Managing Pain: A Focus on the Appropriate Use of Methadone
|
|
- Clifton Sparks
- 6 years ago
- Views:
Transcription
1 Managing Pain: A Focus on the Appropriate Use of Methadone Karla Anderson, PharmD Regional Client Liaison Anthony Contreras, RPh Regional Sales Associate Hospice Pharmacia, a division of excellerx, Inc. Office: Disclaimer The information and the materials included in this presentation are intended for educational use. Review or discussion of any agent does not alter in any way the conditions for use contractually agreed upon and outlined in the Hospice Pharmacia Medication Use Guidelines. This program will not be a focus on the Medication Use Guidelines and is intended for educational purposes. Presentation Objectives Describe the mechanism of action, pharmacokinetics, and other properties of methadone. Discuss how to recognize the need for opioid rotation and the practical application of this strategy in the hospice setting. Recognize various patient specific considerations that may influence methadone dosing recommendations. Calculate an equianalgesic dose given a patient case using current methadone dosing guidelines. 1
2 Presentation Overview Mechanism and uses Characteristics of methadone Opioid rotation Methadone dosing Drug interactions and dosing considerations Cases Methadone (Dolophine ) A synthetic opioid developed in Germany Potent and long acting opioid analgesic Chemically unrelated to morphine and semi-synthetic opioids Multiple mechanisms of action Commercially Available Dosage Forms of Methadone Tablets 5mg, 10mg oral tablets 40mg oral disintegrating or water soluble tablets Liquid 10mg/5ml, 10mg/ml Parenteral 10mg/ml for injection 2
3 Methadone Methadone Methadone is in a different chemical class than morphine and related opioids Oxycodone, hydromorphone, hydrocodone, etc. Can be used in patients with true opioid allergies Related to propoxyphene Use with caution in patients who cannot tolerate Darvocet, Darvon, etc. Receptor Effects of Opioid Analgesics Receptor: Mu Morphine High Methadone Low Kappa Morphine High Methadone Low/none Delta Morphine Low/none Methadone High Response: Analgesia, respiratory depression, miosis, euphoria, constipation Analgesia, dysphoria, hallucinations, miosis, respiratory depression Analgesia Oxford Textbook of Palliative Medicine; 2nd edition: 332 Methadone Mechanisms of Action mu and delta receptor agonist Treats cancer and other visceral pain Other opioids act at Mu and Kappa receptors NMDA receptor antagonist Counteracts opioid tolerance, physical dependence, and treats hyperalgesia and allodynia Increases visceral pain relief of opioids NE reuptake inhibitor Useful for neuropathic pain Similar mechanism to tricyclic anti-depressants Very weak Serotonin reuptake inhibitor Support Care Cancer 2001;9:73-83; Oncology 1999;13(9);
4 Methadone for Neuropathic Pain Possibly from combination of methadone s mechanisms Shown effective for PHN, post-stroke pain, diabetic neuropathy, and sciatica pain Pain described as dull, burning, stabbing, tingling, electric-like, etc. Pain in response to non-painful stimuli or nothing at all Hyperalgesia exaggerated response to painful stimulus Allodynia pain produced by normally non-painful stimulus Both are potential consequences of morphine tolerance Additional benefit of methadone Patients experiencing neuropathic pain along with visceral pain Methadone: Characteristics Absorption: Quick onset (30-60min) High bioavailability (approximately 80% of dose by mouth) Can be given PO, PR, IV 1:1 PO to PR conversion 1:2 IV to PO conversion Distribution: Two-Compartment Model Acute Dosing Alpha distribution phase= 2-3 hours Alpha elimination phase = 6-8 hours Chronic Dosing Beta distribution phase = 8-12 hours Betaelimination phase = hours Support Care Cancer 2001;9:73-83 Methadone Variability What s the significance of this variability? We must use caution when dosing methadone An adequate dose for one may be too high for another Methadone can be especially dangerous because of its long half life Rule of thumb with dosing: start low, go slow 4
5 Methadone: Characteristics Metabolism: By CYP3A4 iso-enzyme in the liver CYP1A2 and CYP2D6 to a lesser extent No active metabolites No accumulation in renal insufficiency Elimination: Fecal and urinary excretion Acidifying urine enhances elimination of methadone Methadone: Characteristics Side Effects Nausea, vomiting, euphoria, and respiratory depression Less sedation, constipation, and hallucinations Possible Torsades de Pointes at high doses (>200mg/day) Drug Interactions Inducers and inhibitors of CYP3A4, 2D6, 1A2 Drugs that increase arrhythmia risk Methadone Dosing Considerations Enzyme inhibitors Drug Interactions fluconazole (Diflucan ) ketoconazole erythromycin clarithromycin (Biaxin ) cimetidine (Tagamet ) paroxetine (Paxil ) amiodarone Others Increase methadone levels Enzyme inducers phenobarbital carbamazepine phenytoin (Dilantin ) St. Johns Wort Rifampin Steroids Others Decrease methadone levels 5
6 Drug Interactions Cont. Some medications increase risk for lifethreatening arrhythmias Some examples Amiodarone Chlorpromazine (Thorazine ) Clarithromycin (Biaxin ) Fluoxetine (Prozac ) Haloperidol (Haldol ) Paroxetine (Paxil ) Quinidine Risperidone (Risperdal ) Use cautiously with methadone and with patients at risk for arrhythmias Drug Interactions Cont. Acidifying the urine can increase clearance Acidic medications like Vitamin C Citric foods and juices Half-life and duration of action of methadone can be drastically reduced May see treatment failures requiring higher doses of methadone Patient Specific Factors Severe renal impairment Reduce methadone interval No more often than every 12 hours Hepatic impairment No dose reduction needed for stable chronic liver disease Use with caution in patients with acute liver failure Genetics Some patients are genetically predisposed to metabolize methadone faster or slower than others 6
