Article Figures & Data
Figures
Tables
- Table 1.
General Dos and Don’ts Regarding the Use of Opioid Therapy in Patients with Chronic Noncancer Pain
Do Don’t Consider opioids only after all other reasonable attempts at analgesia have failed Forget to evaluate patients (ie, history and physical examination) Recognize that a history of substance abuse, severe character pathology, and chaotic home environment are contraindications Initiate treatment without first establishing a diagnosis Ensure that the primary responsibility for treatment is assumed by a single practitioner Forget to obtain outside medical records or to talk with previous practitioners (any verification at all) Obtain informed consent from the patient before initiating therapy Prescribe treatment without establishing specific goals (ie, reduction in pain, improvement in function) Prescribe doses on an around-the-clock basis Fail to screen for addictive potential and monitor patient through treatment Reassess if failure to achieve at least partial analgesia at relatively low initial doses in the nontolerant patient Fail to document the diagnosis, treatment plan, goals for treatment, continuing need for medication, and laboratory results Emphasize gains in physical and social function Fail to understand what drug testing can and cannot tell you Permit patients to transiently escalate dose on days of increased pain Deviate from the ‘contract’ (ie, misbehavior is never addressed either verbally or written) See patients and prescribe drugs at least monthly, at least in the initial phases of treatment Accept blindly whatever is said by the patient Manage exacerbations of pain in the hospital, where dose escalation can be observed and the dose returned to baseline Attempt to bully law enforcement or regulatory agents, or assume an arrogant ‘I-know-best’ attitude when confronted by them Assess patients for evidence of drug hoarding, acquisition of drugs, uncontrolled dose escalation, or other aberrant behaviors Incorporate comfort, side effects, functional status, and existence of aberrant drug-related behaviors into pain assessment at each visit Consider use of self-reporting instruments, an example of which is shown in Table 2 Remember that documentation is essential and should address all elements of the visit assessment Adapted with permission from Portenoy28 and Gallagher.18
- Table 2.
Items on the Screener and Opioid Assessment for Patients With Pain (SOAPP) Questionnaire
Item Concept Domain How often do you feel that your pain is out of control? Neurobiologic need for medicine How often have you felt a need for higher doses of medication to treat your pain? Neurobiologic need for medicine How often have you felt a craving for medication? Neurobiologic need for medicine How often do you take more medication than you are supposed to? Medication-related behaviors How often have you taken medication other than the way that it was prescribed? Medication-related behaviors How often have your medications been lost or stolen? Medication-related behaviors How often have others expressed concern over your use of medication? Medication-related behaviors How often has more than one doctor prescribed pain medication for you at the same time? Antisocial behaviors How often, in your lifetime, have you had legal problems or been arrested? Antisocial behaviors How often do you smoke a cigarette within an hour after you wake up? Substance abuse history How often have any of your family members, including parents and grandparents, had a problem with alcohol or drugs? Substance abuse history How often have any of your close friends had a problem with alcohol or drugs? Substance abuse history How often have others suggested that you have a drug or alcohol problem? Substance abuse history How often have you attended an AA or NA meeting? Substance abuse history How often have you been treated for an alcohol or drug problem? Substance abuse history How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past 5 years? Substance abuse history How often do you have mood swings? Psychiatric history How often have you been seen by a psychiatrist or a mental health counselor? Psychiatric history How often do you do things that you later regret? Psychosocial problems How often has your family been supportive and encouraging? Psychosocial problems How often have others told you that you have a bad temper? Psychosocial problems How often have you had a problem getting along with the doctors who prescribed your medicines? Doctor-patient relationship How often have you been asked to give a urine screen for substance abuse? Doctor-patient relationship Compared with other people, how often have you been in a car accident? Personal care/lifestyle AA, Alcoholic’s Anonymous; NA, Narcotics Anonymous.
Adapted with permission from Butler et al.25
Enzymes Opioids Popular Medications/ Substrates CYP2D6 Codeine Carvedilol Dextromethorphan Propafenone Dihydrocodeine Amitriptyline Oxycodone Paroxetine Tramadol Risperidone Thioridazine Fluoxetine Lidocaine Nortriptyline Propranolol Tamoxifen Venlafaxine CYP3A4 Buprenorphine Clarithromycin Fentanyl Erythromycin Methadone Alprazolam Oxycodone Cyclosporine Chlorpheniramine Diltiazem Lovastatin Hydrocortisone Buspirone Caffeine Nifedipine Verapamil Diazepam Data from Flockhart57 and Lalovic et al.58
Drug Approximate Equianalgesic Oral Dose Approximate Equianalgesic Parenteral Dose Recommended Starting Dose (Adults >50 kg Body Weight) Oral Parenteral Morphine 20–60 mg/day initial starting dose; then 30 mg q3-h (IR) 10 mg q3–4 hours 30 mg q3–4 hours* 10 mg q3–4 hours (use of IV route is preferable) Fentanyl 0.1† Oxycodone 30 mg q3–4 hours (IR) NA 10 mg q3–4 hours NA Hydromorphone‡ 7.5 mg q3–4 hours 1.5 mg q3–4 hours 6 mg q3–4 hours 1.5 mg q3–4 hours Methadone 5–10 mg q6–8 hours 5–10 mg q6–8 hours 5–10 mg q6–8 hours 2.5–5 mg q6–8 hours IR, immediate release; IV, intravenous; NA, not available.
* Starting dose of 20 to 60 mg/day may be used to avoid adverse effects such as vomiting.
† Transdermal fentanyl 100 μg/hr is approximately equivalent to 2 to 4 mg/hr of IV morphine. A conversion factor for transdermal fentanyl that can be used for equianalgesic calculation is 17 μg/hr. Roughly, the dose of transdermal fentanyl in μg/hr is approximately one-half of the 24-hour dose of oral morphine.
‡ For morphine and hydromorphone, rectal administration is an alternate route for patients unable to take oral medication, but equianalgesic doses may differ from oral and parenteral doses because of pharmacokinetic differences.
Reprinted with permission from Nicholson.8
