Morphine

[foxtrot]

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Well, the ABA-ASA exam kicked me ass today.

Does anyone know how in the hell you convert IM morphine to po doses?

Thanks

 

[Lizard1]

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 🙁 I couldn't even guess right and follow the laws of statistics 🙁

AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh

 

[jetproppilot]

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 🙁 I couldn't even guess right and follow the laws of statistics 🙁

AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh

When in doubt, pick C.

120 mg. Final answer.

And since I have no idea how to do that, I wouldda picked C.

Hopefully SDN1977 will chime in and enlighten us.

 

[supahfresh]

20 mg IM Q 4 hours is like 60 mg BID. They ask you to convert to PO BID. Normally, IV to PO is 3:1 which would give you answer of 180 mg which was among the answer choices. I havent looked it up yet, but I feel like IM to PO is 2:1 and thus 120 mg is the correct answer. anybody agree?

I'm bran-dead and pissed off cuz i'm on call and not out drinking with the rest of my class.

 

[camkiss]

I think the question asked for a dose of sustained release morphine if I am not mistaken. Not sure if that matters. I had no idea and picked B.

 

[InductionAgent]

Does anyone know how in the hell you convert IM morphine to po doses?

Thanks

According to the chart in Tarascon, IM doses are treated the same as IV, therefore a 1:3 parenteral to oral ratio would be used for a sustained-release dosage in chronic pain.

The Duragesic website also supports this. "Table B" is most useful.

http://www.duragesic.com/html/dur/hcp_dosing.jsp;jsessionid=AYXNZI5QKMBOECQPCCGTC0YKB2IIQNSC

 

[Noyac]

Yeah, I'm fairly sure IM and IV are the same doses.

I don't remember exactly the conversion from IV/IM to PO but it seems like it was different from the 1:3 ratio. But then again that is starting to sound familiar. So what the bleep do I know.

 

[jetproppilot]

Yeah, I'm fairly sure IM and IV are the same doses.

I don't remember exactly the conversion from IV/IM to PO but it seems like it was different from the 1:3 ratio. But then again that is starting to sound familiar. So what the bleep do I know.

ALL I WANNA KNOW IS.....................IS IT C? 120 mg?................

 

[Lizard1]

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 😀

 

[toughlife]

20 mg IM Q 4 hours is like 60 mg BID. They ask you to convert to PO BID. Normally, IV to PO is 3:1 which would give you answer of 180 mg which was among the answer choices. I havent looked it up yet, but I feel like IM to PO is 2:1 and thus 120 mg is the correct answer. anybody agree?

I'm bran-dead and pissed off cuz i'm on call and not out drinking with the rest of my class.

if it is 120mg then I am a lucky guesser cuz that's what I put and I had no frigging idea how to figure it out.

 

[toughlife]

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 😀

Hey those stats questions were bs but I remember choosing either student t-test or ANOVA as answers to all of them. Prolly got them wrong too.

 

[SleepIsGood]

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 🙁 I couldn't even guess right and follow the laws of statistics 🙁

AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh

I came to 120mg too.

 

[InductionAgent]

ALL I WANNA KNOW IS.....................IS IT C? 120 mg?................

I believe that 180mg would be the answer. 20mg x 3 (converting from IM to PO) = 60mg. 60mg x 3 (converting 4hr dose to 12hr dose) = 180mg.

I've recently looked up the conversion factor and cited references, and am quite sure the conversion for IM to PO is 1:3

 

[jetproppilot]

I believe that 180mg would be the answer. 20mg x 3 (converting from IM to PO) = 60mg. 60mg x 3 (converting 4hr dose to 12hr dose) = 180mg.

I've recently looked up the conversion factor and cited references, and am quite sure the conversion for IM to PO is 1:3

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...............

 

[cloud9]

if it is 120mg then I am a lucky guesser cuz that's what I put and I had no frigging idea how to figure it out.

Ditto.

 

[sdn1977]

Okay....I'm only posting because Jet asked.

First...you have an opiod tolerant pt so the conversion is 1:3 (for a naive pt it could be 1:6 - hence the variations in the tables) - BUT this is a guide only! For conversion to a long acting form, you allow for variations in presystemic elimination (gut wall & liver) so you go slow & conservative & allow for variations with breakthrough coverage.

For morphine - IM & IV are equivalent.