7 Case #1 68 yo woman notes worsening chest and rib pain caused by non-small cell lung cancer Controlled on long-acting morphine 200mg q12h and 40mg q4h prn for 4 months Added Ibuprofen 800mg TID for bone pain and gradually titrated to Morphine 400mg q12h and 80mg q4h prn Despite the increase in dose and the addition of an NSAID, her pain continues to be uncontrolled, and she is experiencing intolerable hallucinations, thought to be opioid-related What is the Goal? To achieve a better balance between pain relief and side effects In this case, our patient s pain management is not in balance What are Our Therapy Options? Reduction in dose of systemic opioid Aggressive management of the adverse effect Changing route of administration Co-administration of non-opioid or adjuvant Non-pharmacologic interventions Opioid rotation 7
8 What is Opioid Rotation? Simply put, it is switching from one opioid to another Why switch? To achieve better balance Better pain relief Reduction of side effects Current Opinions in Oncol 2000;12: When to Consider Switching Intolerable side effects Development of tolerance Can be rapid Difficult pain syndromes Refractory pain Uncontrolled pain Current Opinions in Oncol 2000;12: Opioid Use in Cancer Pain 80% of cancer patients experience moderate to severe pain Strong opioids usually agents of choice 20% of patients respond poorly to opioids Others have dose limiting toxicities Support Care Cancer 2001:9:
9 Adverse Effects of Morphine Morphine is broken down into several metabolites that can Drowsiness cause mild to severe side effects: Hallucinations Nausea and vomiting Euphoria Respiratory depression Myoclonic spasms Sweating Tonic-clonic seizures Morphine metabolites can accumulate with: -High doses -Repeated morphine dosing -Dehydration -Impaired renal function Current Opinions in Oncol 2000;12: Adverse Effects of Morphine Repeated high doses, dehydration, and renal impairment can all be seen in hospice patients Therefore, these patients are at risk for morphine side effects Methadone does not have active metabolites A viable option for patients experiencing intolerable side effects caused by morphine Methadone Dosing Methadone dosing can be difficult Dosing regimens are numerous and their use controversial High variability between patients Methadone seems to be more potent in patients tolerant to other opioids J of Clinical Oncology 1998;16(10)
10 Age of the patient Methadone Dosing Considerations Previous opioid dose Drug interactions Previous cardiac history with arrhythmia risk Structural cardiac disease Atrial fibrillation Electrolyte abnormalities Hypomagnesemia, hyper- and hypokalemia Common Themes of Methadone Dosing Every 8-12 hour dosing Using methadone for breakthrough pain Onset of action remains consistent Get patient to steady state faster Methadone builds up in system to last longer Using for breakthrough cuts time to steady state Ok to use other medications for breakthrough If previous med works well, ok to keep on board Go with methadone if possible Methadone is compared to morphine Convert all previous pain medications to a morphine equivalent Methadone Dosing Three different guidelines presented here Ripamonti, et al Mercadante et al Hospice Pharmacia 10
11 Ripamonti, et al Dosing guidelines: developed by clinical experience Day 1: Reduce morphine total daily dose by 30% and started oral methadone on a q8h schedule at a ratio of: if morphine TDD is 30-90mg, use a dosing ratio of 4:1 (M:ME) if morphine TDD is mg, use ratio of 6:1 (M:ME) if morphine TDD is >300mg, use ratio of 8:1 (M:ME) Day 2: Reduce morphine by 30%. Increase methadone only if patient is in severe pain. Day 3: Discontinue morphine and continue M=Morphine. ME=Methadone methadone q8h ATC with 10% of dose for BTP Ripamonti, et al Pros Prospective, published study Slow titration off morphine and increase of methadone Clearly defined ratios based on previous morphine dose Accounts for high initial morphine dose Cons Many steps and variables 3 day titration 3-tiered conversion ratio Does not account for drug interactions Does not account for patient specific factors Mercadante et al Dosing guidelines: Stop morphine Immediately substitute methadone at a ratio of: if morphine dose is <90mg, use a ratio of 4:1 (M:ME) if morphine dose is mg, use a ratio of 8:1 (M:ME) if morphine dose is >300mg, use a ratio of 12:1(M:ME) Methadone was given q8h and a breakthrough dose of 1/6 the total daily dose was available Titration was based on breakthrough dosage use M=Morphine. ME=Methadone 11
12 Mercadante et al Pros Simple, 1 step titration Clearly defined ratios based on previous morphine dose Prospective, published study Accounts for higher initial dose of morphine Cons 3-tiered conversion ratio Does not account for drug interactions Does not account for patient specific factors Hospice Pharmacia Either a 10:1 or a 20:1 ratio with morphine:methadone. Based on patient age, total daily morphine equivalent intake, drug interactions, and arrhythmia risk Example: Pt > 65 years old: 20:1 (M:ME) Taking > 1000mg morphine/day: 20:1 (M:ME) Dose reduction of 25% for certain drug interactions Arrhythmia risk with high dose of methadone (>200mg/day): avoid use M=Morphine. ME=Methadone Hospice Pharmacia Dose methadone at q8h scheduled Dose methadone at 1/3 total daily dose q3h prn breakthrough pain (max 30mg/dose) Readjust breakthrough after 7 days to 10% total daily dose if necessary 12
