Oxycodone and tapentadol

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LurenD

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Hello!

Switching from 40 mg Oxycodone to tapentadol due to insuffecient effect. Does that seem reasonable or does it make more sense to increase dosage of oxycodone? I feel that the dosage of Oxycodone is fairly low.

Plan was to decrease to 20 mg Oxycodone and add 150 mg Tapentadol, with the intent of tapering Oxycontin further down the line.

Thanks in advance for any reply.

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What did your attending say? I need more information to answer your Q.
 
Without giving any formal advice, one oxycodone 40mg (Oxycontin?) tablet is 60 MMED, let alone if you are giving more than 1 tablet per day. Tapentadol 150mg is roughly 67 MMED.

Guidelines say increased risk of overdose over 50MMED and very high over 90MMED. I'd say your patient is on too much already and first step should be a wean down, not increase, in opiates.
 
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I am not a believer in that tapentadol conversion. Someone on 60 morphine is going to be miserable switching to that dose Nucynta.
 
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I am not a believer in that tapentadol conversion. Someone on 60 morphine is going to be miserable switching to that dose Nucynta.

That may be so, but if the state's PDMP believes it, frankly it doesn't matter what you believe.
 
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That may be so, but if the state's PDMP believes it, frankly it doesn't matter what you believe.

Not correct. The PDMP overrates Nucynta for no good reason and not based in science. Mu binding is 1/17th or so of morphine. LD50 data not available in humans (thank goodness). Pubmed tells of 2 oral OD deaths from Nucynta. Another from IV abuse.
 
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Not correct. The PDMP overrates Nucynta for no good reason and not based in science. Mu binding is 1/17th or so of morphine. LD50 data not available in humans (thank goodness). Pubmed tells of 2 oral OD deaths from Nucynta. Another from IV abuse.

Medically speaking, you're correct. The whole MMED thing is scientifically tenuous anyway. What I meant was that I will still get flagged by the state the same for writing Nucynta 50 TID vs MS Contin 30 BID.
 
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Medically speaking, you're correct. The whole MMED thing is scientifically tenuous anyway. What I meant was that I will still get flagged by the state the same for writing Nucynta 50 TID vs MS Contin 30 BID.

How can there be accurate "morphine equivilents" to a drug that works not through mu opiate receptors, but by norepinephrine? It would be like classifying NSAIDs or anti-convulsants with morphine equivilents.

Nucynta is a great drug- I have prescribed it quite a bit and have been on it for three years for cancer pain. Very little to no sedation, no impairment of cognitive function, no fatigue, no constipation. I was put on oral opioids in the past and they were terrible- poor pain relief and lots of side effects. I could not function well while on them.
 
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Accuracy is unfortunately sacrificed in order to simplify and protocolize things.

I do love Tapentadol for patients when they can obtain/afford it. I do find patients struggle sometimes with the transition to it though when they are chemically coping as it doesn't seem to have the same anxiolysis/mood effects that full mu-agonists do.
 
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Medically speaking, you're correct. The whole MMED thing is scientifically tenuous anyway. What I meant was that I will still get flagged by the state the same for writing Nucynta 50 TID vs MS Contin 30 BID.

In the great state of Georgia, I know one of the idiots who do a lot of reviews for the medical board, DEA, State and local LE. I trust he will help if the situation arises.
 
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That may be so, but if the state's PDMP believes it, frankly it doesn't matter what you believe.
A local internist converted one of my patients from nucynta to morphine using the conversion factor and overdosed him. Thankfully he was in the hospital.
 
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Hello. The former dosage was 20 mg Oxycontin 2 times a day. I've been told that Tapentadol is 5 times less potent as an opioid than Oxycontin, but there seems to be some different numbers around. I know that Tapentadol also has an NRI effect, but I thought it was just the opioid effect that they took into account when making the conversion number.

Thanks for all the replies!

Do Tapentadol and Oxycontin have a synergistic effect so that one has to switch abruptly over to the other medication instead of a gradual switch like reducing the dosage of oxycontin and adding a safe ammount of tapentadol using conversion factors?

Is the effect generally unpredictable (even when using conversion factors) when combining opioids?

We were considering doing a taper off, taper on, approach to switching the type of opioid instead of changing abruptly hopefully in order to reduce possible withdrawal symptoms from the old medication and side effects of the new medication.
 
tapentadol has both norepinephrine and mu receptor agonist activity. it is a dual agonist.

I personally would not use both at the same time. potential for excessive mu agonist activity. taper off oxycodone and at 40 mg daily, that is not a dose that I associate with significant withdrawal symptoms. but go to 20 mg daily for a 1-2 days, then start tapentadol. start with 50 mg three times daily to start.
 
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tapentadol has both norepinephrine and mu receptor agonist activity. it is a dual agonist.