So..20mg IM q4h = 120mg ms/24hr
Multiply x 3 for the oral equivalence = 360mg/24h orally - should be ...yes, as someone said 180mg q 12h.....

But...that wasn't a choice. Now that you know you're @ 180mg or therabout q 12h - choice a & b are out - too low. Choice 3 is way too high.

Now..this is where you need to know your drug choices. Long acting morphine is only available as 15, 30, 60, 100 & 200mg tablets - not crushable or breakable. So....given that knowledge - it could be either c or b because each dose would require multiple tablets of an available strength.

However, taking 5 x 30mg tablets is an issue for CA pts & 2x60mg tablets is a more reasonable alternative (altho 3x60mg tablets would probably be closer to the mark and as someone pointed out - it wasn't a choice). But...120mg q12h might put someone in withdrawal unless there is sufficient breakthrough coverage. But...the answer could be 150mg from a strictly arithmetic conversion.

Personally, having converted lots of pts like this.....I wouldn't have chosen any of the answers, but thats just me. (I'm more decisive when you ask for an opinion rather than trying to explain a question on a test!)

Now....I will throw out just one more thing to consider.....if you read the question & consider when they ask "which of the following DOSES could be given......" & interpret that to mean multiples of "available dosage strengths" to reach your equianalgesic dose.....then b is the correct answer since 3x60mg is your target of 180mg q 12h (altho I guess you could do 6x30mg q 12h - that would make anyone vomit!)

But...I don't know how anal your testing folks are - would they ask something that obscure (like knowing what strengths are available)?

I'd offer an opinion here....but...I'll refrain ( 😉 Noyak!)

 

[md2k]

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 🙁 I couldn't even guess right and follow the laws of statistics 🙁

AND speaking of statistics!!!!!!!!! Since when have there been so many stat questions.....arghh

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??? 😀

 

[jetproppilot]

The answer is C

HAHHAHHAHAHAHAHAHAHAHAHHAHAHAHAHAHAHAHAHHAHAHAHAHAHA

when in doubt pick C.

 

[Lizard1]

maybe i got one right then 😀

 

[supahfresh]

sorry guys, but 180 mg was a choice. the operator just forgot to put it in.

 

[sdn1977]

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??? 😀

Decrease due to cross tolerance??? Shouldn't be a factor here. Cross tolerance is only a consideration when changing from one drug to another - ms to oxycontin or fentanyl for example. Cross tolerance is not of any significance when staying within the same drug & if I remember those studies - they support that as well....I'll have to go find them.

But....I'm curious since this is actually your business. If this were a real pt, would you REALLY have ordered 120mg bid in this cancer pt?

 

[Noyac]

Decrease due to cross tolerance??? Shouldn't be a factor here. Cross tolerance is only a consideration when changing from one drug to another - ms to oxycontin or fentanyl for example. Cross tolerance is not of any significance when staying within the same drug & if I remember those studies - they support that as well....I'll have to go find them.

But....I'm curious since this is actually your business. If this were a real pt, would you REALLY have ordered 120mg bid in this cancer pt?

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

 

[md2k]

Decrease due to cross tolerance??? Shouldn't be a factor here. Cross tolerance is only a consideration when changing from one drug to another - ms to oxycontin or fentanyl for example. Cross tolerance is not of any significance when staying within the same drug & if I remember those studies - they support that as well....I'll have to go find them.

But....I'm curious since this is actually your business. If this were a real pt, would you REALLY have ordered 120mg bid in this cancer pt?

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 20–40 mg orally every 6 hrs prn (10–20% of 240)
2. Increase the daily amount by 25–30%.
-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]

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

No I am not talking about cross tolerance b/w MS or Methadone. Read the answer I gave. 🙂
Yeah, you got it right. This pt would possibly be good candidate for an intrathecal pump. Especially in the face of increasing narcotic requirments.

 

[apma77]

are you guys aware that its illegal to post "exact" test questions ..aba forbids it and you could lose your board eligibility and resgistration status

dont want to be a party pooper ..sorry guys

 

[VentdependenT]

ampa you always rain on a parade.

I think I put 180mg down. Mushahahhahahahah!

 

[InductionAgent]

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...............

Jet, take a deep breath...relax...

