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Pain Policy Update Opioid Update

Pain Policy Update Opioid Update. Stuart Beatty, PharmD, BCPS. Opioids. Tramadol (Ultram) Not scheduled (still abused) SNRI activity works for neuropathic pain Risk of seizures Interaction with SSRIs (serotonin syndrome). Opioids. Schedule III-IV Codeine, Propoxyphene, Hydrocodone

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Pain Policy Update Opioid Update

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  1. Pain Policy UpdateOpioid Update Stuart Beatty, PharmD, BCPS

  2. Opioids • Tramadol (Ultram) • Not scheduled (still abused) • SNRI activity works for neuropathic pain • Risk of seizures • Interaction with SSRIs (serotonin syndrome)

  3. Opioids Schedule III-IV • Codeine, Propoxyphene, Hydrocodone • Can call Rx in; 5 refills Schedule II • Oxycodone, Morphine, Methadone, Fentanyl, Oxymorphone, Hydromorphone • Must have written Rx; No refills All patient should receive Senna S or Peri-Colace

  4. Opioids • Codeine (Tylenol #3) • Low amount of APAP (300mg/tablet) • More constipation than others • Propoxyphene (Darvocet) • High APAP dose (650mg/tablet) • Metabolite accumulates in renal dysfunction • DO NOT USE!!!

  5. Opioids • Hydrocodone (Lortab, Vicodin, Norco) • APAP ranges from 325-750mg/tablet (Norco has lowest amount) • Street value, abuse

  6. Opioids • Oxycodone (Percocet, Oxycontin) • Immediate release available + APAP • Sustained release should be dose Q12H • Can be crushed to remove time release • Street value, abuse

  7. Opioids • Morphine (MS Contin, Avinza, Kadian) • Lots of dosage forms (immediate and time release) • Active metabolite can accumulate in renal dysfunction • Hydromorphone (Dilaudid) • Short-acting only • Very potent

  8. Opioids • Fentanyl • Patch allows Q72H steady release • DO NOT USE IN CACHETIC PATIENTS • Methadone • Long t½ makes it good long-acting option • May cause QT prolongation • Need to wait 3-5 days to adjust dose • Action at NMDA receptor treats neuropathic pain

  9. Chronic Non-Malignant Pain Policy • 2006 • Pain Registry • 38% violations • 2007 • Move to Martha Morehouse / EMR • 2008 • Revised and reimplemented • 2009 • Current policy introduced

  10. Current Policy • NO NEW PATIENTS RECEVING CHRONIC NARCOTICS • Exceptions: • Discharged from GIM service

  11. Controlled Substance Agreement

  12. Policy Requirements • Signed agreement annually (chronic controlled substances = BZD & opioids) • JULY/AUGUST/SEPTEMBER – renew everyone!!! • Review policy with patient • Signed by patient, resident, attending • Scanned into chart • Document under problem list date updated

  13. Urine Toxicology • Needs to be obtained annually when agreement is signed • May be requested by prescriber during any office visit • MUST BE OBTAINED IN CLINIC!!! • Results will take up to 24 hours • Failure to give urine when requested is considered a policy violation

  14. Included in database All controlled substance (II-V) prescriptions Carisoprodol prescriptions Tramadol prescriptions Excluded from database Out-of-state pharmacy Government pharmacy (e.g., VA, IHS) Physician dispensed Inpatient, nursing home, ED administered ED dispensed < 24 hr supply C-V OTC sales OARXRS Should be requested annually when agreement is signed. May be requested during any office visit. Attendings should have access

  15. Interpreting Urine Screens Mayo Clin Proc. 2008;83(1)66-76

  16. Interpreting Urine Screens - Others Mayo Clin Proc. 2008;83(1)66-76

  17. Interpreting Urine Screens Mayo Clin Proc. 2008;83(1)66-76

  18. Opioid Conversion Determine daily opioid use (LA only)

  19. Opioid Conversion Calculate the 24 hour morphine equivalent Current Opioid 24 hr dose of current opioid (from conversion table) Morphine Equivalent 24 hr dose of morphine* (X) (from conversion table) *Use chart if converting to methadone

  20. Opioid Conversion Convert to daily methadone

  21. Opioid Conversion • Begin methadone at BID or TID (available in 5 mg and 10 mg tablets) • 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days) • When in doubt, go conservative!!! • Follow-up appropriately and be prepared to titrate!!! • Patient will still need short-acting • Likely require the same to more tablets while converting

  22. Opioid Conversion Example Patient is taking Oxycontin 60mg TID and Percocet TID PRN daily.

  23. Opioid Conversion Calculate the 24 hour morphine equivalent Current Opioid 24 hr dose of current opioid (from conversion table) Oxycodone – 20 mg Oxycodone – 180 mg Morphine Equivalent 24 hr dose of morphine* (X) (from conversion table) Morphine – 30 mg Morp Eq. = x = 270 mg *Use chart if converting to methadone

  24. Opioid Conversion Convert to daily methadone 270 mg Morph Eq. = 54 mg methadone

  25. Opioid Conversion • Begin methadone at BID or TID (available in 5 mg and 10 mg tablets) • 3-5 days needed to reach steady-state (follow up phone call or visit at 2-3 days) • When in doubt, go conservative!!! • Follow-up appropriately and be prepared to titrate!!! • Patient will still need short-acting • Likely require the same to more tablets while converting Methadone 15mg TID + Percocet 5/325

  26. QUESTIONS ???

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