opiod taper protocols

[meerkat111]

Hi all,
Does any one know good resources for inpatient IV to outpatient PO taper?

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[gutonc]

Hi all,
Does any one know good resources for inpatient IV to outpatient PO taper?

Like taper to off? Or convert from IV to PO?

Taper to off is easy...send them home with a 1w supply of whatever was working as inpatient and have them f/u w/ PCP. Let them figure it out.
Converting is even easier...there's an app for that.

 

[DaTruMD]

Like taper to off? Or convert from IV to PO?

Taper to off is easy...send them home with a 1w supply of whatever was working as inpatient and have them f/u w/ PCP. Let them figure it out.
Converting is even easier...there's an app for that.

What is the app?

 

[meerkat111]

I like calculations, converting no big deal. I sometimes run into people who are kept on IV pain meds for say ten days and now I have to send them home on PO meds. I try to cut back as soon as I get the patient on my shift. So, if someone in on 1 mg dilaudid Q3H (I know, they should not have been left on it that long but they were), should I given them 2 days prior to sending them home on PO meds?

 

[gutonc]

I like calculations, converting no big deal. I sometimes run into people who are kept on IV pain meds for say ten days and now I have to send them home on PO meds. I try to cut back as soon as I get the patient on my shift. So, if someone in on 1 mg dilaudid Q3H (I know, they should not have been left on it that long but they were), should I given them 2 days prior to sending them home on PO meds?

What is the app?

Teh googelz.

I use globalrph which is a website, not an app.

 

[gutonc]

I like calculations, converting no big deal. I sometimes run into people who are kept on IV pain meds for say ten days and now I have to send them home on PO meds. I try to cut back as soon as I get the patient on my shift. So, if someone in on 1 mg dilaudid Q3H (I know, they should not have been left on it that long but they were), should I given them 2 days prior to sending them home on PO meds?

1. Calculate the equivalent oral dose.
2. Give them one to make sure they don't throw it up.
3. D/c

 

[Doc_Mcstuffins]

1. Calculate the equivalent oral dose.
2. Give them one to make sure they don't throw it up.
3. D/c

This is what I do. Only thing I'll add as others have said is at most, give them one week supply. I've changed my practice so I never give more than one week and if it's going to a large number of pills (more than 30) for one week, I'll give even less number of days and just ensure they have a follow up appointment before one week and tell them if they take a pill every four hours, they will run out in X days. Maybe some docs will give more from hospital but this forces patients to follow up with primary care docs and lowers my liability. Occasionally, I'll see older physicians sent non-surgical patients home with 50+ pills of Percocet or dilaudid which blows my mind.

 

[smartparts]

BUT GUYS....pain is WHAT THE PATIENT SAYS IT IS!!!!11! ITS PRACTICALLY THE 5TH VITAL SIGN!!

jk everyone knows those slogans are crap. ill add that it also depends on the indication. ie cancer pain, dyspnea in end stage COPD etc i tend to be more generous. i also try to not screw over their PMD by switching to PO as early as possible, maximizing non-opioid meds, making the first taper step inpatient, and actually giving them enough to make it to the first appointment (maybe 1-2 days beyond if that makes it a nice round number).

 

[DarkLordofSith]

What do you guys do subjectively though? Like if someone's on a PCA the oral equivalents can be crazy high. For cancer pain, I like sending patients out on 2/3 of dose of MS Contin and 1/3 MS IR. But some attendings tell me not to go straight off of the PCA equivalent dose bc it'll be too high. This is a nebulous area for me too.

 

[IM2GI]

What do you guys do subjectively though? Like if someone's on a PCA the oral equivalents can be crazy high. For cancer pain, I like sending patients out on 2/3 of dose of MS Contin and 1/3 MS IR. But some attendings tell me not to go straight off of the PCA equivalent dose bc it'll be too high. This is a nebulous area for me too.

These patients (dying cancer patients) coming off PCAs are appropriate to get palliative care or pain medicine to help with pain medications.

 

[doctor-mom]

we are getting new rules in ohio
for acute, no more than 7 day supply, no more than 30MEQs morphine

 

[Raryn]

What do you guys do subjectively though? Like if someone's on a PCA the oral equivalents can be crazy high. For cancer pain, I like sending patients out on 2/3 of dose of MS Contin and 1/3 MS IR. But some attendings tell me not to go straight off of the PCA equivalent dose bc it'll be too high. This is a nebulous area for me too.

If it's the same drug (morphine->morphine), I convert them to the straight equivalent dose.

If it's a different drug (fentanyl->morphine or something), I decrease by 30-50% to account for incomplete cross-reactivity and start them on that.

Either way, ideally have them on orals for at least a day prior to discharge.

Cancer pain patients get whatever the hell they want.

 

[geripalgal]

The other thing to keep in mind - is it acute pain that is improving (like post procedure) or is chronic pain/the new norm for this patient. If acute pain, i would be reluctant to start long acting meds right away but continue using appropriate dosed breakthroughs untill the medication needs are stable.


If the patient tolerated the pca dose, you shouldnt be scared by the oral equivalent dose, even if the number seems high!