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Opioid pain surgery2010

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Suzana Makowski, MD MMM FACP
Suzana Makowski, MD MMM FACP
Health & Medicine
1 of 55
Pain Management Suzana Makowski, MD Palliative Medicine and Laura Lambert, MD Surgical Oncology
Key concepts ,[object Object],[object Object],[object Object],[object Object]
The 5 th Vital Sign ,[object Object]
What do most surgical patients have in common? ,[object Object],[object Object],[object Object]
How do you assess pain? ,[object Object]
How do you assess pain? ,[object Object],[object Object],[object Object]
Acute vs. Chronic Pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Barriers to assessing and treating pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
What is the easiest pain to bear? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
WHO step-ladder 1 mild 2 moderate 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAID’s ± Adjuvants WHO. Geneva, 1996 . 1-3 4-6 7-10
Opioid Pharmacology ,[object Object],[object Object],[object Object],[object Object]
Opioid kinetics Plasma Concentration 0 Half-life (t 1/2 ) Time IV PO/PR SC/IM C max 6-7 min 15-20 min 45-60 min
Clearance Issues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Opioid pharmacology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Routine oral dosing: immediate release formulations ,[object Object],[object Object],[object Object],[object Object],[object Object]
Routine oral dosing Extended release preparations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Equation: To convert from one opioid to another using same route FROM CHART: Opioid A dose (mg), route X opioid B route = opioid B dose (mg), route opioid A route ( )
Coverting ,[object Object],[object Object],[object Object],[object Object],[object Object]
Example: ,[object Object],[object Object],[object Object],[object Object]
Example ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Example continued ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Opioid Side Effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
POP Quiz ,[object Object],[object Object],[object Object],[object Object],[object Object]
Constipation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Options to Treat Constipation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Nausea/Vomiting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sedation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Delirium/Neuroexcitability ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Respiratory Depression ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Opioid “allergies” ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adjunctive Analgesics ,[object Object],[object Object],[object Object]
Adjunctive Analgesics: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Routes of Delivery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Contacts ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Take home messages ,[object Object],[object Object],[object Object],[object Object],[object Object]
Questions?
Corticosteroids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Interventional Pain Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Radiation Therapy ,[object Object]
Non-pharmacologic interventions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fentanyl patch (Duragesic) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
To start Fentanyl Patch ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adjunctive Analgesics: Anticonvulsants ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adjunctive Analgesics: Tricyclic Antidepressants ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Adjunctive Analgesics: SSNRI ,[object Object],[object Object]
Adjunctive Analgesics: NMDA Receptor Antagonists ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Methadone
Changing opioids… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ripamonti C, Zecca E, Bruera E. Pain . 1997.
Adjusting for cross-tolerance
Breakthrough dosing ,[object Object],[object Object],[object Object],[object Object],[object Object]
Relative strengths of routes ,[object Object],PO/PR to SC, IV, IM 2-3 ~ 1
Using a PCA ,[object Object],[object Object],[object Object],[object Object]

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Opioid pain surgery2010

  • 1. Pain Management Suzana Makowski, MD Palliative Medicine and Laura Lambert, MD Surgical Oncology
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  • 10. WHO step-ladder 1 mild 2 moderate 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAID’s ± Adjuvants WHO. Geneva, 1996 . 1-3 4-6 7-10
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  • 12. Opioid kinetics Plasma Concentration 0 Half-life (t 1/2 ) Time IV PO/PR SC/IM C max 6-7 min 15-20 min 45-60 min
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  • 18. Equation: To convert from one opioid to another using same route FROM CHART: Opioid A dose (mg), route X opioid B route = opioid B dose (mg), route opioid A route ( )
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