Back in a few minutes Geoff

Back in a few minutes Geoff

Conflict of Interest Speaker Name; Dr. Geoff Davis Program Title FINANCIAL DISCLOSURE Grants/Research Support: Archimedes Research Speakers Bureau/Honoraria:Purdue Pharma, Pfizer Canada, Janssen-Ortho, Biovail Pharmaceuticals, Bayer, Thunder Bay Medical Society, Northern Ontario School of Medicine, Lakehead University Consulting Fees: Paladin Labs Inc. Other:

Geoff Davis M.D. Nov 2010 davisg@tbh.net

http://www.cancercare.on.ca/

Delerium in Adults

PAIN

D o w n

NAUSEA and VOMITING

Dyspnea

New Medications Niche Market Drugs Transdermal Buprenorphine (Butrans ) Once Daily Hyromorphon ( Jurnista ) Oxycodone/Naloxone (Targin ) Buccal Fentanyl (Onsolis ) Oxymorphone (Opana ) Methylnaltrexone(Relistor ) Tapendolol (Nucynta )

Transdermal Buprenorphine Butrans, 5,10,20 mcg/hr patch NOC March 2010 7 day patch

Buprenorphine myths and facts Ceiling dose Withdrawal Coverson Addiction potential Downloads/opioid-conversion-guide.pdf

Once Daily Hydromorphine

N JURNISTA * hydromorphone hydrochloride Prolonged Release Tablets N JURNISTA * hydromorphone hydrochloride Prolonged Release Tablets in 4, 8, 16, and 32 mg JURNISTA tablets use the oral osmotic pump (OROS ) Push-Pull technology to deliver hydromorphone by a membranecontrolled, osmotically activated process at a constant, controlled rate over 24 hours. All JURNISTA dosage strengths have qualitatively similar formulations, and are designed to deliver proportionately similar amounts of hydromorphone over the 24-hour dosing period. The JURNISTA tablet is a small, round tablet with hydromorphone hydrochloride as the active ingredient. The JURNISTA tablet is composed of a bilayer tablet core surrounded by a semi-permeable membrane, and coloured and clear overcoating. JURNISTA* (hydromorphone hydrochloride Prolonged-Release Tablets) Product Monograph,

OROS + Hydromorphone: Laser-drilled hole A unique delivery system in Pain Management (point of drug release) Cross-Sectional View Rate-controlling Membrane OROS is a proven technology e.g. DITROPAN XL* (oxybutynin chloride) CONCERTA* (methylphenidate HCl) Hard shell (clear, colored overcoat) Hydromorphone HCl + Oral Osmotic Pump Osmotic pump (Push layer) Gupta et al. J Pain Symptom Manage 2007;33:S19 - S24 *All trademark rights used under license

Oxycodone/Naloxone (Targin)

Abuse? If abused parenterally, intranasally by individuals dependent on opioid agonists, Targin is expected to produce marked withdrawal symptoms because of the opioid receptor antagonist characteristics of naloxone or to intensify withdrawal symptoms already present.

Buccal Fentanyl (Onsolis)

Methylnaltrexone

Methylnaltrexone (Relistor) PrRELISTORTMMethylnaltrexone bromide injection, 20 mg /ml For Subcutaneous useμ-opioid receptor antagonist Deaths:Of the 286 advanced illness patients treated with RELISTOR in the phase II and III clinical studies, 138 died while on study, or during follow-up. The causes of death as assessed by investigators were the underlying primary disease or complications related to concurrent illnesses in all but 1 case. One patient with terminal breast cancer developed severe diarrhea and dehydration subsequent to treatment with study drug. In the investigator s opinion, this exacerbated her underlying cardiovascular status, which ultimately led to cardiovascular collapse. This death was deemed by the investigator to be related to treatment with RELISTOR.

Relistor Dosing:RELISTOR is administered as a subcutaneous injection every other day, as needed. Physicians should consider discontinuing treatment in patients who fail to show an adequate response to RELISTOR after 4 doses (1 week).recommended Dose and Dosage AdjustmentThe recommended dose of RELISTOR is 8 mg for patients weighing 38 to less than 62 kg or 12 mg for patients weighing 62 to 114 kg given as subcutaneous injection every other day as needed.

Oxymorphone (Opana) Oxymorphone (Opana, Numorphan, Numorphone) or 14-Hydroxydihydromorphinone is a powerful semisynthetic opioid analgesic first developed in Germany circa 1914, patented in the USA by Endo Pharmaceuticals in 1955 and introduced to the United States market in January 1959 and other countries around the same time. It differs from morphine in its effects in that it generates less euphoria, sedation, itching and other histamine effects. Depending on the individual patient, it can be either more or less nausea- and vomit-inducing than morphine.

Oxymorphone (Opana) 2:1 Oxycodone Abuse potential Less histamine antidepressant

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Noncancer pain

Undertreated Pain and Opioid Misuse: Can we kill two birds with one guideline? A general population telephone interview conducted in Canada showed that 25% of the respondents live with CNCP (Boulanger 2007) A study suggests that 1 million Canadians live with neuropathic pain. (Moulin 2007) Workers who have diabetes with neuropathic symptoms lose the equivalent of $3.65 billion/yr in health-related lost productive time (LPT) (Stewart 2007) Workers with back pain exacerbations account for a disproportionate share of the cost of back pain-related lost productive time. (Ricci 2006) Workers with arthritis pain exacerbation account for a disproportionate share of the arthritis-related LPT cost. Stratifying workers for appropriate treatment management based on pain exacerbation status could significantly decrease arthritis-related LPT and offer employees and employers an effective return on health care use. (Ricci 2005) Thirteen percent of the total workforce experienced a loss in productive time during a 2- week period due to a common pain condition. Headache was the most common (5.4%) pain condition resulting in lost productive time. It was followed by back pain (3.2%), arthritis pain (2.0%), and other musculoskeletal pain (2.0%). (Stewart 2003)

Undertreated Pain and Opioid Misuse: Can we kill two birds with one guideline? Canada is currently the world s third-largest opioid analgesic consumer In Ontario, oxycodone prescriptions rose by 850% from 1991 to 2007, from 23 prescriptions/1000 individuals per year to 197/1000 per year, and the average amount per prescription of long-acting oxycodone increased from 1830 mg to 2280 mg. (Dhalla 2009) The increase in opioid prescribing has been accompanied by simultaneous increases in abuse, serious injuries, and overdose deaths among individuals taking these drugs (Kuehn 2007). From 1991 to 2004 in Ontario, the mortality rate due to unintentional opioid overdose increased from 13.7/million to 27.2/million/year, more than double the mortality rate from HIV (12/million) (Dhalla, 2009).

http://nationalpaincentre.mcmaster.ca/opioid/

http://issuu.com/cafp.sc/docs/udtmonograph6.3

Recommendations address key clinical questions 1. What should I consider before writing an opioid prescription? 2. How do I titrate the opioid dose? 3. What should I do to ensure patient safety? 4. When do I stop the patient s opioids?

Guideline Implementation Conferences Local Strategies Workshops Based on needs of community Patient education Other