Naturally, I wasn't referring specifically to the copyrighted ASA/ABA exam, but I would imagine that whoever thought that the "D" option was 150mg misread and misquoted it, that it was probably 180mg.

Agree with sdn1977 that cross-tolerance not a factor since it's morphine-to-morphine.

 

[md2k]

Jet, take a deep breath...relax...

Naturally, I wasn't referring specifically to the copyrighted ASA/ABA exam, but I would imagine that whoever thought that the "D" option was 150mg misread and misquoted it, that it was probably 180mg.

Agree with sdn1977 that cross-tolerance not a factor since it's morphine-to-morphine.

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%.
Look up the sources I cited.

 

[jetproppilot]

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%.
Look up the sources I cited.

After all that very respectful clinical banter,

one coudda rednekked out, and picked C.

HAHAHAHHAHAHAHAHAHAHAHAHAHAHHA

 

[sdn1977]

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 20–40 mg orally every 6 hrs prn (10–20% of 240)
2. Increase the daily amount by 25–30%.
-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. 😀

You certainly have far more experience in pain management than I, however, I would respectfully disagree that cross tolerance is an issue here. If there is a LACK of cross tolerance...then adjusting the dose is unnecessary In my understanding of the pharmacologic definition of cross tolerance with respect to opioids & their actions on the mu receptors (which is only one of many, many receptors narcotics act on, certainly), cross tolerance is not an issue when changing from one form of ms to another form of ms. It is an issue when changing from one opioid to another, which was not the example given.

At least that has not been a significant influence in my experience when I need to recommend a hospitalized cancer pt be transferred to an appropriate amount of oral morphine so they can return to their home setting. The considerations which come into play, in my limited experience, are ease of dosing, the number of tablets required (since the fillers & binders are nauseating as well as the difficult to swallow as the disease progresses), the cost of the medications & insurance coverage (often insurance limits coverage to #'s of tablets per day - not mg/day - similar to paroxetine or effexor) & the ability of the pt or caregiver to have appropriate breakthrough pain medications to give sl when the pt can no longer swallow (usually a liquid form which can be given with atropine to decrease secretions).

As much as I appreciate your approach to have the pt return to a clinic in a week, for a cancer pt, who appears to be terminal, altho that was not specifically stated, I've never known one to return to a physician setting to adjust the narcotic dose. Normally, the dose is adjusted by hospice nursing with protocol set parameters & orders to inform the physician when the parameters no longer meet the pts needs. This does in no way imply the physician is no longer an integral part of the dosing & titrating of the pts pain requirements for comfort - he/she is, however, not usually by a clinic visit - at least in my area. The balance, in my opinion, in the pt given as an example, is to provide easy, convenient pain relief with the ability to continue interactions with family as long as possible in as comfortable a setting as possible. I've done intravenous ms on pts at home & that is usually a huge burden to the family. I can't imagine an intrathecal pump....

That said....if the pt were a chronic, non-terminal pain patient, yes, I would agree with your recommendations since these folks need to maintain an active life while being treated for their chronic pain, however, that was not the pt mentioned.

There is actually lots of literature out there with regard to narcotic dosing and cancer. NCCN has Practice Guidelines In Oncology for both the pediatric & adult cancer pain patient. Also, most cancer pain pharmacologic measures have been based on principles promoted by WHO (Cancer Pain Relief, WHO, 1986) & have been validated & updated since. There really is no upper limit to analgesia with cancer pain & doses may vary 100-fold, but few patients need doses above the equivalent of 200-300mg/day without the addition of other adjuvant agents.

However, I do recognize the pain clinic which is affiliated with my institution does not consult often on cancer patients. Normally the oncologist handles these patients on their own, so your experience is certainly a different perspective & one in which I would be interested to see in a real patient, which is why I asked. I do thank you for your thoughtful reply and will consider all you've said next time I encounter a similar patient.

 

[tulAnesthesia]

edit:
reading too quickly. my apologies. bad post.

 

[Laryngospasm]

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%.
Look up the sources I cited.

Simple 3 to 1 conversion.

 

[Noyac]

You certainly have far more experience in pain management than I, however, I would respectfully disagree that cross tolerance is an issue here. If there is a LACK of cross tolerance...then adjusting the dose is unnecessary In my understanding of the pharmacologic definition of cross tolerance with respect to opioids & their actions on the mu receptors (which is only one of many, many receptors narcotics act on, certainly), cross tolerance is not an issue when changing from one form of ms to another form of ms. It is an issue when changing from one opioid to another, which was not the example given.

