There are hundreds of opioid conversion calculators available online, though they are not all of good quality. I would like to direct you to one of the opioid conversion calculators that I find to be most useful and evidence based. Locate http://opioidcalculator.practicalpainmanagement.com/ and complete opioid conversions for the following two scenarios, read the description of your “answer” and discuss your findings.
- KR is on 240mg of MS Contin® q12h. He is admitted to the hospital for intractable vomiting and needs an opioid route change. How much IV morphine should he receive?
According to the opioid conversions calculator provided from “Practical Pain Management” (2020), KR, who was receiving 480mg of MS Contin® (Morphine Sulfate ER)/ day, would receive an equianalgesic dose of morphine IV 160mg/ day administered in divided doses every 4-6 hours (40mg if administered every 6 hours, and approximately 26.6 mg if administered every 4 hours). The dose was calculated with an oral to IV morphine conversion factor of 1:3, and therefore the total daily dose of oral morphine (480mg) was divided by 3 to yield 160mg of IV morphine. It is noted that a prophylactic bowel regimen should be added when taking this opioid and that stool softeners for opioid-induced constipation are ineffective; a recommended therapy is the addition of stimulation laxatives to increase peristalsis (Opioid Conversions and Opioid Dosing Calculator, 2020). Pain Management Discussion
- A 79 year old white male is taking hydrocodone/APAP 10/325 for lower back pain (pt diagnosed with degenerative disc disease several months ago). The physician had written a prescription for Vicodin® 10/325 i-ii Q4-6h prn pain with a quantity of 120. Her expectation was that this would last the patient for one month. The patient is now requesting refills about every 10-14 days. He states he has been taking 2 tabs Q4h (12 tablets per day) because “the pain is so bad I just can’t stand it!”.
- What is the problem with the way the patient is taking this medication versus the way it was prescribed
- Based on your assessment, it is determined this patient should be converted to extended release morphine for better, more consistent pain control. Perform this conversion and provide an appropriate recommendation (drug, dose, frequency). (*Please note- this scenario was not part of this weeks discussion- I answered it before it was changed and thought I would add the work I already completed for class contribution and discussion*) Pain Management Discussion
The 79-year-old male patient was prescribed Vicodin® 10/325 i-ii Q4-6h prn for pain with a quantity of 120, and states that he has have been taking 2 tabs Q4h (12 tabs/day). The patient has been taking the maximum dose, but instead of using the prescription as a prn, he has been using it as maintenance therapy. The dose he has been taking yields 3900 mg of acetaminophen per day, which is very close to the historic daily maximum of 4g. It is not mentioned whether or not the patient has any established hepatic insufficiency or failure, however, his age puts him at greater risk for toxicity. Due to concerns of hepatic toxicity in adults, McNeil Consumer Healthcare voluntarily reduced the total daily recommended maximum of acetaminophen 500mg tabs to 3000mg and regular strength 325mg tabs to 3250mg(Farrell, 2020). According to these limits, the patient is exceeding the daily recommended dose and is at risk for hepatic toxicity. According to the opioid dose conversion calculator, a 120 mg daily dose of hydrocodone is equivalent to a 120 mg daily dose of morphine (the calculator does not distinguish between IR and ER morphine) and this daily dose should be divided and administered every 4-6 hours (20mg if administered Q4H and 30mg if administered Q6H) (Opioid Conversions and Opioid Dosing Calculator, 2020).
Pain management in elderly patients pose unique risks as this population is at an increased risk of falls, cognitive impairment, respiratory depression, polypharmacy, organ metabolism impairment, as well as other age-related issues (U.S. Department of Health and Human Services, May 2019). Therefore, a multidisciplinary approach should be taken for pain management of elderly adults including non-pharmacologic approaches such as various forms of therapies and complementary and integrative health techniques, such as yoga, tai chi, spirituality, acupuncture, mindfulness-based stress-reduction, massage therapy, etc. (U.S. Department of Health and Human Services, May 2019)Another pharmacologic consideration would be the addition of an SNRI, such as venlafaxine or duloxetine, as they are effective for a variety of chronic pain conditions, such as musculoskeletal pain, and have significantly fewer side effects than TCAs and additional opioids (U.S. Department of Health and Human Services, May 2019). Pain Management Discussion
Migraine is a major neurological disease that affects more than 36 million men, women and children in the United States. There is no cure for migraine. Most current treatments aim to reduce headache frequency and stop individual headaches when they occur. Let’s look at a case example:
CM is 20 years old female with severe, prolonged 2 to 3day migraines twice per month. She has difficulty sleeping and is mildly anxious. She occasionally utilizes an inhaler for asthma.
- Provide an evaluation of CM’s condition including non-pharmacological interventions and treatment options
- Is Cm a candidate for prophylactic therapy, and if so, what option would be best suited to her? Pain Management Discussion
There is currently much debate over choice of initial therapy for migraine attacks as well as no consensus for initial therapy for migraine prevention (Chisholm-burns et al., 2019). CM is experiencing severe migraines, approximately twice per month that last 2-3 days. It is not indicated how long CM has been experiencing migraines, whether they are with or without aura, and whether she has tried any previous medications for treatment or management. However, it is represented as enough to impact her quality of life and maintenance therapy is something that should be considered as preventative therapy for episodic migraines as it may help decrease migraine frequency and severity as well as progression to chronic migraines (Ha & Gonzalez, 2019). According to guidelines from the American Family Physicians (2019) for migraine prophylaxis treatment, first-line therapies that should be considered are divalproex, topiramate, propranolol, metoprolol, and timolol. Though beta-blocker prophylaxis might be a good choice for CM considering they may also assist with sleep and anxiety, beta-blockers are contraindicated in patients with reactive airway diseases, and it is indicated that CM has asthma (Chisholm-burns et al., 2019). Ca channel blockers, ARB’s, or ACE-inhibitors may be utilized when beta-blockers cannot be tolerated, however, there are no Ca channel blockers which are FDA approved for migraine prophylaxis and only lisinopril and candesartan have shown possible efficacy (Chisholm-burns et al., 2019). Divalproex and topiramate are both anti-epileptics are that recommended for first-line migraine prophylaxis; both must be titrated, and serum drug-levels monitored (Chisholm-burns et al., 2019). Weight gain is common with divalproex, whereas it is not with topiramate and therefore that drug may be a better choice between the two. Low-dose TCA’s, such as amitriptyline, have proven efficacy and due to the side-effect of sedation, may assist with CM’s difficulty sleeping (Chisholm-burns et al., 2019). Additionally, venlafaxine, an SNRI, has demonstrated probable efficacy, however, it should not be used with a triptan to due risk of serotonin syndrome and that would limit CM’s management for breakthrough pain relief (Chisholm-burns et al., 2019). Overall, topiramate may be the best choice for CM provided the side-effects profile of other medications for prophylaxis migraine management. Pain Management Discussion
