I couldn't even guess right and follow the laws of statistics 
Lizard1 said:the question was: a metastasized CA pt requiring 20mg IM MSO4 q4hrs needs to be converted to a po regimen. Which of the following doses could be given every 12hrs in po form for equianalgesia?
a)30mg
b)60mg
c)120mg
d)150mg
e)300mg
ps - i don't want to know the answer because on all the questions that i didn't know, i could atleast narrow them down to 2 or 3 possibles. i've looked up the answers and so far have only gotten 1 right out 7 questions
AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh
foxtrot said:
Noyac said:
supahfresh said:
Lizard1 said:i was thinking.....oh that equals 60mg po bid.....but then i was thinking that methadone was the only narcotic that had 1:1 dosing of po and IV(IM ?) so maybe it was 2:1? So I picked C and moved on to the next statistic question about student t-test and some other crap that I hadn't looked at since cramming for a med school test
I came to 120mg too.Lizard1 said:the question was: a metastasized CA pt requiring 20mg IM MSO4 q4hrs needs to be converted to a po regimen. Which of the following doses could be given every 12hrs in po form for equianalgesia?
a)30mg
b)60mg
c)120mg
d)150mg
e)300mg
ps - i don't want to know the answer because on all the questions that i didn't know, i could atleast narrow them down to 2 or 3 possibles. i've looked up the answers and so far have only gotten 1 right out 7 questions
AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh
jetproppilot said:ALL I WANNA KNOW IS.....................IS IT C? 120 mg?................
InductionAgent said:
Noyak!)Lizard1 said:the question was: a metastasized CA pt requiring 20mg IM MSO4 q4hrs needs to be converted to a po regimen. Which of the following doses could be given every 12hrs in po form for equianalgesia?
a)30mg
b)60mg
c)120mg
d)150mg
e)300mg
ps - i don't want to know the answer because on all the questions that i didn't know, i could atleast narrow them down to 2 or 3 possibles. i've looked up the answers and so far have only gotten 1 right out 7 questions
AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh
md2k said:
md2k said:Well, there have been several different opinions and I will tell you what I do according to the literature.
IMIV to PO dose is 1:3
20mg IM Q4hrs = 120mg/day
Converted to PO 120x 3 = 360 mg/day
Given in BID dosing it = 180 mg
Decrease the dose by 25% over 24 hrs = 270mg /day
New dose is 135mg BID. The closest anwer is 120 mg BID.
I go with C.
If you reduce it by 33% over 24 hrs = 241mg/day
Now the dose is 120mg BID.
The answer is C
In our insitution we usually decrease the dose by 33% d/t the lack of cross tolerance,
So how do you figure it out?
Always Round Down When Doing Dosage Conversions
1. Calculate total 24h dose of current opioid.
2. Convert 24h dose to new 24h dose using equi-analgesic dosing table.
3. Decrease the converted equi-analgesic dose by proper percentage for the type of drug (e.g. 25-50% for most opioids, 75-90% for methadone).
4. Determine the administration interval of the new drug
Two articles that review equianalgesic calculations are useful to keep on hand for reference. They are:
1. Gordon DB, Stevenson KK, et al. Opioid equianalgesic calculations. J Pall med 1999;2(2): 209-218.
2. Gammaitoni AR, Fine P, et al. Clinical application of opioid equianalgesic
data. Clin J Pain 2003;19:286-297.
I hope this helps???
sdn1977 said:
sdn1977 said:
No I am not talking about cross tolerance b/w MS or Methadone. Read the answer I gave.Noyac said:Maybe he is talking about cross tolerance b/w MS and methadone.
If this were a real cancer pt, yes I would have ordered 120mg BID, but I know- your not asking me.
Personally, I would probably have put the pt on methadone with percocet for breakthrough and possibly even a fentanyl patch. I don't hold back with cancer pain. And once this started to lose effect, I would put a intrathecal ms pump in and add baclofen if the cancer/pain fit the bill. were was that in the answer choices? I pick F
jetproppilot said:uhhhhhh.....dude......180 mg is not a choice.
Yes, your calculations may be correct, but stick to the %^&*ing question, which is, WHATS THE RIGHT ANSWER????
And if the right answer is C, 120 mg, I'm gonna, as the native New Orleanians do when something happens , gonna FALL OUT.
ER DOCTOR IN NEW ORLEANS: "What happened?"
"He FELL out." ....whatever that means...............
