● 8 mg daily of oral hydromorphone. ● 25 mg daily of oral oxymorphone.
Particular care is essential, not only during opioid dose initiation but also whenever doses are increased, changed to a different opioid, or when CNS- depressant medications are added to the regimen. Patients should be monitored carefully, particularly within 24 to 72 hours of opioid initiation or upward titration. Studies show that patients are particularly vulnerable to respiratory depression at these times. 119,120 HCPs should consider opioid initiation a trial, discuss with the patient the risks and benefits of continuing opioid therapy beyond 90 days,19 and, if opioids are continued, reevaluate the treatment plan at least every three months. Patients who require repeated dose escalations to achieve sufficient pain relief should be reevaluated for the cause, and the risk-to- harm benefit of long-term opioid therapy should be reconsidered. 78 Self-Assessment Question 8 Which dosage of transdermal fentanyl administered for a week would an adult patient be considered opioid tolerant?
Product information for individual formulations contain guidance on degree of opioid tolerance necessary for administration and minimum titration intervals. IR/SA opioids are sometimes used for severe exacerbations of pain (i.e., “breakthrough pain”) that occur against a background of chronic pain that is being treated with ER/LA opioids. This practice has support but is controversial in chronic noncancer pain, because the rapid-onset medications used as rescue medications may increase risk for misuse. 78 Because patient response varies, titrating to a therapeutic dose should be individualized with close attention to efficacy, tolerability, and presence of adverse effects. The CDC recommends reassessing risk versus benefit at ≥50 MME per day, avoiding increasing dosages to ≥90 MME per day, or carefully considering the rationale. 64 Authors of the CDC guideline subsequently clarified that the guideline does not support sudden dismissal of patients or hard limits on dosage and treatment durations. 18 These circumstances particularly affect patients who are already receiving long-term opioid therapy and who seek continuation of care after losing access elsewhere. 137 It must be reemphasized that recommended threshold doses do not remove the necessity of exercising caution at any dose or the importance of individualizing the dose. Opioid rotation A patient who suffers inadequate analgesia or intolerable side effects from one opioid may do better with a different opioid. 74 Because mu-agonists produce varied effects, switching a patient to a different medication may allow for pain control at a lowered dose. Care must be taken during the switch, because tolerance to a particular opioid does not translate to tolerance to another, a concept known as incomplete cross-tolerance. Patients should be monitored especially closely during any dose or formulation changes. Equianalgesic dosing tables, conversion charts, and calculators allow for the conversion of any opioid dose to the standard value of morphine (i.e., MME). 138 These tables have limitations because Naloxone prescription Naloxone can be used to save lives during overdose from a prescribed or illicit opioid, and its presence increases safety for the patient and others who live in or visit the home. 64 Strong evidence shows that providing naloxone to patients reduces opioid-related emergency-department visits. 93 Take-home naloxone can be easily prescribed and is generally recommended for all patients who receive an opioid prescription. It is particularly recommended with the presence of opioid overdose risk factors, such as history of overdose, history of SUD, clinical depression, opioid dosages ≥50 MME/day, concurrent benzodiazepine use,61 or with evidence of increased risk by other measures. Two easily administered
a. 25 mcg per hour. b. 50 mcg per hour. c. 75 mcg per hour. d. 100 mcg per hour.
the supporting studies were conducted on single doses in patients with limited opioid exposure and did not report on dosing over time. 139 Therefore, experts have advised HCPs to use the equianalgesic dosing tables only as a starting point for opioid rotation, then reduce the dose (≥25% to 50% is advised, more with methadone) when converting to the new opioid. 78 A greater reduction is advised in patients who are older or medically frail. A 75% to 90% reduction 140 or considering the patient opioid naïve is advised for rotating to methadone followed by careful monitoring. 78 Conversions to transdermal routes of fentanyl and buprenorphine require special considerations, and HCPs should closely follow instructions in the prescribing information. products are an auto-injection device and a nasal spray that requires no assembly. Patients given naloxone should keep it available at all times. 119 Naloxone administration can cause withdrawal symptoms, and people who have been administered it should have follow-up medical care. Laws vary by state regarding immunity for physicians or laypeople administering naloxone and can be checked here: https://pdaps.org/datasets/good-samaritan-overdose- laws-1501695153. Patients and their caregivers and other family members should be instructed on the signs of overdose and counseled to do the following if an opioid overdose is suspected: 141
Book Code: MDCO1025
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