13 Hospice Pharmacia Pros Conservative ratio geared towards hospice patients Takes into account patient specific factors Age Previous morphine dose Drug interactions Arrhythmia risk Evidence taken from many studies Cons Not published in peer reviewed journal Complex dosing conversion Heavily reliance on breakthrough dosing early in treatment Case #1 Revisited 68 y/o woman titrated to Morphine 400mg q12h and 80mg q4h prn 800mg + 480mg = 1280mg morphine/day Severe hallucinations + uncontrolled pain Side effect of morphine and apparent tolerance Let s convert the patient to methadone using the Mercadante method vs. the HP method for comparison Case #1 Mercadante conversion Patient is taking 1280mg morphine/day Stop Dosing morphine protocol immediately 1280mg 12 Dosing calculations = 106mg if morphine dose is <90mg, methadone per day use a ratio of 4:1 (M:ME) 106mg 3 = 35mg q8h if morphine dose is mg, use a ratio of 8:1 (M:ME) scheduled if morphine dose is >300mg, use 1/6 total methadone dose use a ratio of 12:1 (M:ME) as breakthrough q3h prn Methadone given q8h and a 106mg 6 ~ 15mg q3h prn breakthrough dose of 1/6 the breakthrough pain total daily dose was available Final prescription: Methadone 35mg q8h scheduled and 15mg q3h as needed for breakthrough pain 13
14 Case #1 HP Conversion Total daily morphine 1280mg/day Pt > 65 years old. Use 20:1 ratio, every 8 hours No drug interactions or cardiac risk 1280mg 20 = 64mg methadone/day 64mg 3 ~ 20mg q8h scheduled Use 1/3 total methadone dose as breakthrough (max 30mg per dose) 64mg 3 ~ 20mg q3-4h prn breakthrough pain Readjust after 1 week No drug interactions or cardiac risk No further adjustment needed Final prescription: Methadone 20mg q8h scheduled and 20mg q3-4h prn breakthrough pain Case #1 Results Mercadante method results in higher dose than HP 35mg q8h > 20mg q8h Does not make one conversion superior to another Methadone dosing should be individualized for the patient Base on clinical experience Case #2 MP is a 45 y/o male receiving morphine treatment for severe pain secondary to pancreatic cancer PHM significant for CRF and Type I diabetes He describes his pain as a deep stabbing pain with an electric-like shock around and down his back He is receiving morphine LA at 60mg q8h with little to no relief He now reports frequent muscle jerks and spasms in his arms and legs 14
15 Case #2 Is methadone a good choice? Uncontrolled pain Neuropathic pain a component (electric-like) Renal failure with morphine resulting in mycoclonic jerks What dose to recommend Let s use the Ripamonti method Case #2: Ripamonti Dosing protocol Day 1: Reduce morphine total daily dose by 30% and started oral methadone on a q8h schedule at a ratio of: if morphine TDD is 30-90mg, use a dosing ratio of 4:1 (M:ME) if morphine TDD is mg, use ratio of 6:1 if morphine TDD is >300mg, use ratio of 8:1 Day 2: Reduce morphine by 30%. Increase methadone only if patient is in severe pain. Day 3: Discontinue morphine and continue methadone q8h ATC with 10% of daily dose for BTP TDD = Total Daily Dose Patient is taking 180mg morphine/day Dosing calculations Day 1: 180mg morphine/day 30% ~ 135mg morphine/day -> 45mg q8h 180mg morphine/day 6 = 30mg/methadone/day > 10mg q8h Day 2: 135mg morphine/day 30% ~ 90mg morphine/day -> 30mg morph q8h Assess pt s pain for methadone increase Day 3: Stop morphine Assuming pain controlled: methadone 10mg q8h with 5mg q3h prn breakthrough pain Case #2 Results After 3 days, morphine is stopped and methadone is started at 10mg q8h Breakthrough dose is 5mg q3h prn Final prescription: Methadone 10mg po q8h routine and 5mg q3h prn breakthrough pain Methadone is titrated based on patient need 15
16 Conclusion Methadone has several uses and benefits Dosing can be difficult Many patient specific considerations must be taken into account Monitoring for pain relief and side effects are a must Clinical experience plays a large role in dosing methadone References 1. Fishman S, Wilsey B, Mahajan M, Molina O. Methadone reincarnated: Novel Clinical Applications with Related Concerns. Pain Medicine 2002;4: Davis MP, Walsh D. Methadone for relief of cancer pain: a review of pharmacokinetics, pharmacodynamics, drug interactions, and protocols of administration. Support Care Cancer 2001;9: Morley J, Bridson J, Nash T, Miles J, White S, Makin M. Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial. Palliative Medicine 2003;17: Hansen S. Pathophysiology. Foundations of Disease and Clinical Intervention. 1998, pg Price D, Mayer D, Mao J, Caruso F. NMDA-Receptor Antagonists and Opioid Receptor Interactions as Related to Analgesia and Tolerance 6. Mancini I, Lossignol DA, Body JJ. Opioid switch to oral methadone in cancer pain. Current Opinion in Oncology 2000;12: Gillman P K. Monoamine oxidase inhibitors, opioid analgesics, and serotonin toxicity. British Journal Anesthesiology 2005;95:
17 References 8. Lugo R, Satterfield K, Kern S. Pharmacokinetics of Methadone. Journal of Pain and Palliative Care Pharmacotherapy 2005;19(4): Ripamonti C, Groff L, Brunelli C, Polastri D, Stavraski S, De Conno F. Switching from Morphine to Oral Methadone in Treating Cancer Pain: What isthe Equianalgesic Ratio? Journal of Clinical Oncology 1998;16: Mercadante S, Casuccio A, Fulfaro F, Groff L, Boffi R, Villari P, Gebbia V, Ripamonti C. Switching from Morphine to Methadone to improve Analgesia and Tolerability in Cancer Patients: A Prospective Study. Journal of Clinical Oncology 2001;19: Allen W L, et. al. Pharmacogenomics. 2004, pg
ANSWER # 1 PHARMACOLOGY. Methadone answers Stoltzfus 4/5/2012 METHADONE: WHY GRANDMA S TAKING A DIPHENYLHEPTANE (ANSWERS) JANUARY 26, 2017
METHADONE: WHY GRANDMA S TAKING A DIPHENYLHEPTANE (ANSWERS) JANUARY 26, 2017 Ky Stoltzfus, MD Assistant Professor, Internal Medicine University of Kansas Medical Center ANSWER # 1 Your response might be
More informationPain Management Strategies Webinar/Teleconference
Pain Management Strategies Webinar/Teleconference Barry K. Baines, MD April 16, 2009 Objectives Describe the principles of pain management. Identify considerations in the use of opioids. Describe the benefits
More informationOpioid Rotation. Dr Bruno Gagnon, M.D., M.Sc.
