Event 5: Follow-Up

Follow-up With Nestor's Treatment With Morphine

Initially, Nestor tolerates the morphine well, and his episodes of pain occur less frequently and are less intense. However, after a few days he seems increasingly uncomfortable. His mother calls and says he seems restless. She reports that he is urinating fine and his discomfort does not seem like pain. He has not had a bowel movement in 2 days, and when he went 2 days ago, it was a small amount and more firm than his usual stools. He typically has 1–2 bowel movements a day. You believe he is constipated.

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What is your next step in management?

Incorrect

Correct

Incorrect

Dr. Korones Speaks With Nestor's Mother About Increasing Dosage of Miralax

With the morphine and polyethylene glycol 3350, Nestor is feeling better for a while. However, after about a week, he seems increasingly uncomfortable. His mother calls and says he seems restless again, although she does not think his pain is worse. In addition, he is not urinating as much and sort of dribbles when he goes, although she does not think his pain is worse. He is otherwise the same. In particular, he is still moving his bowels.

You see him to the office that day. You palpate his lower abdomen and note that it is full in the suprapubic region and that he cries when that area is palpated. You suspect that it his bladder and you insert a Foley catheter, upon which he voids 400 mL of normal-appearing urine.

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What is your next step in management?

Incorrect. While a Foley catheter might be necessary acutely, it is best to stop the medication that is presumably causing it.

Incorrect. It is correct to stop the morphine, but an equianalgesic dose of another opioid should be substituted. Acetaminophen and ibuprofen are unlikely to be effective for pain that requires morphine.

Correct. The patient is suffering from a relatively common opioid toxicity: Urinary retention There is no simple medication or non-invasive measure to reverse this toxicity. For such opioid toxicities (urinary retention, pruritis refractory to antihistamines), an empiric change to a different opioid should be considered. When such changes are made, the toxicities often resolve.

Incorrect. It is not reasonable to expect a prompt intervention by the orthopedist, and Nestor needs something to control his pain.

Incorrect. A fentanyl patch may be helpful, but a short-acting, immediate-release medication is also needed.

Treatment of Opioid Side-Effects

Constipation
- Suitable diet (increased fluids and bulk)
- Docusate sodium (stool softener)
- Senna (stimulant)
- Polyethylene glycol 3350 (osmotic agent)
Nausea and Vomiting
- Metoclopramide
- Promethazine
Pruritus
- Diphenhydramine or hydroxyzine
- Change opioid to agent causing less histamine release
Respiratory Depression
- Naloxone

Nestor's Updated Treatment

You prescribe oxycodone. An hour later, the pharmacist calls to tell you that he cannot fill the prescription because the insurance company requires prior authorization. They send you a form to complete to request that they authorize reimbursement for the oxycodone. You do that, and explain on the form, that morphine had been tried but the patient developed a toxicity and that a change in opioid was required. The following day, you receive a fax that says your request was denied. On the fax it says, “see comments from the pharmacist regarding why the medication was denied,” but that section is blank, so you don’t why it was denied. There is no contact name on form, but there is a phone number.

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What is your next step in management?

Incorrect. Try another opioid is not the best choice. However, sometimes it is necessary if an appeals process for the best medication takes an inordinate amount of time.

Correct. You have carefully reviewed the various options for Nestor and have decided that oxycodone is the best way to minimize his pain and avoid opioid toxicity. A denial from the insurance company does not change that medical reasoning. It is the provider’s obligation to advocate for his/her patient. Part of that advocacy is making a case to the insurance company regarding the necessity of this medication for Nestor. At the same time, it must be acknowledged that advocacy takes time, and one does not want to keep one’s patients in pain while taking days to weeks to get the right medication. Hence, sometimes it is necessary to resort to alternatives as one advocates.

Incorrect. This puts a financial burden on the family and can create guilt and a sense of inadequacy, especially if the family cannot afford the medication.

Incorrect. Nestor’s pain is moderate to severe and he has shown that opioid therapy is necessary to control his pain.

You call the number on the fax, and after about 30 minutes on hold and a transfer to several different departments, you gain approval for the oxycodone. It helps the pain and he tolerates it well. He takes about 5 doses (3 mg each) per day. He is moving his bowels. He remains alert and he seems to like his music again.

His mother is very pleased, but says it is hard being hypervigilent and always having to be ready to give him something at the first inkling of any pain. She wonders if there is anything “longer acting” that can be given. You agree.

Test Your Knowledge

What long-acting opioid would you prescribe?

Incorrect. A fentanyl patch could also be considered. However, even the lowest dose patch is a higher dose of opioid than Nestor is currently receiving. A 12 mcg fentanyl patch (the lowest dose) is equivalent to 30-59 mg PO morphine a day, and Nestor is receiving a morphine equivalent of 22.5 mg morphine a day. Hence the patch could be sedating.

Correct. Methadone is unique among opioids with the following attractive features: In addition to mu receptor binding, it is an NMDA receptor blocker and therefore is effective against neuropathic pain. It is not cleared by the kidney and therefore can be used in patients with renal compromise. It has a variable half-life but is generally longer than the other opioids (oxycodone = 2 – 4 hours, methadone = approximately 24-hours). It is particularly attractive for children with severe developmental disabilities because it is the only long-acting opioid that can be given in liquid formulation, particularly helpful for children with G-tubes.

Incorrect. Sustained release morphine and oxycodone come only in tablet form and cannot be crushed. There are a few sustained-release morphine preparations that are beads in capsules and can be removed from the capsules put in a slurry and administered through a G-tube. However, they are not widely available.

Incorrect. Hydromorphone is not available as a sustained-release preparation.

As part of comprehensive care, the primary care physicians asks the pharmacist to review the use of methadone with Nestor’s mom.