omit buprenorphine and other opioids used to treat opioid use disorder. Compared to dosages of 1 to <20 MME/day, dosages of 50 to <100 MME/day increase the risks of opioid overdose by factors of 1.9 to 4.6 (Dowell et al., 2016). CDC guidance states that clinicians should carefully assess patients when considering increasing dosage to >50 MME/day and should avoid or carefully assess and justify a decision to increase the total opioid dose to >90 MME/day (AAFP, 2021). While the CDC has not explicitly stated that opioids should not be used in quantities >90 MME/day, many states and payers limit opioid prescriptions to <90 MME/day regardless of the underlying condition (CDC, 2021) (see Table 6). Table 5. Selected Opioid Oral MME Conversion Factors
opioid use disorder. The MME conversion factor and amount may overestimate the amount for conversion, resulting in serious adverse effects such as respiratory depression or death. To calculate a daily MME for a patient: 0. Determine the total daily amount of each opioid the patient takes. 1. Convert each amount to MME by multiplying the total daily amount by the appropriate conversion factor (see Table 5). 2. Total all MMEs to obtain the MME/day for the patient. Example MME Calculation Patients evaluated in the clinic report taking the following ● Flexeril 10 mg three times a day ● Xanax 0.5 mg three times a day The total amount of oxycodone per day: 50 mg (20 mg × 2) + (10 mg × 3) MME/day = 75 (50 mg/day oxycodone × 1.5 [MME conversion factor]) Table 6. Examples of 50 and 90 MME/day for Commonly Prescribed Opioids (CDC, 2022a) Opioid Strength 50 MME/Day 90 MME/Day medication for their back pain. ● OxyContin 20 mg twice daily ● Oxycodone 10 mg three times a day (usually)
Oral Opioids (doses in mg/ day except where noted)
Conversion Factor
Codeine
0.15
Fentanyl transdermal (mcg/ hour)
2.4
Hydrocodone
1
Hydromorphone
4
Methadone: 1-20 mg/day
5 mg/325 mg
50 mg (10 tablets)
Exceeds acetaminophen maximum daily dose
4
Hydrocodone- acetaminophen
21-40 mg/day
8
41-60 mg/day
10
10 mg/325 mg
50 mg (5 tablets) 33 mg (~2 tablets)
90 mg (9 tablets) 60 mg (4 tablets)
61-80 mg/day
12
15 mg
Morphine
1
Oxycodone sustained release
Oxycodone
1.5
Oxymorphone
3
30 mg
33 mg (~1 tablet) 12 mg (< 3 tablets)
60 mg (2 tablets) ~20 mg (4 tablets)
Tramadol 0.1 IMPORTANT : Do not use the MME conversion factor or the MME amount determined for conversion from one opioid to another or to guide dosing medication or assisted treatment for
Methadone
5 mg
Prescribing of opioids in the management of acute and chronic noncancer pain in adults Pain is an unpleasant sensory and emotional experience
pain resolves when the affected tissue heals; however, some patients progress from acute to chronic pain in a process called pain chronification. The underlying cause(s) is/are not established but may be related to central nervous system changes in pain facilitation and inhibition (Pak et al., 2018). Pain chronification is based on acute pain (e.g., low back, postsurgical, diabetic neuropathy) and social and psychological factors, including maladaptive pain, coping behaviors, concurrent psychiatric illness, and pain catastrophizing. Other factors associated with chronic pain include female gender, increased age, and lower household income (Pak et al., 2018). Chronic pain is characterized by persistent pain, disability, emotional disturbances, and social withdrawal symptoms that coexist and influence each other. The source of the pain may be known or unknown and may be considered a chronic disease syndrome (Halpape et al., 2022). The role of opioid analgesics in managing acute and chronic pain is well established, and opioid prescriptions for pain- related issues increased dramatically in the 1990s. As a result, the number of ED visits, substance abuse treatment admissions, hospital stays, and deaths due to unintentional drug overdoses increased substantially, and this led to a significant public health issue in the subsequent decades. Opioid prescriptions decreased by 44.4% between 2011 and 2020, including a 6.9%
associated with actual or potential tissue damage or described in terms of such damage (Cohen et al., 2021). It is critical to understand that pain is not only a neuronal response but also involves cognitive processes that make it a subjective experience that does not require identifiable tissue damage to be significant (Halpape et al., 2022). Pain perception may be related to the site of the pain, such as the face or eye pain. Pain in children and pregnant women has unique considerations that a specialist should evaluate. In addition, pain accompanied by other physical and psychological conditions needs to be evaluated. Masking a comorbid condition by simply treating the pain could result in exacerbating the condition. Chronic pain that lasts beyond the average healing time for a given injury is operationalized as pain lasting over three months (Cohen et al., 2021). Chronic pain is often clinically distinguished as related to cancer (or other terminal illness) or noncancer/terminal illnesses. The physiologic purpose of acute pain is to bring attention to potential or actual tissue damage so that appropriate action can alleviate the pain (e.g., remove your finger from the hot stove). The firing rate of peripheral neurons that detect painful stimuli, known as nociceptors, leads to the interpretation of pain intensity. However, the perception of nociceptor firing may influence the painful stimulus and the sensitization of the peripheral and central nervous systems. In most patients, acute
EliteLearning.com/Nursing
Book Code: AUS3024
Page 17
Powered by FlippingBook