Opioid Rotation Dr Bruno Gagnon, M.D., M.Sc. Associate Professor Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval Consultant in Palliative Medicine CHU de Québec-Université
More information6/6/2018. Nalbuphine: Analgesic with a Niche. Mellar P Davis MD FCCP FAAHPM. Summary of Advantages. Summary of Advantages
Nalbuphine: Analgesic with a Niche Mellar P Davis MD FCCP FAAHPM 1 Summary of Advantages Safe in renal failure- fecal excretion Analgesia equal to morphine with fewer side effects Reduced constipation
More informationAppendix D: Drug Tables
Appendix D: Drug Tables A. Short-acting, Orally Administered Opioids Table D-1: Use of Short-acting, Orally Administered Opioids in Adults [198] Additional Maximum APAP dose: 4000 mg/d (2000 mg/d in chronic
More informationMethadone: Essential Hospice Analgesic or Too Risky for Prime Time?
Methadone Background Methadone: Essential Hospice Analgesic or Too Risky for Prime Time? Developed originally as an antispasmodic and later used as an analgesic, starting in late 1940 s Used extensively
More informationOverview of Essentials of Pain Management. Updated 11/2016
0 Overview of Essentials of Pain Management Updated 11/2016 1 Overview of Essentials of Pain Management 1. Assess pain intensity on a 0 10 scale in which 0 = no pain at all and 10 = the worst pain imaginable.
More informationPain in advanced illness
Methadone: Safe and Effective Use for Hospice Pain Management for Adult and Pediatric Patients Nathaniel Hedrick, PharmD ProCare HospiceCare Clinical Pharmacist Nhedrick@procarerx.com Jeremy L. Brown,
More informationAgonists: morphine, fentanyl Agonists-Antagonists: nalbuphine Antagonists: naloxone
Opioid Definition All drugs, natural or synthetic, that bind to opiate receptors Agonists: morphine, fentanyl Agonists-Antagonists: nalbuphine Antagonists: naloxone Opioid agonists increase pain threshold
More informationFighting the Good Fight: How to Convert Opioids Just Right!
Fighting the Good Fight: How to Convert Opioids Just Right! Tanya J. Uritsky, PharmD, BCPS, CPE Clinical Pharmacy Specialist - Pain Medication Stewardship Hospital of the University of Pennsylvania - Philadelphia,
More informationKetamine and Methadone Supra- Regional Audit Presentation
Ketamine and Methadone Supra- Regional Audit Presentation Audit Group: Alison Coackley, Anthony Thompson, Graham Whyte, Helen Bonwick, Ruth Clark, Agnes Noble, Aileen Scott, Andrew Dickman, Sarah Fradsham
More informationPain Management: The Use of Methadone in Hospice and Palliative Care. By: Kiran Hamid, RPh August 16, 2018.
Pain Management: The Use of Methadone in Hospice and Palliative Care By: Kiran Hamid, RPh August 16, 2018. Conflict of Interest and Disclosures of Relevant Financial Relationships The planners and presenters
More informationGUIDELINES FOR CONVERSION FROM A STRONG OPIOID TO METHADONE
GUIDELINES FOR CONVERSION FROM A STRONG OPIOID TO METHADONE GENERAL PRINCIPLES Methadone may be used as a strong opioid alternative when severe cancer-related pain responds poorly to other opioids, or
More informationAdvanced Pain Management LYRA SIHRA MD
Advanced Pain Management LYRA SIHRA MD Objectives Describe the importance of pain management Define the types of pain Discuss opioid pharmacology Identify barriers to pain management Discuss ethical responsibilities
More informationCHAMP: Bedside Teaching TREATING PAIN. Stacie Levine MD. What is the approach to treating pain in the aging adult patient?
CHAMP: Bedside Teaching TREATING PAIN Stacie Levine MD Teaching Trigger: An older adult patient is identified as having pain. Clinical Question: What is the approach to treating pain in the aging adult
More informationLong Term Care Formulary HCD - 08
1 of 5 PREAMBLE Opioids are an important component of the pharmaceutical armamentarium for management of chronic pain. The superiority of analgesic effect of one narcotic over another is not generally
More informationAcute Pain Management in the Hospital Setting. Alexandra Phan, PharmD PGY-1 Pharmacy Practice Resident Medical Center Hospital Odessa, TX
Acute Pain Management in the Hospital Setting Alexandra Phan, PharmD PGY-1 Pharmacy Practice Resident Medical Center Hospital Odessa, TX 2 What is Pain? An unpleasant sensory and emotional experience associated
More informationKetamine and Methadone Supra- Regional Audit Presentation
Ketamine and Methadone Supra- Regional Audit Presentation Audit Group: Alison Coackley, Anthony Thompson, Graham Whyte, Helen Bonwick, Ruth Clark, Agnes Noble, Aileen Scott, Andrew Dickman, Sarah Fradsham
More informationFENTANYL CITRATE TRANSMUCOSAL UTILIZATION MANAGEMENT CRITERIA
FENTANYL CITRATE TRANSMUCOSAL UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAMES: HICL = H3AT Fentanyl citrate transmucosal Actiq (fentanyl citrate) lozenge on a handle 200, 400, 600, 800,
More informationOpioid Case Studies. Thomas P. Pittelkow, D.O., M.P.H. Mayo Clinic College of Medicine Rochester, MN. September 29, MFMER slide-1
Opioid Case Studies Thomas P. Pittelkow, D.O., M.P.H. Mayo Clinic College of Medicine Rochester, MN September 29, 2016 2015 MFMER slide-1 Disclosures Relevant Financial Relationship(s) None Off Label and/or
More informationJim McGregor MD. What s New in Pain and Symptom Management. CAHSAH CHAPCA Annual Conference & Expo May 22 24, 2018, Monterey, CA
What s New in Pain and Symptom Management Jim McGregor MD Play the 2018 Conference Post to Win Game for a chance to win different prizes each day! 1 Objectives Describe patients who are appropriate for
More informationEnd-of-Life Pain Management: How to do it right Wayne Kohan MD Medical Director Chaplaincy Hospice Care
End-of-Life Pain Management: How to do it right Wayne Kohan MD Medical Director Chaplaincy Hospice Care Objectives Discuss the rational use of opioid medications, including dosing and dose titration, routes
More informationGUIDELINES AND AUDIT IMPLEMENTATION NETWORK