Dude, read # 17. The answer is C. I literally wrote the answer for you. And yes there is no cross tolerance and that's why you decrease the dose by 25-50%.InductionAgent said:
md2k said:
md2k said:If you read what i typed I said I would only decrease by 33% d/t LACK of cross tolerance. As far as prescribing 120mg bid to this pt, Yes I would.
Again you must individualize your dose to meet your patient needs.
There are a number of options for consideration:
1. Cut back the daily amount by approximately 33% due to lack of cross tolerance between opioids.
-useful when changing opioids due to the development of side effects in a patient whose pain is adequately controlled.
In this pt we could do:
Long-acting morphine 120 mg/12 hours (total 240 mg/d)
Short-acting morphine 2040 mg orally every 6 hrs prn (1020% of 240)
2. Increase the daily amount by 2530%.
-I would use this approach if the pt is in severe pain in which it affects the pts quality of life. An additional consideration is that his exposure to a moderate dose of opioids over several months has created a buffer of tolerance, allowing for safety when rapid upward titration is warranted.
So, yes. I would give 120mg BID and also give 20-40 mg q6hrs for breakthrough if needed. I would have the pt f/u in clinic in 1 wk.
With that being said high dose narcotics are not safe and the side fx profile changes to the point that we dont really understand. There have been no studies done on high dose narcotics that I know of. For that reason I would have the pt f/u with me in clinic in 1 week initially then in 1 month once he develops more tolerance.
md2k said:
sdn1977 said:
Laryngospasm said:
sdn1977 said:
md2k said:SDN, I agree that X-tolerance is not an issue here. However, I disagree that not adjusting the dose is unneccessary.
While there have been multiple opioid conversion charts developed, none are reliable and none take into consideration the individual differences in effect and metabolism b/w pts and within medications. Brand name and generic meds may have significant differences in bioavailability, and metabolism of medications may be influenced by genetic polymorphism and drug interactions. It is therefore important to recognize that equipotent doses of medications may have very different degrees of analgesia and side effects. In general, to switch between medications, the clinician must calculate a rough equivalent 24 hour dose, divide by the dosing schedule, and then "under-dose, with subsequent titration to effect.
We treat several CA pts as we are often consulted by oncology. We mainly perform interventional procedures on this pts and also for help with adjustments of thier pain medicines. If there Ca is stable and pts are not in hospice we will take over thier pain management. Obviously, we dont have hospice pts come in. In fact if they are hospice we dont even see them. Why are we talking about hospice???
Why do we take care of there pain meds? Here in the state of texas, prescribing schedule II drugs is highly detered by the texas state board. They require your DEA and also a DPS number which is for the state of texas. Thus, many physicians are unwilling to write for schedule II drugs and we get a crapload of pts dumped on us. Isn't university medicine great??
Thank you for your input
md2k said:SDN, I agree that X-tolerance is not an issue here. However, I disagree that not adjusting the dose is unneccessary.
While there have been multiple opioid conversion charts developed, none are reliable and none take into consideration the individual differences in effect and metabolism b/w pts and within medications. Brand name and generic meds may have significant differences in bioavailability, and metabolism of medications may be influenced by genetic polymorphism and drug interactions. It is therefore important to recognize that equipotent doses of medications may have very different degrees of analgesia and side effects. In general, to switch between medications, the clinician must calculate a rough equivalent 24 hour dose, divide by the dosing schedule, and then "under-dose, with subsequent titration to effect.
We treat several CA pts as we are often consulted by oncology. We mainly perform interventional procedures on this pts and also for help with adjustments of their pain medicines. If there Ca is stable and pts are not in hospice we will take over thier pain management. Obviously, we dont have hospice pts come in. In fact if they are hospice we dont even see them. Why are we talking about hospice???
Why do we take care of there pain meds? Here in the state of texas, prescribing schedule II drugs is highly detered by the texas state board. They require your DEA and also a DPS number which is for the state of texas. Thus, many physicians are unwilling to write for schedule II drugs and we get a crapload of pts dumped on us. Isn't university medicine great??
Thank you for your input
sdn1977 said:It also prevents pts who have to travel unexpectedly out of the state to obtain refills on their medications in another state.....as you say - Texas seems to want to deter the use....gotta wonder why?)
Interesting that you mentioned that. I recently came from capitol hill where I was speaking with congressmen for funding support on a bill called NASPER.
What is NASPER??
