ate-release products (perhaps 30 to 90 minutes) but offers a much longer duration of action (4 to 72 hours). These potent products are typically reserved for patients suffering from constant, chronic pain who have had previous exposure to opioids (DiPiro et al., 2019). Respiratory depression is the most serious adverse effect of opi- oids; it can be immediately life-threatening. The risk of respiratory depression or respiratory arrest is higher in patients with an upper respiratory infection, asthma, or other respiratory problems. Con- stipation is the most common long-term side effect but can often be managed with laxatives or stool softeners. Other common side effects are sedation, dizziness, vomiting, physical dependence, and tolerance. Less frequently observed side effects of opioid use are delayed gastric emptying, hyperalgesia (increased sensitivity to pain), immunologic or hormonal dysfunction, muscle rigidity, Case study Mr. Johnson is a 36-year-old male who was admitted to the hospi- tal after a motorcycle accident. His left ankle was broken in several places, and he suffered a number of abrasions to his legs, torso, and arms as well. He had reconstructive surgery on his ankle and stayed overnight in the hospital for observation. Now that he is being discharged, he is very concerned about how his pain can be managed when he is at home, as he experienced a lot of pain during his hospital stay. Self-Assessment Quiz Question #2 Mr. Johnson is expected to have pain around the clock for at least the first few days, so his doctor decides to prescribe an opiate for pain relief. Which of the following would be most appropriate?
and myoclonus (spasmodic jerky contractions of groups of mus- cles) (DiPiro et al., 2019). Evidence-based practice! A systematic review conducted in 2017 established a better understanding on what is known about opioid use during pregnancy and birth defects. It found maternal opioid use may be linked to several congenital defects in ne- onates. These malformations include oral clefts, septal defects in the heart, and clubfoot. In addition, prenatal opioid exposure was also noted to be related to spontaneous abortion, prema- ture membrane rupture, preeclampsia, neonatal abstinence syn- drome, and fetal death. Due to the risk of poor outcomes for mother and baby, opioid use in pregnant women should be as- sessed on a case-by-case basis (Lind et al, 2017).
Self-Assessment Quiz Question #3 Mr. Johnson is experiencing significant swelling of his ankle. Which of the following would be the most appropriate non- opi- oid therapy to add as adjunctive treatment? a. Pregabalin, b. Acetaminophen.
c. Naproxen. d. Methadone.
a. A short-acting opiate. b. A long-acting opiate. c. A long-acting opiate patch. d. An injectable opiate.
Morphine milligram equivalents (MME) Since higher dosages of opioids are associated with a higher risk of overdose and death, it is important to keep in mind the total daily dose in order to reduce the risk of poor outcomes. Calculat- ing the total daily dose of opioids helps to identify patients who may require close monitoring or other measures to lower the risk of overdose. Using morphine milligram equivalents is a standard- ized method of calculating the total amount of opioids consumed in a day, regardless of which opioid the patient is taking. To cal- culate a patient’s total daily dose of opioids, one must first deter - mine the total daily dose of each opioid the patient is prescribed. Next, convert to MME by multiplying the dose of each opioid by its conversion factor. Then, add the MMEs together to determine Considerations for opioid prescribing If opioid therapy is chosen, prescribers should ensure treatment goals are established with all patients before starting medication therapy. Realistic goals for pain and function should be deter- mined on a patient-specific basis, and consideration should be given to how opioids will be discontinued if risks outweigh the benefits of treatment. Opioids should be continued only if the patient displays clinically meaningful improvements in pain and function that outweigh potential patient safety risks. Risks and possible benefits should be discussed with the patient before opioid therapy is started (Dowell et al., 2016). When starting opioid therapy in an opioid-naïve patient, imme- diate-release opioids should be used first before considering long-acting opioids at the lowest effective dosage. Prescribers should carefully evaluate the risks and benefits of increasing opi - oid dosages to more than 50 morphine milligram equivalents (MME) per day because of the lower effectiveness of high doses and the high risk of overdosage and death. Dosages of more than 90 MME per day should be avoided unless very carefully justified
the total MME per day. The following conversion factors are used in the calculation of MME (CDC, n.d.): ● Codeine: 0.15. ● Fentanyl transdermal: 2.4. ● Hydrocodone: 1. ● Hydromorphone: 4 Methadone. ○ 1-20mg/day: 4. ○ 21-40mg/day: 8. ○ 41-60mg/day: 10. ○ >/= 61-80mg/day: 12. ● Morphine: 1. (Dowell et al., 2016). Patients receiving more than 50MME per day should have their pain and function assessed more frequently, be considered for dose reductions if the benefits do not outweigh the risks, and be offered naloxone for overdose prevention (CDC, n.d.). Because most patients who take opioids long term start with the treatment of acute pain, prescribers should ensure the lowest effective dose is used at the beginning of acute treatment. The quantity prescribed should be no more than what is needed for the duration of pain severe enough to require opioids. As a gen- eral rule, three days or less is often sufficient, and more than sev - en days of opioid treatment is rarely necessary for the treatment of acute pain (Dowell et al., 2016). ● Oxycodone: 1.5. ● Oxymorphone: 3. Within one to four weeks of starting opioid therapy for chronic pain, prescribers should assess the risks and benefits of continu - ing treatment or increasing the dosage, and risks and benefits should be continually assessed every three months or less. If at
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