Goals

2. Goals • Discuss possible pain intervention for CRIT case • Describe opioid side effects • Initiate opioid therapy, convert from iv to po and calculate breakthrough dosing

3. Case Mrs. HH. is an 84-year old woman admitted with perforated diverticulitis, awaiting surgery. How do you treat her pain?

4. Opioid initiation In opioid naïve patient: • Max. effect iv morphine: 5 min • Max. effect sc morphine: 30-60 min • Max. effect po morphine: 1 hour Once you have steady state: T ½ is 4-6 hours for short acting opioids

5. Opioid side effects • Constipation • Fatigue/Drowsiness/Sedation • Nausea/Vomiting • Pruritus • Hypotension • Confusion/Delirium • Urinary retention • Myoclonus • Respiratory depression

6. Opioid conversion and breakthrough dosing • 2mg/hour x 24 hours = 48 mg/day iv (for ease of calculation let’s assume 50mg/day) • Conversion iv:po Morphine: 1:3 • 50 mg/day iv = 150 mg/day po • MS Contin is 12 hourly formulation (divide daily dose by 2) = 75 mg MS Contin bid • Breakthrough (10-20% of daily dose): 15-30 mg q 4h PRN breakthrough pain

7. Pearls • Treat acute pain with short-acting medication until you achieve pain control, then convert to long-acting • Keep it simple (use same opioid for scheduled and PRN) • Demented/delirious patients don’t ask for pain medication: if you think they have pain, schedule the analgesia and avoid PRN only

8. Pearls • Patients with renal insufficiency become toxic easily – better opioid choices for them are oxycodone and hydromorphone • Do not forget to treat constipation • Do ask your pharmacist for help if you worry about conversions • NEVER use Propoxyphene or Meperidine

9. Summary • Treat pain adequately, ideally by mouth and scheduled • Keep it simple • Monitor and treat side effects • Educate families