NASPER was signed into law on August 11, 2005 making it the only statutorily authorized program to assist states in combating prescription drug abuse of controlled substances through a prescription monitoring program (PDMPs).
NASPER fosters interstate communication by providing grants to set up or improve state systems that meet basic standards of information collection and privacy protections that will make it easier for states to share information. This will enable authorities to identify prescription drug abusers as well as the problem doctors who betray the high ethical standards of their profession by over or incorrectly prescribing prescription drugs.
The Secretary of Health and Human Services (HHS) in support of the new grant program is charged with developing minimum standards to safeguard personal information. The Secretary will only be able to approve an application for a NASPER grant if a state meets these requirements, which must include use of encryption technology, limiting access to approved personnel, and defined penalties for unauthorized use or disclosure of information contained in the database. Furthermore, states are also welcome
to enact privacy protections above and beyond federal requirements.
Although NASPER has been signed into law, Congress has yet to appropriate funds to HHS. Without this appropriation, although authorized, NASPER is unfunded. NASPER is currently administered by the Department of Health and Human Services (HHS) and provides grants to states to establish and improve prescription drug monitoring programs (PDMPs). The law authorizes $15 million in FY 07 and $10 million each year through FY 10. Authorization of the full allowed amount of $15 million vital to the grant awards process.
In a January 10, 2006 letter to Joshua Bolton, Director for the Office of Management and Budget, 22 members of congress, representing states across the country, requested that funding for the NASPER program be added to the FY 07 budget.
In a nut shell the bill was passed but it has no funding.
Jet, this was my last paragraph.
md2k said:sdn1977 said:It also prevents pts who have to travel unexpectedly out of the state to obtain refills on their medications in another state.....as you say - Texas seems to want to deter the use....gotta wonder why?)
Interesting that you mentioned that. I recently came from capitol hill where I was speaking with congressmen for funding support on a bill called NASPER.
What is NASPER??
NASPER was signed into law on August 11, 2005 making it the only statutorily authorized program to assist states in combating prescription drug abuse of controlled substances through a prescription monitoring program (PDMPs).
NASPER fosters interstate communication by providing grants to set up or improve state systems that meet basic standards of information collection and privacy protections that will make it easier for states to share information. This will enable authorities to identify prescription drug abusers as well as the problem doctors who betray the high ethical standards of their profession by over or incorrectly prescribing prescription drugs.
The Secretary of Health and Human Services (HHS) in support of the new grant program is charged with developing minimum standards to safeguard personal information. The Secretary will only be able to approve an application for a NASPER grant if a state meets these requirements, which must include use of encryption technology, limiting access to approved personnel, and defined penalties for unauthorized use or disclosure of information contained in the database. Furthermore, states are also welcome
to enact privacy protections above and beyond federal requirements.
Although NASPER has been signed into law, Congress has yet to appropriate funds to HHS. Without this appropriation, although authorized, NASPER is unfunded. NASPER is currently administered by the Department of Health and Human Services (HHS) and provides grants to states to establish and improve prescription drug monitoring programs (PDMPs). The law authorizes $15 million in FY 07 and $10 million each year through FY 10. Authorization of the full allowed amount of $15 million vital to the grant awards process.
In a January 10, 2006 letter to Joshua Bolton, Director for the Office of Management and Budget, 22 members of congress, representing states across the country, requested that funding for the NASPER program be added to the FY 07 budget.
In a nut shell the bill was passed but it has no funding.
Jet, this was my last paragraph.
I do apologize since this thread has gone so off topic from that poor pt on IM ms & the students who were agonizing if they chose the correct answer....so - I'll keep this short!
Check out the Harold Rogers Prescription Drug Act of (2001 or 2002???). States have received funding for programs from this act for 3 or 4 years & in my state (CA) it has allowed the following:
1. All CII & III rxs are reported to the Dept of Justice in real time
2. Prescribers & pharmacies located in the CA can obtain a request from the Dept of Justice for the CII or III history of a particular patient or for themselves, if they suspect someone using their DEA # inappropriately. Pharmacies can obtain histories on both pts & prescribers.
It is my understanding that the folks who wrote the NASPER bill are working with the folks who are actually giving grants under the Harold Roger's bill together to provide a more cohesive & comprehensive plan of addressing drug diversion. The problem is....the issues in CA are different from those in TX....and those in MN.
The issue with drug laws are....state laws always trump federal law if state law is stricter - hence the TX differences.