At least that has not been a significant influence in my experience when I need to recommend a hospitalized cancer pt be transferred to an appropriate amount of oral morphine so they can return to their home setting. The considerations which come into play, in my limited experience, are ease of dosing, the number of tablets required (since the fillers & binders are nauseating as well as the difficult to swallow as the disease progresses), the cost of the medications & insurance coverage (often insurance limits coverage to #'s of tablets per day - not mg/day - similar to paroxetine or effexor) & the ability of the pt or caregiver to have appropriate breakthrough pain medications to give sl when the pt can no longer swallow (usually a liquid form which can be given with atropine to decrease secretions).

As much as I appreciate your approach to have the pt return to a clinic in a week, for a cancer pt, who appears to be terminal, altho that was not specifically stated, I've never known one to return to a physician setting to adjust the narcotic dose. Normally, the dose is adjusted by hospice nursing with protocol set parameters & orders to inform the physician when the parameters no longer meet the pts needs. This does in no way imply the physician is no longer an integral part of the dosing & titrating of the pts pain requirements for comfort - he/she is, however, not usually by a clinic visit - at least in my area. The balance, in my opinion, in the pt given as an example, is to provide easy, convenient pain relief with the ability to continue interactions with family as long as possible in as comfortable a setting as possible. I've done intravenous ms on pts at home & that is usually a huge burden to the family. I can't imagine an intrathecal pump....

That said....if the pt were a chronic, non-terminal pain patient, yes, I would agree with your recommendations since these folks need to maintain an active life while being treated for their chronic pain, however, that was not the pt mentioned.

There is actually lots of literature out there with regard to narcotic dosing and cancer. NCCN has Practice Guidelines In Oncology for both the pediatric & adult cancer pain patient. Also, most cancer pain pharmacologic measures have been based on principles promoted by WHO (Cancer Pain Relief, WHO, 1986) & have been validated & updated since. There really is no upper limit to analgesia with cancer pain & doses may vary 100-fold, but few patients need doses above the equivalent of 200-300mg/day without the addition of other adjuvant agents.

However, I do recognize the pain clinic which is affiliated with my institution does not consult often on cancer patients. Normally the oncologist handles these patients on their own, so your experience is certainly a different perspective & one in which I would be interested to see in a real patient, which is why I asked. I do thank you for your thoughtful reply and will consider all you've said next time I encounter a similar patient.

Thank You for participating. 😀

You see, you know we need you.

 

[tulAnesthesia]

Simple 3 to 1 conversion.

thank you, laryngospasm. i read this thread too fast. simple, indeed.

 

[md2k]

You certainly have far more experience in pain management than I, however, I would respectfully disagree that cross tolerance is an issue here. If there is a LACK of cross tolerance...then adjusting the dose is unnecessary In my understanding of the pharmacologic definition of cross tolerance with respect to opioids & their actions on the mu receptors (which is only one of many, many receptors narcotics act on, certainly), cross tolerance is not an issue when changing from one form of ms to another form of ms. It is an issue when changing from one opioid to another, which was not the example given.

At least that has not been a significant influence in my experience when I need to recommend a hospitalized cancer pt be transferred to an appropriate amount of oral morphine so they can return to their home setting. The considerations which come into play, in my limited experience, are ease of dosing, the number of tablets required (since the fillers & binders are nauseating as well as the difficult to swallow as the disease progresses), the cost of the medications & insurance coverage (often insurance limits coverage to #'s of tablets per day - not mg/day - similar to paroxetine or effexor) & the ability of the pt or caregiver to have appropriate breakthrough pain medications to give sl when the pt can no longer swallow (usually a liquid form which can be given with atropine to decrease secretions).

As much as I appreciate your approach to have the pt return to a clinic in a week, for a cancer pt, who appears to be terminal, altho that was not specifically stated, I've never known one to return to a physician setting to adjust the narcotic dose. Normally, the dose is adjusted by hospice nursing with protocol set parameters & orders to inform the physician when the parameters no longer meet the pts needs. This does in no way imply the physician is no longer an integral part of the dosing & titrating of the pts pain requirements for comfort - he/she is, however, not usually by a clinic visit - at least in my area. The balance, in my opinion, in the pt given as an example, is to provide easy, convenient pain relief with the ability to continue interactions with family as long as possible in as comfortable a setting as possible. I've done intravenous ms on pts at home & that is usually a huge burden to the family. I can't imagine an intrathecal pump....

