine ≈ Hydrocodone ≈ Codeine*
 IV time to max efficacy = 10 min
 PO time to max efficacy = 60 min

Duration: informs the dose frequency
 Dilaudid, Morphine, Hydrocodone, Oxycodone = 4 hours*

Practically Speaking…
• Opioids should be dosed at least Q4H to prevent gaps in the
maintenance of pain control
 PRN or “As
• PROS
Needed” Dosing
 Patient triggered – they can only get what they ask for
 Added layer of overdose protection
 Set it and forget it – less thought, faster ordering
• CONS
 Time to administration can take 30-60 min depending on staff
 Leads to coverage gaps, poorly controlled pain
 Makes patient’s feel dependent, disempowered, or “seeking”
 Creates nursing-patient tension => increased nursing stress
 Overlooks altered or less verbal patients
 Interferes with patient sleep
 Around-the-clock
or “Scheduled” Dosing
• PROS




Better coverage, better control, better sleep
Patients are empowered – reduces patient/nursing tension
Easier on nursing workflow
Don’t need, don’t want: patients can always refuse
• CONS
 Need holding parameters*
 Dynamically inflexible with changes in metabolism or
mental status
 Takes more time and thought
 Basal-Breakthrough
Dosing
 ATC dose provides basal coverage
 PRN dose covers breakthrough pain
• PROS
 Less nursing pages
 Better satisfaction scores
• CONS
 More time ordering, thinking
 Can increase demands on nursing staff*

Enter the PCA
• Best of every world
 Patient finally feels some control over their illness
 Nursing can set and forget
 Doctor can set and [sort-of] forget
• Responsiveness + Precision => Finesse




Smaller doses, greater frequencies, immediate delivery
Allows for precise and expeditious titration up or down
No coverage gaps
Streamlines opioid consolidation and conversion
• No safer alternative than Bolus-only PCA*
• CONS
 Requires cognitive function and trigger-ability
 Parenteral administration only
 # 1: Opioid Solidarity
• Stick to a single opioid type
• Less medication errors
• Easier for titration and conversion
 # 2: Opioid Equivalency
• No one opioid activates receptors better than others
• Some opioids are more potent, but potency can be
overcome by concentration
• But some patients will maintain that one opioid
“works better for me” than another…
 Opioids
are more like loop diuretics than
antibiotics
 With antibiotics, one may “cover” the patient’s infection
where another fails
 With opioids – Morphine : Lasix as Dilaudid : Bumex*
 Consequences of sub-optimal utilization
• Can inadvertently reinforce drug-anchoring or drug-
seeking behaviors
• Can detract from future encounters and therapeutic
relationships
You give the patient an basal-breakthrough
opioid regimen. Later on that night, the
nurses calls to inform you the patient’s
oxygen saturation is 80%. He wants to
know if you should dial back on the
opioids…
See Notes Section for Discussion
 Not
all opioid-related sleep is opioid
narcosis
 Opioid-induced narcosis produces resistant or refractory
somnolence
 Healthy opioid-related sleep in wake-able
 Opioid
overdose always leads to
somnolence before respiratory failure
 Respiratory failure is caused by decreased respiratory
drive*
 Keep in mind: respiratory rates of 8-10 are normal in
healthy individuals


Responsiveness to naloxone in altered mental
status is not diagnostic for opioid-narcosis
Naloxone blocks the body’s natural endorphinmediated suppression of pain
• Can cause pain and discomfort, even in healthy individuals
Responsiveness to naloxone = responsiveness to noxious stimulus


Morphine SR + percocet for breakthrough
Morphine IVP PRN for moderate pain + Dilaudid IVP
PRN for severe pain

Fentanyl drip + oral dilaudid q6h as needed

Norco q4H ATC + Norco Q2H PRN

Oxycontin + tramadol
See additional slides for supplemental material*
EQUIANALGESIC DOSING GUIDELINES FOR CHRONIC PAIN
CHANGING ROUTES OF ADMINISTRATION
PO/PR
IV/SC/IM
3
1
CHANGING ANALGESICS
OPIOIDS
Enteral Dose
Analgesic
(Oral, Rectal)
150
Meperidine
150
Tramadol
150
Codeine
15
Hydrocodone
15
Morphine
10
Oxycodone
5
Oxymorphone
3
Hydromorphone
2
Levorphanol
Fentanyl
*1000 mcg = 1 mg: must convert to mg to calculate equianalgesic dose
Epidural
0.1
Intrathecal
0.01
Parenteral Dose
(SC/IV/IM)
50
50
5
1
1
0.050 mg*
TRANSDERMAL FENTANYL
METHADONE
Daily Morphine Dose
(mg/24 hrs PO)
< 100
101 - 300
301 - 600
601 - 800
801 - 1000
> 1000
> 2000 - 5000
> 5000
Conversion Rates
Morphine PO
Methadone PO
3
1
5
1
10
1
12
1
15
1
20
1
40
1
80
1
METHADONE SC DOSING
1. Convert from daily Morphine Equivalent PO Dose / 24 hrs to Methadone
PO Dose / 24 hrs using the Methadone PO Dosing Table above
2. Then ÷ 2 to convert to Methadone SC Dose/24 hrs
ADJUSTING FOR INCOMPLETE CROSS TOLERANCE
Complete
Near-complete
Incomplete
Morphine 50 mg PO in 24 hrs ≈ Fentanyl 25 mcg transdermal patch q 72 hrs
Ferris FD and Pirrello RD: Improving Equianalgesic Dosing for Chronic Pain Management, American Association for Cancer Education Annual Meeting,
oral presentation, Cincinnati, Ohio, September 2005
These are guidelines only and do not replace clinical judgement. © International Programs, OhioHealth, 2013.
Permission to reproduce material is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed
To reproduce for all other purposes, contact The International Programs at 1-888-278-6615 or visit IPCRC.net
100%
75%
33-50%
 Faster
onset, time to peak, and other
factors can increase the euphoria
associated with a given opioid
 Euphoria
is sometimes mistakenly
perceived by patients as increased
efficacy
• => increased drug-anchoring/requesting
behaviors
• Euphoria ~> dependency, STREET VALUE
 Not
all aberrant behavior is drug-seeking
behavior
• Traffickers are not always abusers
 Desperate
or anchoring behavior ≠ “drugseeking” behavior
• Legitimate patients with undertreated pain or
opioid withdrawal have genuine needs









Negative or discordant urine
drug screen
Inconsistency of story
Splitting
Provider-jumping
Losing prescriptions
RED FLAGS
Poor self-care or selfinvestment
Running out of medication
Haggling or making demands
Irrationality, especially
regarding equivalent doses
YELLOW FLAGS