GUIDELINES AND AUDIT IMPLEMENTATION NETWORK General Palliative Care Guidelines The Management of Pain at the End Of Life November 2010 Aim To provide a user friendly, evidence based guide for the management
More informationNuplazid. (pimavanserin) New Product Slideshow
Nuplazid (pimavanserin) New Product Slideshow Introduction Brand name: Nuplazid Generic name: Pimavanserin Pharmacological class: Atypical antipsychotic Strength and Formulation: 17mg; tablets Manufacturer:
More informationOPIOID- INDUCED NEUROTOXICITY*
OPIOID- INDUCED NEUROTOXICITY* Sriram Yennu MD, MS, FAAHPM Palliative Care, Rehabilitation and Integrative Medicine U.T. M.D. Anderson Cancer Center *Slide Deck courtesy Dept PRIM MDACC PATIENT #1: MRS
More informationOP01 [Mar96] With regards to pethidine s physical properties: A. It has an octanol coefficient of 10 B. It has a pka of 8.4
Opioid MCQ OP01 [Mar96] With regards to pethidine s physical properties: A. It has an octanol coefficient of 10 B. It has a pka of 8.4 OP02 [Mar96] Which factor does NOT predispose to bradycardia with
More informationOpioid Pearls and Acute Pain Management
Opioid Pearls and Acute Pain Management Jeanie Youngwerth, MD University of Colorado Denver Assistant Professor of Medicine, Hospitalist Associate Director, Colorado Palliative Medicine Fellowship Program
More informationIF I M NOT TREATING WITH OPIOIDS, THEN WHAT AM I SUPPOSED TO USE?
NON-OPIOID TREATMENT OPTIONS FOR CHRONIC PAIN Alison Knutson, PharmD, BCACP Medication Management Pharmacist Park Nicollet Creekside Clinic Dr. Knutson indicated no potential conflict of interest to this
More informationPharmacogenetics of Codeine. Lily Mulugeta, Pharm.D Office of Clinical Pharmacology Pediatric Group FDA
Pharmacogenetics of Codeine Lily Mulugeta, Pharm.D Office of Clinical Pharmacology Pediatric Group FDA 1 Codeine Overview Naturally occurring opium alkaloid Demethylated to morphine for analgesic effect
More informationAmber D. Hartman, PharmD Specialty Practice Pharmacist James Cancer Center & Solove Research Institute Ohio State University Medical Center
Pharmacologic Management of Pain Amber D. Hartman, PharmD Specialty Practice Pharmacist James Cancer Center & Solove Research Institute Ohio State University Medical Center Objectives Identify types of
More informationMethadone Maintenance
Methadone Maintenance A Practical Guide to Pharmacotherapy Methadone/Buprenorphine 101 Workshop, April 1, 2017 Ron Joe, MD, DABAM Objectives I. Pharmacology Of Methadone II. Practical Application of Pharmacology
More informationWhat Do You Mean The Morphine Isn t Working? Objectives. Opioid Epidemic. Ellen Fulp, PharmD, BCGP Clinical Education Coordinator AvaCare, Inc.
What Do You Mean The Morphine Isn t Working? Ellen Fulp, PharmD, BCGP Clinical Education Coordinator AvaCare, Inc. 42 nd Annual Hospice & Palliative Care Conference September 2018 Charlotte, NC Objectives
More informationSlide 1. Slide 2. Slide 3. Opioid (Narcotic) Analgesics and Antagonists. Lesson 6.1. Lesson 6.1. Opioid (Narcotic) Analgesics and Antagonists
Slide 1 Opioid (Narcotic) Analgesics and Antagonists Chapter 6 1 Slide 2 Lesson 6.1 Opioid (Narcotic) Analgesics and Antagonists 1. Explain the classification, mechanism of action, and pharmacokinetics
More informationPALLIATIVE TREATMENT BY DR. KHRONGKAMOL SIHABAN MEDICAL ONCOLOGIST
PALLIATIVE TREATMENT BY DR. KHRONGKAMOL SIHABAN MEDICAL ONCOLOGIST TREATMENT IN ONCOLOGY Main treatment : surgery Neoadjuvant treatment : RT, CMT Adjuvant treatment : Tx micrometastatic disease -CMT,Targeted
More informationBJF Acute Pain Team Formulary Group
Title Analgesia Guidelines for Acute Pain Management (Adults) in BGH Document Type Issue no Clinical guideline Clinical Governance Support Team Use Issue date April 2013 Review date April 2015 Distribution
More informationGUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS
GUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS Bristol Palliative Care Collaborative Contact Numbers: Hospital Specialist Palliative Care Teams: North Bristol 0117 4146392 UH Bristol 0117
More informationClinical Guideline. Guidelines for the use of opioid analgesics in the management of acute pain in adults
Clinical Guideline Guidelines for the use of opioid analgesics in the management of acute pain in adults Document detail Document location West Kent and MTW Formulary Version 1.0 Effective from July 2017
More informationAnalgesia for Patients with Substance Abuse Disorders. Lisa Jennings CN November 2015
Analgesia for Patients with Substance Abuse Disorders Lisa Jennings CN November 2015 Definitions n Addiction: A pattern of drug use characterised by aberrant drug-taking behaviours & the compulsive use
More informationPrescription Pain Management. University of Hawai i Hilo Pre- Nursing Program NURS 203 General Pharmacology Danita 1 Narciso Pharm D
Prescription Pain Management University of Hawai i Hilo Pre- Nursing Program NURS 203 General Pharmacology Danita 1 Narciso Pharm D 2 Objectives Understand how to preform a pain assessment Know which medications
More information1/21/14. Cancer Related Pain: Case-Based Pharmacology. Conflicts of Interest. Learning Objective
Cancer Related Pain: Case-Based Pharmacology Jeannine M. Brant, PhD, APRN, AOCN Oncology Clinical Nurse Specialist Nurse Scientist Billings Clinic Conflicts of Interest Jeannine Brant has served on the
More informationCHRONIC PAIN MANAGEMENT
CHRONIC PAIN MANAGEMENT Betty J Harris, PharmD. 2014 Objectives Explain the consequences of untreated pain. Identify common causes of chronic non-malignant pain in adults. Identify steps to assessing pain,
More informationNEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES
NEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES GENERAL PRINCIPLES Neuropathic pain may be relieved in the majority of patients by multimodal management A careful history and examination are essential.
