Please note: The scenarios presented in this module are intended to highlight and reinforce broad principles. Specific case details are left out (e.g. source of pain, reason for admission).
Scenario 1
Assess for Treatment, Identify Risk Factors, Comply with Regulations, Refer to Specialist
Mr. Jones is a new admit from the Emergency Department (ED) and will require opioids to treat his acute severe pain. He received a total of 2 mg of IV hydromorphone in the past 4 hours in the ED and responded with satisfactory pain relief and minimal sedation. Let’s take a look at his history and physical exam to review his risk factors and determine an opioid regimen.
Speak to Pharmacist
The pharmacist says, “We should check the Prescription Monitoring Program (PMP) to find out if Mr. Jones has been receiving opioids from other prescribers in the state.”
Electronic Health Record Overview
Name: John Jones
DOB: 03/01/1964
Age: 52
Gender: male
BMI: 36
Key Points from Hx and Px
Sleep apnea
Asthma
Hypertension
Type II diabetes
Normal renal function
Somnolent but rouses easily
Knee osteoarthritis
Anxiety disorder
Prior recent surgery
Medications from Home
Albuterol
Hydrocodone 5mg/325 1 q6 prn
Clonazepam 1mg PO at bedtime daily
Lisinopril
Metformin
Test Results
Urine Drug Test (UDT) done in ED positive for hydrocodone
Drug | Dispensed | # Dispensed | Prescriber |
---|---|---|---|
Clonazepam | This month | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | This month | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | Last month | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | Last month | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 2 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 2 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 3 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 3 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 4 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 4 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 5 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 5 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 6 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 6 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 7 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 7 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 8 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 8 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 9 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 9 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 10 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 10 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Clonazepam | 11 months ago | 1mg 30 tabs/30 days | Dr. Smith |
Hydrocodone | 11 months ago | 5mg/325 30 tabs/7.5 days | Dr. Smith |
Test Your Knowledge
Urine Drug Test (UDT)
Benzodiazepine was missing in the UDT, even though the patient is on clonazepam. Why could that be?
Referral
Would you refer your patient to a specialist?
Risk Factors for Over-Sedation/Respiratory Depression
What risk factors for over-sedation or respiratory depression from opioids does Mr. Jones have?
Discussion
All choices are potential risk factors for opioid induced over-sedation or respiratory depression. Mr. Jones has 4 risk factors: sleep apnea, opioid analgesic tolerance, concurrent use of other sedating drugs and specific medical comorbidities.
Mr. Jones has 4 risk factors: sleep apnea, opioid analgesic tolerance, concurrent use of other sedating drugs and specific medical comorbidities.
Risk for Difficult to Control Pain
What risk factors does Mr. Jones have for difficult to control pain?
Discussion
All of the choices are potential risk factors for difficult to control pain. Mr. Jones has 3 risk factors: opioid tolerance, chronic pain and anxiety.
Appropriate Dosing Ranges
Explore appropriate dosing ranges by reviewing each drug and considering naïve or tolerant patients.
(Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effect over time.)
Oxycodone
Child
Naïve
Between 0.09mg/kg/dose and 0.11mg/kg/dose
Tolerant
Refer or consult specialist
Adult
Naïve
Between 5mg and 15mg
Tolerant
Between 9mg and 23mg
Older Adult
Naïve
Between 2mg and 11mg
Tolerant
Between 3mg and 16mg
Morphine IV
Child
Naïve
Between 0.02mg/kg/dose and 0.03mg/kg/dose, under 6 months, or between 0.07 and 0.08mg/kg/dose over 6 months (max 2-4mg)
Tolerant
Refer or consult specialist
Adult
Naïve
Between 1mg and 3mg
Tolerant
Between 1.5mg and 6mg
Older Adult
Naïve
Between 0.5mg and 1.5mg
Tolerant
Between 1.5mg and 4mg
Test Your Knowledge
Appropriate Oral Opioid Regimen
Which is the appropriate oral opioid regimen of oxycodone for Mr. Jones? Keep in mind his history and risk factors for opioid treatment and severe acute pain management in hospital.
Appropriate IV Opioid Regimen
Which is the appropriate IV opioid regimen of morphine for Mr. Jones? Keep in mind his history for opioid treatment and severe acute pain management in hospital.
Discussion
Mr. Jones has significant risk factors for respiratory depression and has not received morphine. A range of 1-3mg is reasonable to start. Many sources say a starting dose for IV morphine in an adult s 2-4mg, but given the presence of a benzodiazepine, use of caution (e.g. start low and go slow) is warranted.
Summary
Check the state Prescription Monitoring Program (PMP) to ensure accurate prescribing record
- Assess for risks of respiratory depression
- Assess for need for referral to specialist
- Avoid new prescriptions of benzodiazepines, sedative-hypnotics, anxiolytics, or CNS depressants
- Consider a number of factors when selecting starting dose including opioid tolerance, response to past treatment and risk factors for adverse side effects