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Objectives CASE: Practical Principles of Inpatient Opioid Pain Management
College of Mount St. Joseph, US has reference to this Academic Journal, Practical Principles of Inpatient Opioid Pain ManagementCory Taylor, MDJanuary 15, 2016CASE:56 year-old veteran alongside obstructive sleep apnea presents alongside subacute abdominal pain. CT findings are concerning in consideration of gastric adenocarcinoma. The patient is complaining of 10/10 pain in addition to the nurse wants so that know what you would like so that give him?ObjectivesUnderstand practical pharmacology behind selecting dose amounts in addition to frequenciesAppreciate the different ways of making opioids available so that patientsBring balance so that the Force in addition to order so that your opioid selectionPrepare in consideration of the possible respiratory side effects of opioid administration
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Opioid Dosing: PrinciplesOnset: informs the dose amountIV speed of onset (fastest-slowest)Fentanyl ? Heroin : Dilaudid : MorphinePO speed of onset (fastest-slowest)Oxycodone ? Dilaudid : Morphine ? Hydrocodone ? Codeine*IV time so that max efficacy = 10 minPO time so that max efficacy = 60 minDuration: informs the dose frequencyDilaudid, Morphine, Hydrocodone, Oxycodone = 4 hours*Practically Speaking?Opioids should be dosed at least Q4H so that prevent gaps in the maintenance of pain controlOpioid Availability: MechanismsPRN or ?As Needed? Dosing PROSPatient triggered ? they can only get what they ask forAdded layer of overdose protectionSet it in addition to forget it ? less thought, faster orderingCONSTime so that administration can take 30-60 min depending on staffLeads so that coverage gaps, poorly controlled painMakes patient?s feel dependent, disempowered, or ?seeking?Creates nursing-patient tension => increased nursing stressOverlooks altered or less verbal patientsInterferes alongside patient sleepOpioid Availability: MechanismsAround-the-clock or ?Scheduled? DosingPROSBetter coverage, better control, better sleepPatients are empowered ? reduces patient/nursing tensionEasier on nursing workflowDon?t need, don?t want: patients can always refuseCONSNeed holding parameters*Dynamically inflexible alongside changes in metabolism or mental statusTakes more time in addition to thought
Opioid Availability: MechanismsBasal-Breakthrough DosingATC dose provides basal coveragePRN dose covers breakthrough painPROSLess nursing pagesBetter satisfaction scoresCONSMore time ordering, thinkingCan increase demands on nursing staff*Opioid Availability: MechanismsEnter the PCABest of every worldPatient finally feels some control over their illnessNursing can set in addition to forgetDoctor can set in addition to [sort-of] forgetResponsiveness + Precision => FinesseSmaller doses, greater frequencies, immediate deliveryAllows in consideration of precise in addition to expeditious titration up or downNo coverage gapsStreamlines opioid consolidation in addition to conversionNo safer alternative than Bolus-only PCA*CONSRequires cognitive function in addition to trigger-abilityParenteral administration onlyOpioid Selection: Principles# 1: Opioid SolidarityStick so that a single opioid typeLess medication errorsEasier in consideration of titration in addition to conversion# 2: Opioid EquivalencyNo one opioid activates receptors better than othersSome opioids are more potent, but potency can be overcome by concentrationBut some patients will maintain that one opioid ?works better in consideration of me? than another?
Opioid Selection: PrinciplesOpioids are more like loop diuretics than antibioticsWith antibiotics, one may ?cover? the patient?s infection where another failsWith opioids ? Morphine : Lasix as Dilaudid : Bumex*Consequences of sub-optimal utilizationCan inadvertently reinforce drug-anchoring or drug-seeking behaviorsCan detract from future encounters in addition to therapeutic relationshipsCASE, cont:You give the patient an basal-breakthrough opioid regimen. Later on that night, the nurses calls so that inform you the patient?s oxygen saturation is 80%. He wants so that know if you should dial back on the opioids?See Notes Section in consideration of DiscussionOpioid Narcosis: PearlsNot all opioid-related sleep is opioid narcosisOpioid-induced narcosis produces resistant or refractory somnolenceHealthy opioid-related sleep in wake-ableOpioid overdose always leads so that somnolence before respiratory failureRespiratory failure is caused by decreased respiratory drive*Keep in mind: respiratory rates of 8-10 are normal in healthy individuals
A Note on Naloxone: Responsiveness so that naloxone in altered mental status is not diagnostic in consideration of opioid-narcosisNaloxone blocks the body?s natural endorphin-mediated suppression of painCan cause pain in addition to discomfort, even in healthy individualsResponsiveness so that naloxone = responsiveness so that noxious stimulusWhich of these regimens is the most optimized?Morphine SR + percocet in consideration of breakthroughMorphine IVP PRN in consideration of moderate pain + Dilaudid IVP PRN in consideration of severe painFentanyl drip + oral dilaudid q6h as neededNorco q4H ATC + Norco Q2H PRNOxycontin + tramadolThe EndSee additional slides in consideration of supplemental material*
A Super User-Friendly Conversion TableA Side Note on EuphoriaFaster onset, time so that peak, in addition to other factors can increase the euphoria associated alongside a given opioidEuphoria is sometimes mistakenly perceived by patients as increased efficacy => increased drug-anchoring/requesting behaviorsEuphoria ~> dependency, STREET VALUEA Brief Guide so that Aberrant BehaviorNot all aberrant behavior is drug-seeking behaviorTraffickers are not always abusersDesperate or anchoring behavior ? ?drug-seeking? behaviorLegitimate patients alongside undertreated pain or opioid withdrawal have genuine needs
A Brief Guide so that Aberrant BehaviorNegative or discordant urine drug screenInconsistency of storySplittingProvider-jumpingLosing prescriptionsPoor self-care or self-investmentRunning out of medicationHaggling or making demandsIrrationality, especially regarding equivalent dosesRED FLAGSYELLOW FLAGS
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