More informationComedy of Errors: Methadone and Buprenorphine
Comedy of Errors: Methadone and Buprenorphine Douglas Gourlay MD, MSc, FRCP(C), DFASAM Disclosures Nothing to disclosure 2 1 Learning Objectives Explain the pharmacology of methadone and buprenorphine
More informationPain Management Management in Hepatic Hepatic and and Renal Dysfunction
Pain Management in Hepatic and Renal Dysfunction Review the pharmacologic basis for medications used in pain management Identify pain medications which hshould ldbe avoided in patients with hepatic dysfunction
More informationOpioid Conversions Mixture of Science and Art
Opioid Conversions Mixture of Science and Art Matthew J. Pingree, MD Assistant Professor Division of Pain Medicine Physical Medicine and Rehabilitation and Anesthesiology Mayo Clinic, Rochester Pingree.Matthew@Mayo.edu
More informationInterprofessional Webinar Series
Interprofessional Webinar Series Opioids in the Medically Ill: Principles of Administration Russell K. Portenoy, MD Chief Medical Officer MJHS Hospice and Palliative Care Director MJHS Institute for Innovation
More informationPalliative Prescribing - Pain
Palliative Prescribing - Pain LAURA BARNFIELD 21/2/17 Aims To understand the classes of painkillers available in palliative care To gain confidence in counselling regarding opiates To gain confidence prescribing
More informationPalliative Care and the Critical Role of the Pharmacist. Arti Thakerar Education/ Palliative Care Peter MacCallum Cancer Centre
Palliative Care and the Critical Role of the Pharmacist Arti Thakerar Education/ Palliative Care Peter MacCallum Cancer Centre Overview What is palliative care Role of a pharmacist in palliative care Issues
More informationSharon A Stephen, PhD, ARNP, ACHPN. September 23, 2014
Sharon A Stephen, PhD, ARNP, ACHPN September 23, 2014 Case-based presentation selected to discuss: Pain assessment Barriers to adequate pain relief Pharmacologic interventions Non-Pharmacologic interventions
More informationOPIOIDS ARE THE MAINSTAY of moderate to severe
Rapid Switching From Morphine to Methadone in Cancer Patients With Poor Response to Morphine By Sebastiano Mercadante, Alessandra Casuccio, and Luciano Calderone OPIOIDS ARE THE MAINSTAY of moderate to
More informationObjectives. What is pain? 9/27/2017. Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP
Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP Photo credit: http://multiple-sclerosis-research.blogspot.com/2013/10/pain-and-unemployment.html Objectives Consider personal goal of pain management
More informationDomain 1 Pharmacokinetic and pharmacodynamics properties of methadone
Methadone Survey Knowledge Domains: Domain 1 Pharmacokinetic and pharmacodynamics properties of methadone Domain 2 Appropriate/inappropriate candidates for methadone Domain 3 Risk stratification with methadone
More informationOST. Pharmacology & Therapeutics. Leo O. Lanoie, MD, MPH, FCFP, CCSAM, ABAM, MRO
OST Pharmacology & Therapeutics Leo O. Lanoie, MD, MPH, FCFP, CCSAM, ABAM, MRO Disclaimer In the past two years I have received no payment for services from any agency other than government or academic.
More informationMitigating Risks While Optimizing the Benefits of Pharmacologic Agents to Manage Pain in the Elderly
Mitigating Risks While Optimizing the Benefits of Pharmacologic Agents to Manage Pain in the Elderly Mary Lynn McPherson, PharmD, MDE, MA, BCPS, CPE Professor and Executive Director, Advanced Post-Graduate
More informationPalliative and Hospice Care of the Terminally Ill Introduction
Palliative and Hospice Care of the Terminally Ill Introduction There has been an increase in life expectancy for men and women of all races to 77.6 years Leading causes of death in older patients are chronic
More informationPOST OPERATIVE PAIN MANAGEMENT: PAIN AND COMPLICATIONS
POST OPERATIVE PAIN MANAGEMENT: PAIN AND COMPLICATIONS November 9, 2018 Aimee LaMere, CNP Molly McNaughton, CNP Leslie Weide, MSW, LICSW, ACM Disclosures: Conflict of interest statement: We certify that,
More informationB. Long-acting/Extended-release Opioids
4 Opioid tolerance is assumed in patients already taking fentanyl 25 mcg/hr OR daily doses of the following oral agents for 1 week: 60 mg oral morphine, 30 mg oxycodone, 8 mg hydromorphone, 25 mg of oxymorphone
More informationSymptom Management Challenges at End-of-Life
Symptom Management Challenges at End-of-Life Amanda Lovell, PharmD, BCGP Clinical Pharmacist- Inpatient Units Optum Hospice Pharmacy Services February 15, 2018 Hospice Pharmacy Services Objectives Identify
More informationPalliative Care for Primary Care Providers QUYNH BUI, MD MPH DECEMBER 2015
Palliative Care for Primary Care Providers QUYNH BUI, MD MPH DECEMBER 2015 Objectives Define palliative care and primary palliative care Describe the rationale for providing primary palliative care in
More informationJ Clin Oncol 23: by American Society of Clinical Oncology INTRODUCTION
VOLUME 23 NUMBER 22 AUGUST 1 2005 JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T Rapid Switching Between Transdermal Fentanyl and Methadone in Cancer Patients Sebastiano Mercadante, Patrizia
More informationORAL TRANSMUCOSAL AND NASAL FENTANYL UTILIZATION MANAGEMENT CRITERIA
ORAL TRANSMUCOSAL AND NASAL FENTANYL UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAMES: Fentanyl by oral transmucosal and nasal delivery Actiq (fentanyl citrate) lozenge on a handle 200,
