opiates

[backpain]

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I am curious what the general opinion among board certified pain docs is regarding chronic use of SAOs versus LAOs, assuming we are talking about a compliant patient, low risk.

 

[deleted185747]

that is a very broad question. please specify your own background and what led you to ask this question.

 

[Aether2000]

Depends on many factors including the predictable or unpredictable variability in pain (baseline or evoked), insurance coverage of medications (or not), reliability of the patient, past history of substance abuse, etc.
The cost of long acting medications can be substantially more than short acting medications. Intermediate acting medications such as methadone are much less expensive but far more hazardous and lethal. Short acting medications are more abused but less often lead to death.
If a patient experiences pain only during physical activity and not at rest, then short acting or low dose intermediate acting meds during the time of physical activity may be appropriate and no opioids during rest. Use of a long acting medication in this circumstance may cause respiratory depression at night and the development of a more rapid tolerance.
If patients have continual uninterrupted pain, then a long acting medication such as Avinza, Exalgo, Butrans, or Duragesic may be appropriate.
Frequently we will prescribe a combination of short and long acting medications and attempt to tailor relief to their pain patterns.
Of course using the lowest dose possible of any of these medications is preferable.

 

[Louisville04]

Depends on many factors including the predictable or unpredictable variability in pain (baseline or evoked), insurance coverage of medications (or not), reliability of the patient, past history of substance abuse, etc.
The cost of long acting medications can be substantially more than short acting medications. Intermediate acting medications such as methadone are much less expensive but far more hazardous and lethal. Short acting medications are more abused but less often lead to death.
If a patient experiences pain only during physical activity and not at rest, then short acting or low dose intermediate acting meds during the time of physical activity may be appropriate and no opioids during rest. Use of a long acting medication in this circumstance may cause respiratory depression at night and the development of a more rapid tolerance.
If patients have continual uninterrupted pain, then a long acting medication such as Avinza, Exalgo, Butrans, or Duragesic may be appropriate.
Frequently we will prescribe a combination of short and long acting medications and attempt to tailor relief to their pain patterns.
Of course using the lowest dose possible of any of these medications is preferable.

1) Is methadone considered intermediate acting since it is dosed tid? I have seen morphine cr prescribed as tid as well and Fentanyl Q48 instead of Q72.

2) If patients are using SAO on a regular basis vs PRN, would you increase the LAO? I always get resistance from the patient when this is suggested.

3) Do you prescribe SAO PRN only? I can see it prescribed for post-op pain but unsure on a chronic basis.

 

[Ducttape]

i always consider methadone as long acting, even if pain relieving effects are 4-6 hours, because of the intrinsically long half life. i never let people take methadone as a prn.

for morphine cr and fentanyl, some patients notice significant waning of pain relief at the end of the dosing interval.

for some of my patients, there is that buzz effect when they take a SAO, so they resist changing to a LAO, unless that LAO is oxycontin. and, as you know, 40% or so of oxycontin is released in the first hour or so...

finally, i always prescribe SAO as prn. most patients end up making them ATC, instead, but i specifically tell them to use it as needed. it does make it easy when they ask for early refills...

ive found the cost of long acting medications are not substantially more than short acting meds, not when you discuss the opioids by their MEDs. A monthly supply of vicodin 5/325, 6 a day, where i live runs for, without insurance, $260. A monthly supply for Oxycontin 20 bid runs $280 without insurance. Fentanyl patch 50 mcg/hr runs $240.

but guess which script patients always want???

finally, algos, your description of developing more rapid tolerance in patients who do not need an opioid during rest is correct, but my experience is that most patients take SAO around the clock, and because of the peaks and troughs, tolerance probably develops faster in more patients being treated with SAOs than LAOs.

 

[Jcm800]

Why do you guys answer these "questions"?

 

[Ducttape]

Why do you guys answer these "questions"?

its a reflex... nurses ask questions all day long ("why... why... why..."). kids ask questions all day long("why... why.... why..."). patients ask questions all day long("why not... why not... why not...").

 

[mid|ine]

I am curious what the general opinion among board certified pain docs is regarding chronic use of SAOs versus LAOs, assuming we are talking about a compliant patient, low risk.

You will not find a consensus. Nor will you find agreement on who fits into the "low risk" category. I don't prescribe long acting opiates to any patients. The few patients I have on chronic opiates get on average ~40-60 short acting tablets per month, and must use them wisely, at times of peak need or worst pain. They are not intended to control pain around the clock for my patients.

 

[specepic]

you will not find a consensus. Nor will you find agreement on who fits into the "low risk" category. I don't prescribe long acting opiates to any patients. The few patients i have on chronic opiates get on average ~40-60 short acting tablets per month, and must use them wisely, at times of peak need or worst pain. They are not intended to control pain around the clock for my patients.

+1

 

[ultm8frisbee]

Why do you guys answer these "questions"?

Agreed, don't bite.