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24 Cards in this Set
- Front
- Back
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No ceiling effect (codeine? Fx dose ceiling w/constip take ....
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<400mg day
<100mg dose |
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Pure (Full) Agonists
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Fentanyl, Hydrocodone, Morphine, Methadone, Oxycodone, Oxymorphone
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Agonist-Antagonists
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butorphanol,nalbuphine, pentazocine
block mu, activate kappa |
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Partial Agonist
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Buprenorphine
celing, reverse pure ag effects |
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Antagonists
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Reverse or block agonist effects of pure opioids
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Advantage of Time-Contingent Dosing
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Prevents need for routine PRN use
Minimizes centrally mediated pain processese |
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Long Acting Oral Opioids (3)
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methadone
levorphanol morphine MS contin Kadian Morphine ER OxyContin |
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Adjust opioid dose ____ (once steady state reached)
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2-4 days
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Adjust methadone dose no more frequently than ____ days in most patients
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4–7 days
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Guideline for increasing opioid dose w/uncontrolled pain....say 10mg MSContin
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Increase total daily dose of opioid by 25-50%.
BTP 10% of daily dose |
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Dose escalation
Mild to moderate pain continues after 24 hours increase the routine dose by ____ Severe or uncontrolled pain Adjust more quickly for severe uncontrolled pain 6 is top of moderate pain, maybe severe Can increase after 1 or 2 doses (eg, crescendo pain) Increase the routine dose by ____ If using time contingent approach with PRN analgesics Increase by an amount at least equal to the total dose of PRN medication used during the previous ____. |
25% to 50%
50% to 100% 24 hrs |
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Opioid Hypersensitivity
Phenylpiperidines =? Phenylheptylamines =? Could have x-hypersensitivity with these Mixed Agonist-Antagonist |
Meperidine like: synthetic
Meperidine, Fentanyl, Sufentanil, Alfentanil methadone-like: synthetic methadone, propoxyphene Pentazocine Butorphanol Nalbuphine Buprenorphine* Dezocine |
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Explain
Tolerance to Analgesia, Resp depression, and constipation |
Tolerance to Analgesia
may occur in first DAYS to WEEKS of therapy; rare after pain relief achieved with consistent dosing without increasing or new pathology. Tolerance to Respiratory Depression and Sedation occurs predictably after 5-7 DAYS of consistent opioid administration Tolerance to Constipation does not occur; scheduled stimulating laxatives are indicated with regularly scheduled opioids |
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Opioid-Induced Neurotoxicity (OIN)
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Neuropsychiatric syndrome characterized by:
Cognitive dysfunction Delirium Hallucinations Myoclonus/seizures Hyperalgesia/allodynia |
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if oliguria or anuria in morphine tx...what do you do?
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STOP routine dosing of morphine
use ONLY prn |
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Opioid Metabolites, active and their effect
metabolites are primary cause for OIN |
Morphine-6-glucuronide = analgesic
Morphine-3-glucuronide (antianalgesic – problem if renal or hep fail) Normorphine-neurotoxic Noroxycodone-neurotoxic Oxymorphone-Opana Norfentanyl Nor = neurotoxic |
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OIN: Treatment
Two approaches Primary drug changes |
Opioid rotation
Change route Primary drug changes --Morphine / hydromorphone/oxycodone Second line agents Fentanyl/methadone Reduce opioid dose Hydration Circadian modulation Psychostimulants Emerging TX’s |
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Tables do not account for incomplete cross-tolerance between opioids
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25 - 50% dose reduction if changing drug where patient has had good analgesic response
No dose reduction may be necessary if patient with continuing pain problems or worsening in pain prior to conversion Methadone is an exception! |
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Methadone
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Extremely long half-life (24-36+ hours)
Use caution on days 2-5 of dosing Generally not first line therapy Morphine : Methadone 10+ : 1 |
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Components to a PCA Order
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Drug and Concentration
Route Loading Dose Demand or PCA Dose (mg) Basal or Continuous Rate (mg/hr) Demand Dose Lockout or Delay (min) 1 or 4 Hour Dose Limit |
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Lockout Interval:
Dose Limit: Basal/Continuous Dose |
Period during which the PCA will not deliver another dose despite demands by patient.
Amount of drug a patient can receive over typically 4 hours. Acute Pain: Use 1/3 average hourly usage (>12hours) Chronic Pain: Use up to 2/3 average hourly usage Attempt to keep an average of 2-3 successful demand doses per hour |
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Spinal Opioid Administration
Epidural Intrathecal |
outside of the dura
epidural space is a vascular potential space drug must crosses dura to reach CNS subdural, subarachnoid drug delivered directly into the cerebrospinal fluid drug delivered very near to opioid receptors |
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Spinal Analgesic Duration & Spread
Determined by physicochemical characteristics of the drug low lipophilicity more lipophilic high lipophilicity |
prolonged and widespread activity drug, morphine
intermediate duration and spread, methadone short duration and limited spread, fentanyl |
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Epidural approximately 1/10th IV dosing
Intrathecal (IT) approximately 1/10th Epidural dosing 10 mg IV = 1 mg Epidural = 0.1 mg IT |
reminder only
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