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• Hydromorphone
• Oxycodone
• Fentanyl
• Methadone
What route to use?
• GI tract and level of consciousness
• How rapidly you need to get pain under
control
• Cmax
– po ~ 1 hour
– sc ~ 30 minutes
– IV ~ 5-10 minutes
• This indicates how frequently you can give
breakthrough doses
Respiratory Depression
• In those who do not have pain or
respiratory symptoms it is an ongoing risk
• For those who are opioid naïve and
receive more drug than needed for pain it
is a risk – i.e. post operative
• Not an issue when opioids used
appropriately to treat pain and dyspnea
even in patients with cardiopulmonary
disease
Respiratory Depression
• Best measure is the rise in peripheral
pCO2 and peripheral pO2
• Study of patients with moderate to severe
dyspnea due to advanced cancer, ALS
• Patients administered short acting opioid
for dyspnea and parameters measured
before, 30, 60, 90, 120 mins after opioid
• Opioid naïve and opioid tolerant patients
Respiratory Depression
• Visual analogue scale shows significant
reduction in dyspnea p<.001
• Significant reduction in respiratory rate p<.002
• No significant rise in pCO2 or fall in pO2 during
any measurement p = 0.203 to p= 0.686
• Opioids work through reduction of respiratory
rate and workload
• Clemens et al J. Palliative Medicine 2008
Opioid Side Effects
• Nausea
– Metoclopramide 10mg qid
– If doesn’t resolve in a week switch opioid
• Itch
– Histamine release – not allergy
– Antihistamine until it subsides
Constipation
• Interindividual variation
• Need osmotic laxative or stimulant
• Some evidence that fentanyl patch may
result in less constipation
• PEG 3350 (Laxaday) – RCT: more
effective, better tolerated than lactulose
• No evidence to support use of docusate
Principles of opioid rotation
• Calculate the equianalgesic dose
• Reduce the dose of the new opioid by 25-
50% - potential greater sensitivity to new
opioid
• Prescribe new opioid with adequate
breakthrough dose
• Reassess and titrate to target dose
Equianalgesic conversion
• Morphine 10mg
• Tylenol #3 2 tablets
• Codeine 60mg
• Hydromorphone 2mg
• Oxycodone 5-7.5mg
• Methadone 1mg (not q4hr)
» variable ratio
Case 1
• 62 year old man on hemodialysis with
chronic neuropathic pain secondary to
diabetes
• Opioid: fentanyl with hydromorphone
breakthrough OR methadone
• Neuropathic pain adjuvant
Case 2
• 76 year old woman with rheumatoid and
osteoarthritis
• Normal renal function
• Moderate constant joint pain
• Opioid: tramadol OR buprenorphine OR
low dose long acting oxycodone,
hydromorphone
Case 3
• 89 year old man with severe osteoporosis
• eGFR = 32
• Mild dementia
• Living in community on own
• Opioid: long acting oxycodone in blister
pack OR fentanyl patch with follow up by
home care nurse
Case 4
• 94 year old woman with moderate to
severe dementia
• Resistant to care and calling out
• Known spinal stenosis
• Opioid: long acting oxycodone OR fentanyl
patch OR methadone
• Neuropathic adjuvant: SNRI or
mirtazepine
Case 5
• 54 year old man with metastatic bowel
cancer causing bowel obstruction and liver
mets
• eGFR = 40
• Opioid: hydromorphone sc infusion via
CADD pump OR methadone
Case 6
• 48 year old man with history of alcoholism
and illicit drug use
• Previous work accident resulting in
moderate to severe chronic neuropathic
pain
• Opioid(after trials of all reasonable non-
opioids): fentanyl patch dispensed one at
a time with exchange
• Neuropathic pain adjuvants
Case 7
• 57 year old woman with advanced COPD
• Moderate to severe dyspnea with minimal
exertion
• eGFR = 55
• Opioid: long acting morphine
Questions??