More informationAntipsychotics. Something Old, Something New, Something Used to Treat the Blues
Antipsychotics Something Old, Something New, Something Used to Treat the Blues Objectives To provide an overview of the key differences between first and second generation agents To an overview the newer
More informationACCORDING TO WORLD Health Organization
Switching From Morphine to Methadone to Improve Analgesia and Tolerability in Cancer Patients: A Prospective Study By Sebastiano Mercadante, Alessandra Casuccio, Fabio Fulfaro, Liliana Groff, Roberto Boffi,
More informationPain. November 1, 2006 Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine
Pain November 1, 2006 Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine Objectives To be able to define pain To be able to evaluate pain To be able to classify types of pain To learn appropriate
More informationMid Essex Locality Guideline for Management of Adult Acute and Chronic Non-Cancer Pain in Primary care
Guideline for Management of Adult Acute and Chronic Non-Cancer Pain in Primary care If possible patients should be assessed using a simple visual analogue scale VAS to determine the most appropriate stage
More informationArresting Pain without Getting Arrested
G. Jay Westbrook, M.S., R.N., CHPN - Clinical Director Compassionate Journey: An End-of-Life Clinical & Education Service CompassionateJourney@hotmail.com 818/773-3700 Arresting Pain without Getting Arrested
More informationDisclosures. Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals
Anne F. Walsh, MSN, ANP BC, ACHPN, CWOCN Kathleen Broglio, MN, ANP BC, ACHPN, CPE Disclosures Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals
More informationPAIN. TREATMENT TABLES Analgesics. NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose
NON-OPIOID SHORT-ACTING LONG-ACTING **** O PAIN TREATMENT TABLES Analgesics NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose Tramadol 50 mg Ultram Every 4 hours 1-2 tabs,
More informationAcute Pain NETP: SEPTEMBER 2013 COHORT
Acute Pain NETP: SEPTEMBER 2013 COHORT Pain & Suffering an unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage International
More informationA Pain Management Primer for Pharmacists. Jessica Geiger-Hayes, PharmD, BCPS, CPE Andrea Wetshtein, PharmD, BCPS, CPE
A Pain Management Primer for Pharmacists Jessica Geiger-Hayes, PharmD, BCPS, CPE Andrea Wetshtein, PharmD, BCPS, CPE Objectives Discuss the differences between somatic, visceral, and neuropathic pain Design
More informationCancer Pain. Suresh K Reddy, MD,FFARCS The University of Texas MD Anderson Cancer Center
Cancer Pain Suresh K Reddy, MD,FFARCS The University of Texas MD Anderson Cancer Center Prevalence of the Most Common Symptoms in Advanced Cancer (1000 Adults) Symptom % Symptom % Pain 82 Lack of Energy
More informationPAIN PODCAST SHOW NOTES:
PAIN PODCAST SHOW NOTES: Dallas Holladay, DO Ultrasound Fellow Cook County Hospital Rush University Medical Center Jonathan D. Alterie, DO PGY-2, Emergency Medicine Midwestern University An overview of
More information2-ethylidene-1,5-dimethyl-3,3diphenylpyrrolidene (EDDP) Safe in stable liver disease Long acting
2012 AAHPM & HPNA Annual Assembly March 7-10, 2012 Denver, CO Methadone the Taming of the Shrew Stefan J. Friedrichsdorf, M.D. Medical Director Department of Pain Medicine, Palliative Care & Integrative
More informationAustedo. (deutetrabenazine) New Product Slideshow
Austedo (deutetrabenazine) New Product Slideshow Introduction Brand name: Austedo Generic name: Deutetrabenazine Pharmacological class: Vesicular monoamine transporter 2 (VMAT2) inhibitor Strength and
More informationCancer Pain: A Clinical Overview. Linda A. King, MD Section of Palliative Care and Medical Ethics
Cancer Pain: A Clinical Overview Linda A. King, MD Section of Palliative Care and Medical Ethics Objectives Define Palliative Care Review prevalence of cancer pain Know barriers to cancer pain management
More informationReview of Pain Management with Clinical and Regulatory Updates
Review of Pain Management with Clinical and Regulatory Updates Palliative Care Collaborative: 8 th Annual Regional Conference October 10, 2014 Michael Stellini, M.D.,M.S. Medical Director, Hospice and
More informationPain management in palliative care. Dr. Stepanie Lippett and Sister Karen Davies-Linihan
Pain management in palliative care Dr. Stepanie Lippett and Sister Karen Davies-Linihan contents Concept of total pain Steps in pain management Recognising neuropathic pain WHO analgesic ladder Common
More informationPAIN CONSIDERATIONS IN PALLIATIVE CARE
PAIN CONSIDERATIONS IN PALLIATIVE CARE Eric Anderson, MD, Palliative Medicine United Hospital September 22, 2017 DISCLOSURE The presenter has no financial relationships to disclose. OBJECTIVES 1. Name
More informationDrug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA opioid analgesics) Avinza Butrans
FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics 7/9/2012 Drug Information Common to the Class of Extended-Release and Long-Acting Opioid Analgesics (ER/LA
More informationDose equivalent of fentanyl patch to oxycontin
Dose equivalent of fentanyl patch to oxycontin 10-3-2018 Detailed dosage guidelines and administration information for OxyContin (oxycodone hydrochloride). Includes dose adjustments, warnings and precautions.
