Event 1: Mr. Jones

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

PMP (Prescription Monitoring Program)
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?

Correct. This can all lead to benzodiazepines not being present in the UDT. A confirmatory test needs to be ordered.
Correct. This can all lead to benzodiazepines not being present in the UDT. A confirmatory test needs to be ordered.
Correct. This can all lead to benzodiazepines not being present in the UDT. A confirmatory test needs to be ordered.

Referral

Would you refer your patient to a specialist?

Incorrect
Correct. This patient may not necessitate a referral; however, he has a history of anxiety and may benefit from a behavioral health consult or a pain specialist for advice on opioid use due to associate risk of concomitant benzodiazepine use. However, if you are uncertain, always default to a referral. : Consider consultation with a specialist (e.g. pain, addiction, behavioral health, laboratory medicine) for patients with complex pain and/or high risk for opioid treatment. Reason for referral may include assistance with evaluation and treatment to address persistent functional impairment due to acute pain, anxiety, aberrant behaviors, and management of transitions of care.
Incorrect

Risk Factors for Over-Sedation/Respiratory Depression

What risk factors for over-sedation or respiratory depression from opioids does Mr. Jones have?

Correct. This is a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.

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?

Incorrect. Not a risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.
Correct. Risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.
Incorrect. Not a risk factor for Mr. Jones.

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.

Incorrect. Too low.
Incorrect. Too low.
Correct
Correct
Correct
Incorrect. Too high.
Incorrect. Too high.
Incorrect. Too high.

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.

Incorrect. Too low.
Correct
Correct
Correct
Incorrect. Too high.
Incorrect. Too high.
Incorrect. Too high.
Incorrect. Too high.

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
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