Event 2: Mrs. Hubbard

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).

Initiating and Modifying Opioid Treatment: Mrs. Hubbard

Your next patient is Mrs. Hubbard. She is 72-years-old and on chronic opioid therapy with oxycodone ER 30mg BID. She’s been admitted with acute severe pain requiring additional opioids.

Mrs. Hubbard says, “I want to be pain free.”

A patient’s request to be pain free is understandable but often not possible. One way you might respond to Mrs. Hubbard’s request could be to say, “We will do our best to relieve your pain, but it’s generally not possible given
the circumstances to make you pain free.”

Mrs. Hubbard then asks, “Can’t you please just give me more OxyContin®?”

Use short-acting “as need” (PRN) opioids as the foundation for acute severe pain in the opioid naïve patient. Do not add or increase extended release or long acting opioids for acute pain. In response to Mrs. Hubbard’s question,
you might answer, “Short acting opioids work faster. It will take several days for additional Oxycontin® to be effective. By then, your acute pain should be less. It’s also unsafe to add or increase long-acting opioids for
acute pain because of the potential for overdose.”

Mrs. Hubbard says, “Well, my pain is 10/10 and I need some relief! What can you give me to be sure I’m pain free or at least bring my pain down to a 3/10? I’m 72-years-old and need to be ready for my grandson’s birthday party this week.”

With older adults, it’s most appropriate to “start low and go slow” when using opioids. A possible response to Mrs. Hubbard could be, “We need to keep you safe, but also keep your pain ‘well-controlled,’ meaning you are able to do the activities you need to do in order to recover, without experiencing severe pain. It does not mean you will be pain-free. There are other types of pain medicine and techniques that don’t involve medicines in order to help control the pain.”

Multimodal Analgesia

Combining medications with different mechanisms of action along with nonpharmacological techniques that result in superior analgesia may lessen the dose needed to control pain.

Example: acetaminophen + gabapentin + opioid + relaxation breathing + cold pack.

Opioid Tolerance

Mrs. Hubbard tells you, “But I have a lot of tolerance for pain medicine!”

Patients considered opioid-tolerant are those who are taking, for one week or longer, at least:

• 60mg oral morphine/day
• 25mcg transdermal fentanyl/hour
• 30mg oral oxycodone/day
• 8mg oral hydromorphone/day
• 25mg oral oxymorphone/day
• OR an equianalgesic dose of another oral opioid

You may consider telling Mrs. Hubbard that, “Tolerance is an important consideration at the start, but our goal is still to taper you off the medications as your pain resolves.”

The FDA Definition of Tolerance

The FDA definition of tolerance is those who are taking, for one week or longer, at least

• 60mg oral morphine/day
• 25mcg transdermal fentanyl/hour
• 30mg oral oxycodone/day
• 8mg oral hydromorphone/day
• 25mg oral oxymorphone/day
• OR an equianalgesic dose of another oral opioid

Test Your Knowledge

Opioid Tolerance2, Scenario 1

A patient is initiated on opioids for severe acute pain and you find out that the patient has been taking 2 tablets daily for 2 weeks of oxycodone 5/acetaminophen 325. Would you consider this an opioid tolerant patient?

Opioid Tolerance, Scenario 2

A patient has been taking 30mg of oral morphine prn averaging 3 doses per day for one month. Would you consider this an opioid tolerating patient?

Opioid Tolerance and Starting Dose

How would opioid tolerance affect your choice of a starting dose? There may be more than one correct answer.

 Modifying Opioid Dosage

What factors should you consider when modifying an opioid dose? More than one may apply.

Mrs. Hubbard says, “I’ve been on opioids before and last time I was in the hospital I needed high doses.”

You may consider responding with, “Thank you for telling me that. I’ll find out what was used in the past, but this is a different time and different situation.”

Starting Dose for Mrs. Hubbard

What starting dose of a prn oral immediate release oxycodone in addition to the oxycodone ER 30mg BID would you order for 72-year-old Mrs. Hubbard?

Mrs. Hubbard asks, “What about methadone? I hear that’s a strong opioid. Or is it only used for addicts?”

You might consider replying with, “Methadone is a very unique long-acting opioid, used only in certain situations for pain or as part of addiction treatment programs. Methadone is not safe to use for acute pain.”

Difference Between Methadone and ER Opioids

What makes methadone unique from extended-release (ER) opioids?

• Unpredictable long half-life (12-120 hours)
• Risk of QTc interval prolongation and Torsades de pointes particularly with high doses or when other medications are given (e.g., fluroquinolones, macrolides, tricyclic antidepressants, SSRI) that prolong the QTc interval or influence metabolism
• No known active metabolites (methadone is metabolized by CYP3AA and CYP2D6 enzymes)
• Lack of accumulation in patients with renal insufficiency; less than 1% removed by peritoneal or hemodialysis
• N-methyl-D-aspartate (NMDA) receptor antagonism, which theoretically may enhance its effectiveness against neuropathic pain

Electronic Health Record

While speaking with Mrs. Hubbard, you notice she’s sleepy. You decide to check her electronic health record.

Overview

Name: Jane Hubbard

DOB: 02-05-1950

Age: 72

Gender: Female

Key Points From Hx and Px

High pain intensity ratings (8-10/10)

Sleeps on and off most of the daytime hours

Medications From Home

Oxycodone ER 30mg BID

Polyethylene glycol 3350 (laxative) 17g, PO, daily

Adjusting to Combat Sedation and Pain Intensity

Mrs. Hubbard is somnolent, sleeps most of the day, yet reports high pain intensity. What would the best action be?

 Adjusting for Severe Pain After No Side Effects

If the patient is wide awake and reporting severe pain after several doses with little to no side effects, what would the best actions be? More than one answer may apply.

Immediate Release VS Extended Release Opioids

Immediate Release opioids feature the following medications:

• Hydrocodone
• Hydromorphone
• Morphine
• Oxycodone

Take note of the following for Immediate Release opioids:

• Indicated for acute pain
• Provide the cornerstone for acute pain management
• Must be swallowed whole (cannot be cut, chewed, or crushed)

Extended Release (ER) opioids feature the following medications:

• Fentanyl
• Transdermal
• Morphine ER
• Oxycodone ER
• Oxymorphone ER

Take note of the following for Extended Release (ER) opioids:

• Most dosage units contain more opioid than a starting dose
• Take days to weeks to obtain steady state after 3-5 half-lives
• Are indicated for tolerant patients only
• Order as prn

Summary

• Counsel patient on realistic expectations for pain control
• Reserve opioids for moderate to severe pain
• If opioids are used, utilize the lowest possible dose as part of a multimodal regimen, including scheduled NSAIDs, acetaminophen, and non-pharmacologic therapies, unless contraindicated.
• Use oral route when possible
• Avoid long-acting opioids for acute pain
• Titrate down or up after initial dose by increments of 25-100%