More informationPharmacologic Considerations for Managing Sickle Cell Pain Claire Saadeh, PharmD, BCOP May 5, 2015
Pharmacologic Considerations for Managing Sickle Cell Pain Claire Saadeh, PharmD, BCOP May 5, 2015 Table 1: Physiologic changes that occur during sickle cell pain crisis 1-3 Phase Description / Complications
More informationPAIN & ANALGESIA. often accompanied by clinical depression. fibromyalgia, chronic fatigue, etc. COX 1, COX 2, and COX 3 (a variant of COX 1)
Pain - subjective experience associated with detection of tissue damage ( nociception ) acute - serves as a warning chronic - nociception gone bad often accompanied by clinical depression fibromyalgia,
More informationBASICS OF OPIOID PRESCRIBING 10:30-11:45AM
PROVIDING QUALITY CARE TO PAIN PATIENTS IN IOWA BASICS OF OPIOID PRESCRIBING 10:30-11:45AM ACPE UAN: 107-000-14-013-L01-P Activity Type: Application-Based 0.125 CEU/1.25hr Learning Objectives for Pharmacists:
More informationPostoperative Pain Management. Nimmaanrat S, MD, FRCAT, MMed (Pain Mgt)
Postoperative Pain Management Nimmaanrat S, MD, FRCAT, MMed (Pain Mgt) Topics to be Covered Definition Neurobiology Classification Multimodal analgesia Preventive analgesia Step down approach Measurement
More informationNon Malignant Pain: Symptom Management
Non Malignant Pain: Symptom Management Renal Care Symposium July 2018 Anica Vasic Pain Management Unit St George Hospital Definitions Prevalence Assessment Treatment Medications Newer agents: tapentadol,
More informationCORE SAFETY PROFILE OXYCODONE HYDROCHLORIDE NL/H/PSUR/0054/ January 2013
CORE SAFETY PROFILE OXYCODONE HYDROCHLORIDE NL/H/PSUR/0054/001 16 January 2013 1 4.2 Posology and method of administration (safety aspects only) Posology Elderly patients For oral preparations A dose adjustment
More informationTo Infinity and Beyond! Safe and Effective Opioid Titration Strategies
To Infinity and Beyond! Safe and Effective Opioid Titration Strategies Alexandra L. McPherson, PharmD, MPH Slide development Mary Lynn McPherson, PharmD, MA, BCPS, CPE Professor and Executive Director,
More informationE-Learning Module N: Pharmacological Review
E-Learning Module N: Pharmacological Review This Module requires the learner to have read Chapter 13 of the Fundamentals Program Guide and the other required readings associated with the topic. Revised:
More informationSubstitution Therapy for Opioid Use Disorder The Role of Suboxone
Substitution Therapy for Opioid Use Disorder The Role of Suboxone Methadone/Buprenorphine 101 Workshop, December 10, 2016 Leslie Lappalainen, MD, CCFP, dip ABAM Prepared by Mandy Manak, MD, ABAM, CCSAM
More informationPAIN TERMINOLOGY TABLE
PAIN TERMINOLOGY TABLE TERM DEFINITION HOW TO USE CLINICALLY Acute Pain Pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection Addiction A chronic
More informationOpioid Use in Serious Illness
Opioid Use in Serious Illness Jeanie Youngwerth, MD University of Colorado School of Medicine Associate Professor of Medicine, Hospitalist Director, Palliative Care Service Associate Director, Colorado
More informationNociceptive Pain. Pathophysiologic Pain. Types of Pain. At Presentation. At Presentation. Nonpharmacologic Therapy. Modulation
Learning Objectives Effective, Safe Analgesia An Approach to Appropriate Outpatient Chronic Pain Treatment By the end of this presentation, participants will be able to: Identify multiple factors that
More informationPain Management in Hospice and Palliative Care
Pain Management in Hospice and Palliative Care A Case-based Approach JoAnne Nowak, M.D. Merrimack Valley Hospice Revised November 2011 Objectives Use a case study approach to stimulate discussion and illustrate
More informationSession II. Learning Objectives for Session II. Key Principles of Safe Prescribing. Benefits and Limitations of ER/LA Opioids
Learning Objectives for Session II Session II Best Practices for How to Start Therapy with ER/LA Opioids, How to Stop, and What to Do in Between Upon completion of this module, the participants will be
More informationKnock Out Opioid Abuse in New Jersey:
Knock Out Opioid Abuse in New Jersey: A Resource for Safer Prescribing GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN IMPROVING PRACTICE THROUGH RECOMMENDATIONS CDC s Guideline for Prescribing Opioids
More informationWR Fentanyl Symposium. Opioids, Overdose, and Fentanyls
Opioids, Overdose, and Fentanyls Outline: What are opioids? Why are we experiencing and opioid crisis? Potency, purity, and product How do opioids cause overdose and overdose deaths? What is naloxone and
More informationPain management. Coleman Palliative Care Conference: February 2016 Josh Baru MD Stacie Levine MD
Pain management Coleman Palliative Care Conference: February 2016 Josh Baru MD Stacie Levine MD Case #1 61 yo man with history of Stage 3 colon cancer, s/p resection and adjuvant chemotherapy with FOLFOX
More informationThe Emerging Role of NMDA Antagonists in Pain Management
1 of 5 5/29/16 5:18 PM www.medscape.com The Emerging Role of NMDA Antagonists in Pain Management Dana Jamero, PharmD, BCOP; Amne Borghol, PharmD; Nina Vo, PharmD Candidate; Fadi Hawawini, DO US Pharmacist
More informationNon-opioid and adjuvant pain management
Non-opioid and adjuvant pain management ALLISON JORDAN, MD, HMDC MEDICAL DIRECTOR OF PALLIATIVE CARE SERVICES CHRISTIAN AND ALTON MEMORIAL HOSPITALS ASSOCIATE MEDICAL DIRECTOR, BJC HOSPICE ASSISTANT PROFESSOR
More informationPAIN MANAGEMENT PGY-1. Aaron D. Storms, MD Carin van Zyl, MD Adult and Pediatric Palliative Care, LAC+USC Keck School of Medicine of USC
PAIN MANAGEMENT PGY-1 Aaron D. Storms, MD Carin van Zyl, MD Adult and Pediatric Palliative Care, LAC+USC Keck School of Medicine of USC Perception Matters A builder aged 29 came to the accident and emergency
More information