That said....if the pt were a chronic, non-terminal pain patient, yes, I would agree with your recommendations since these folks need to maintain an active life while being treated for their chronic pain, however, that was not the pt mentioned.

There is actually lots of literature out there with regard to narcotic dosing and cancer. NCCN has Practice Guidelines In Oncology for both the pediatric & adult cancer pain patient. Also, most cancer pain pharmacologic measures have been based on principles promoted by WHO (Cancer Pain Relief, WHO, 1986) & have been validated & updated since. There really is no upper limit to analgesia with cancer pain & doses may vary 100-fold, but few patients need doses above the equivalent of 200-300mg/day without the addition of other adjuvant agents.

However, I do recognize the pain clinic which is affiliated with my institution does not consult often on cancer patients. Normally the oncologist handles these patients on their own, so your experience is certainly a different perspective & one in which I would be interested to see in a real patient, which is why I asked. I do thank you for your thoughtful reply and will consider all you've said next time I encounter a similar patient.

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

 

[jetproppilot]

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

uhhhhhhhhhhhhhhhhhh,

so after all these knowledgable, eloquent posts,

IS IT C?????????

Please keep it simple.

Yes or no.

 

[sdn1977]

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

md2k - thanks for the Texas perspective - is that the state board of medicine or pharmacy? We don't discourage CII's (your DEA only needs to have the 2N designation) here in CA & actually our oncologists start these pts on the more potent CII's (oxycondone, ms, levorphanol, etc. as opposed to the combinations - Percocet) earlier rather than later for a number of reasons. First, it allows the addition of the APAP, ibuprofen portion separately which gives greater flexibility early in the pain management phase of their disease. It also easily allows the titration of the narcotic separately as the disease progresses so we don't have to readjust the drug again...which for us rarely happens. If a pt is started on oxycodone or ms, in the absence of an allergic reaction, we keep them on the same drug until they die. There are also fewer fillers and binders than the combination products (except for the controlled release preparations) which suprisingly causes a significant amount of nausea in these folks.

As for this question....honestly, in my opinion, none of the answers were very good clinically. I think the purpose of the question was to find out if the student could convert a parenteral dose to an oral dose. Altho I appreciate your point about pt individuality & bioavailability between dosage forms....I'd point out again, it should not have been an issue here since the question was addressing going from parenteral to oral. Brand differences & how pts respond to different oral forms comes into play when switching from one oral preparation to another - Oxycontin from oxycodone, for example. I'd be curious to know what the answer is....I think 120mg bid would cause withdrawal sx which to me is an awful thing to happen to a ca pt since the anticipatory aspects of pain is something we work very hard to prevent.

As for using brand or generic.....we could go round & round on this. My professional opinion is for any drug which is titrated to effect - the brand is inconsequential & staying within the brand is necessary only with those drugs which have a narrow therapeutic window (warfarin, digoxin, etc). For morphine...I have never dispensed the brand MS Contin nor Oxymorph SR since the generic came was released & that is both in the acute hospital (which is a contractually driven market) & the ambulatory setting. My hospital does not carry brand name sustained release ms & if a physician orders MS Contin - the pt get ms sustained release.

It very interesting to see the geographic differences with approaches to narcotics. I appreciate you sharing the Texas experience. (On an intersting note: for pts traveling to or from Texas.....Texas pharmacists are not allowed to transfer controlled drug rxs to another state nor are they allowed to take a transfer from another state. They are the only state I'm aware of which does not allow this! This forces pts who do not have a sufficient supply of their controlled drug (& this is any CIII-V, CII's can't transfer in any state once filled) to see a Texas physcian to obtain more. 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?)

Again - I do thank you for your input! It goes to show - there are many ways to skin a cat! 😉

 

[md2k]

uhhhhhhhhhhhhhhhhhh,

so after all these knowledgable, eloquent posts,

IS IT C?????????

Please keep it simple.

Yes or no.

I think so I promise no more paragraphs.

 

[md2k]

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. 😉

 

[sdn1977]

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.