Poor Opioid Responsiveness

If dose escalation results in adverse effects

(4)

Better side effect management

Pcol strategy to low opioid requirement

Opioid Rotation

Non-pcol strategu to low opioid requirement

Opioid Rotation

When is it Used?

Medication Dose (6)

Used when doses become excessive or when SE are intolerable

1.  Reduce equianalgesic dose by 25-50% with provisos

2.  Reduce less if pain is severe

3.  Reduce more if medically frail

4.  Reduce less if same drug by different route

5.  Reduce fentanyl less

6.  Reduce methadone more:  75-90%

Opioid Equivalents Calculation

4 steps

1.  Calculate total daily dose of current opioid

2.  Look up equivalent ratio of new opioid

3.  convert to new opioid using ratio

4.  Divide total daily dose of the new opioid based on dosing frequency of product selected

Individual Agents and Dosage Forms

Immediate Release Morphine

Concentrated Liquid

Hydromorphone

Oxycodone

Methadone

MSIR, Roxanol (10mg/5mL, 20mg/5mL)

Roxanol-T (20mg/mL)

Dilaudid-5 (5mg/5mL)

Roxicodone (5mg/5mL, 20mg/mL)

Methadone (5mg/5mL, 10mg/mL)

Immediate-release Morphine

Use (2)

Ideal for treating breakthrough pain

Start with 10-15% of daily dose

Controlled Release Morphine

Dosing

MS-Contin

Duramorph SR

Kadian

15, 30, 60, 100, 200 mg tab q8-12 hrs

30, 60, 100 mg tabletsq8-12 hrs

10, 20, 30, 50, 60, 80, 100, 200 mg capsules q 24 hrs

Controlled Release Morphine

Avinze Capsules

Contains both IR and ER beads

30, 60, 90, 120 mg capsules

Every 24 hours dosing ONLY

Contents of capsules can be sprinkled in applesauce

Beads should NOT be chewed, crushed, or dissolved

Embeda

Contents

Dosing

Morphine + Naltrexone

20, 30, 50, 60, 80, 100 mg ER capsules

Every 12-24 hours dosing

Contents of capsules can be sprinkled on applesauce

Naltrexone ONLY ACTIVE WHEN CRUSHED

Controlled Realse Oxycodone

OxyContin Tablets

Immediate Release Oxycodone

OxyIR Capsules

10, 20, 40, 80, 160 mg tablets q 12 hrs

5 mg q 4 hours

Oxycontin Toxicity

No known build up of toxic metabolites in patients with decreased GFR

Controlled Released Oxymorphone

Opana ER

Immediate Released Oxymorphone

Opana

5, 10, 20, 40 mg q 12 hours (Adjust dose q 3-7 days)

5, 10 mg q 4 hours

Fentanyl (Duragesic)

Dosing

Application Technique

12, 25, 50, 75, 100 mcg/hr

Patch applied every 72 hours (some patients q 48 hrs)

Clip, do NOT shave hair

Press and hold patch in place for 30 seconds

Rotate application sites

Only one layer of clothing should cover the patch

Dispose of patches properly

Fentanyl (Duragesic)

Risk of Abuse

80% of drug left in patch

"Chiclets"

Fentanyl (Duragesic)

Special Dosing

Start elderly/debilitated patients on 25 mcg uncless > 135 mg of MS per day

Increase dose no more frequently than q 6 days

May be less risk of constipation d/t bypass of opiate receptors in GI tract

Buccal/SL/Nasal Fentanyl

Dosages for different products NOT equivalent

Actiq-Oral Fentanyl

Indication

Dosing

Indicated for breakthrough pain in cancer patients already on chronic opioids

100, 200, 300, 400 mcg

Start with 200 mcg

Strict packaging, storage, and disposal requirements

Fentora-Buccal Fentanyl tablet

Approximate 1/2 is absorbed directly from buccal mucosa

100-800 mcg strengths

indicated for breakthrough pain

Start with 100 mcg strength

 At 30 minutes, swallow any remaining tablet with water

Re-dosing may occur after 30 minutes

DO NOT PUSH THROUGH BLISTER PAK

Lazanda-Fentanyl Nasal Spray (CII)

Management of breakthrough pain in opioid tolerant cancer patients

1 dose no more than every 2 hours (1 spray in 1 nostril = dose)

There are signals to indicate a complete-dose delivery of a full spray

A visual signal appears on dosing counting window, showing the number of doses taken

An audilble signal provides a click sound when complete dose is given

Abstral-Fentanyl SL tablets

For breakthrough pain

100, 200, 300, 400, 600 mcg

Re-dosing may occur after 30 minutes

Onsolis-Fentanyl Buccal Soluble Film

For breakthrough pain

200, 400, 600, 800, 1200 mcg

Re-dosing may occur after 30 minutes

ONLY available in speciality pharmacy

Press and hold to side of cheek for 5 seconds

May consume liquids after 5 minutes

May repeat dose after 2 hours

Methadone

MOA (4)

Bind to mu opioid receptors

Antagonist at the NMDA receptor (blocking reuptake of NE and serotonin)

Highly lipophilic and protein bound

Metabolism varies greatly between patients

Methadone

Dosing

Delayed onset of SE up to 1 week

TCAs and SSRIs can slow metabolism

Duration of analgesic effect = 6-12 hours

Some patients can be dosed q 8 hours at lower cost

Methadone

Avoid in Patients (5)

w/ very limited prognosis (< 1 week)

w/ numerous DIs

at risk for syncope or arrhythmias

w/ history of undpredictable adherence

who live alone, poor cognition

Methadone

Consider for patients (6)

w/ true morphine allergy

w/ significant renal impairment

w/ opioid-induced ADRs

w/ pain refractory to other opioids

w/ neuropathic pain

who need long acting oral dosage forms at a low costr

Tapentadol-Nucynta (CII)

MOA

Dosing

Tepentadol-Nucynta ER

Dosing

Weak mu agonist + inhibits NE reuptake

50, 75, 100 mg IR tablets q 4-6 hours (600 mg max)

50, 100, 200, 250 mg ER tablets q 12 hours (500 mg max)

Buprenorphine Patch

MOA

Toxicity

Dosing

Administration

5, 10, 20 mcg/hr

High dose associated with QT prolongation

Partial agonist at mu receptor antagonist at kappa receptor

Indicated for moderate to severe chronic pain

Taper pt on ATC opioids no more than 30 mg morphine prior to starting Butran

Patch worn for 7 days

Apply to same site no more than q 3 weeks

Dose adjustment no more than q 3 days

Serum concentration decrease 50% in 24 hours once removed