Table 11. Common Opioids Used in Chronic Pain Management (Continued)
Available Oral Strengths
Medication
Dosage
Clinical Considerations
Fentanyl, transdermal patch (72-hour) • Duragesic
Patch Strength 12 mcg/hour 25 mcg/ hour 37.5 mcg/hour 50 mcg/hour 62.5 mcg/hour 75 mcg/hour 87.5 mcg/hour 100 mcg/hour
Conversion from a different opiate agonist to Duragesic:
Recommended initial Duragesic based on daily morphine dose: • Morphine 60 to 134 mg/day PO: Fentanyl transdermal patch 25 mcg/hour • Morphine 135 to 224 mg/day PO: Fentanyl, transdermal patch 50 mcg/hour • Morphine 225 to 314 mg/day PO: Fentanyl transdermal patch 75 mcg/hour • Morphine 315 to 404 mg/day PO: Fentanyl transdermal patch 100 mcg/hour • Morphine 405 to 494 mg/day PO: Fentanyl transdermal patch 125 mcg/hour • Morphine 495 to 584 mg/day PO: Fentanyl transdermal patch 150 mcg/hour • Morphine 585 to 674 mg/day PO: Fentanyl transdermal patch 175 mcg/hour • Morphine 675 to 764 mg/day PO: Fentanyl transdermal patch 200 mcg/hour • Morphine 765 to 854 mg/day PO: Fentanyl transdermal patch 225 mcg/hour • Morphine 855 to 944 mg/day PO: Fentanyl transdermal patch 250 mcg/hour • Morphine 945 to 1034 mg/day PO: Fentanyl transdermal patch 275 mcg/hour • Morphine 1035 to 1124 mg/day PO: Fentanyl transdermal patch 300 mcg/hour Do not use to convert fentanyl transdermal patches to other opioids, as this will result in overestimation and possible fatal overdose . During treatment with extended-release formulations, immediate- release formulations may be required for breakthrough pain.
• Convert the previous 24-hour opioid analgesic requirement to an equianalgesic morphine dose. • Use conversion chart to determine Duragesic initial dosage. • Change the patch every 72 hours. • May titrate ate initial dosage after 3 days (72 hours). • Subsequent dose titrations
should be made no more frequently than every 6 days.
Monitor patients closely for respiratory depression the first 24 to 72 hours after initiating therapy or dose escalation.
Supplemental doses may be required.
*Note: While many ER/LA opioid analgesics are FDA-approved (at specific dosages) for opioid-naive or non-opioid-tolerant patients, current guidelines for chronic pain management do not recommend these products to patients. 103 Therefore, those doses are not provided in the table. It is recommended to stop all other around-the-clock opioid drugs upon initiation of a new ER/LA product.
Opioid-induced constipation is a risk throughout chronic opioid therapy. Therefore, prescribing scheduled use of stool softeners (e.g., docusate) and stimulants for those receiving chronic opioids is warranted. In addition, instruct patients to contact their prescriber if they do not have a bowel movement at least every 2 to 3 days to avoid developing impaction. In some cases, a prescription medication for opioid-induced constipation may be necessary. Patients do not develop tolerance to the opioids’ respiratory depressive effects, even with chronic therapy. Additionally, this risk increases if other CNS depressant agents (prescribed or illicit) or alcohol are concurrent. It is strongly recommended to prescribe naloxone (Narcan), an opioid antagonist, for any patient at risk of opioid- induced respiratory depression. Narcan is safe and effective and instructions for use should be given not only to the patient but also to any family members or acquaintances who may have the opportunity to use naloxone in the setting of an overdose. Narcan has no significant physiologic effect if given to a patient who has not used opioids and can be given safely in almost any patient with undifferentiated altered mental status. When administered to a
patient experiencing an opioid overdose and opioid-induced respiratory depression, naloxone can rapidly reverse all signs and symptoms of opioid intoxication. Many states have passed laws expanding access to naloxone, allowing pharmacists to dispense or distribute naloxone without a prescription under certain circumstances. As part of the FDA’s action plan regarding the safety of opioid analgesics, it has released several safety-related product labeling updates. In addition, the FDA updated warnings across the entire class of opioids regarding drug interactions, adrenal issues, and alterations in sex hormone levels. 117 Specifically, the FDA warns that opioids may interact with other medications that increase serotonin levels (e.g., certain antidepressants and migraine medications), which may lead to serotonin syndrome. In addition, opioids are rarely associated with adrenal insufficiency, and long-term use of opioids decreases sex hormone levels. Consider these potential drug interactions and adverse effects and discuss them with patients when determining the appropriateness of opioid therapy. 118
The FDA issues a BBW for all prescription opioid pain and cough medications and all prescription benzodiazepines regarding the risk for the CNS depression and serious adverse effects, including respiratory depression and death. The BBW was issued after several studies showed an increasing trend in concomitant dispensing of opioid analgesics and benzodiazepines and an increasing frequency of combined benzodiazepine and prescription opioid misuse, abuse, and overdose as measured by national emergency department visit and overdose death rates from prescribed or greater-than-prescribed doses. 119 In addition, other CNS depressants (e.g., barbiturates, antipsychotics, and neuroleptic drugs; antiepileptic and antiparkinsonian drugs; anesthetics; autonomic nervous system drugs; and muscle relaxants) contributed to deaths where opioids were also implicated. 120 It has been documented that alcohol and benzodiazepine coinvolvement in opioid-involved overdose deaths was common, varied by opioid subtype, and was associated with state-level binge drinking and benzodiazepine prescribing rates. 121
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