I personally would not use both at the same time. potential for excessive mu agonist activity. taper off oxycodone and at 40 mg daily, that is not a dose that I associate with significant withdrawal symptoms. but go to 20 mg daily for a 1-2 days, then start tapentadol. start with 50 mg three times daily to start.

That’s a 50% drop. Patient is going to hate you as they withdrawal. I have just changed to Nucynta ER 150 and added some Norco for IR meds. Goal should be to covert from oxycodone to anything else. Oxy is worst drug out there.
 
That’s a 50% drop. Patient is going to hate you as they withdrawal. I have just changed to Nucynta ER 150 and added some Norco for IR meds. Goal should be to covert from oxycodone to anything else. Oxy is worst drug out there.

It’s the person and not the drug.

Xxx inanimate object is the worst. Smh
 
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Oxy causes more dopamine release. That’s the drug.

More people say oxy is the only thing that works. That’s the drug.

Meh. Here is your study:

"For example, in the clinical realm, oxycodone administration to human heroin addicts, compared to other opioids, caused robust reinforcing effects with no increases in negative effects (Comer et al., 2008). Further, in the same study, a verbal report from a heroin-dependent individual stated that oxycodone is the ‘Rolls Royce’ of opioids and that it produces a ‘smooth’ high” (Comer et al., 2008)."

But then, what is the risk in patients who were studied for these drugs?


Pick the person before picking the drug.
 
That’s a 50% drop. Patient is going to hate you as they withdrawal. I have just changed to Nucynta ER 150 and added some Norco for IR meds. Goal should be to covert from oxycodone to anything else. Oxy is worst drug out there.
No they haven’t.
 
I can make more addicts by giving oxy than giving bupe.

And therein lies the problem. IF YOU MAKE AN ADDICT, IT IS ON YOU.

Screening and history will tease out all the addicts as part of your due diligence. It is up to you how strict you wish to adhere to the known risks in any given patient. Failure to understand the risks and ask the appropriate questions, implement screening tools, review history, review PDMP, etc is all on you. If it is pokes for drugs then you do a cursory review and keep em coming back for more. If you are 101N strict, you just turn in your DEA card and go with it is not my problem. Or somewhere along the continuum.

I have never made an addict. Nor will I. We know or should know all the potential confounders/risks and should select those patients for appropriate treatment based on those risks. I start by saying no. One of the hardest things to do in medicine.
 
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And therein lies the problem. IF YOU MAKE AN ADDICT, IT IS ON
I have never made an addict. Nor will I.

Steve

Unfortunately this is likely not to be true. I believe you trained under then worked for a doc that was part of the OxyContin express. The practice was all pills for pokes with satellite pill clinic in KY as well as mothership in GA. You old boss/mentor was sent to jail I thought.

Please don’t pretend u stood up to that meat head pill pusher and prescribed appropriately. Would have been fired in a hot minute. You knew without needing the FDA what you were doing was wrong. Someone died from the torrent of pills that practice put into the community.
 
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Steve

Unfortunately this is likely not to be true. I believe you trained under then worked for a doc that was part of the OxyContin express. The practice was all pills for pokes with satellite pill clinic in KY as well as mothership in GA. You old boss/mentor was sent to jail I thought.

Please don’t pretend u stood up to that meat head pill pusher and prescribed appropriately. Would have been fired in a hot minute. You knew without needing the FDA what you were doing was wrong. Someone died from the torrent of pills that practice put into the community.

He did fire me. April 2007. Told me no margin no mission. I was ordering lots of UDS and DC'd lots of patients. But you know more than I do. Jerky.
From your posts over the years it sounds like you have an ax to grind. Grind it.
 
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And therein lies the problem. IF YOU MAKE AN ADDICT, IT IS ON YOU.

I have never made an addict. Nor will I. We know or should know all the potential confounders/risks and should select those patients for appropriate treatment based on those risks. I start by saying no. One of the hardest things to do in medicine.

Done preaching? It was a rhetorical statement.

The weakness in your data is that there were likely patients taking and abusing oxycodone but not carrying the drug abuse diagnosis. I would guarantee it.
 
He did fire me. April 2007. Told me no margin no mission. I was ordering lots of UDS and DC'd lots of patients. But you know more than I do. Jerky.
From your posts over the years it sounds like you have an ax to grind. Grind it.


You are a better man than I. I had practiced with arbitrary morphine equivilents of 120mg for a long time, as it seemed things got out of control after that. Oddly, that turned out to be not too far off the CDC guidelines. Sounds like you were pretty meticulous and I would imagine had a pretty low addiction rate, but had to have a few- we all did. Good for you in standing your ground and getting fired- I was fired from my practice of 16 years for turning in a few very naughty docs into the board, who subsequently lost their licenses.

I was fooled by MANY patients over the years. I still prescribe narcotics, using the CDC guidelines. I know what the evidence says, but I have seen too many people who continue to work, are compliant, and able to remain functional on low dose opiates. I am an example of this and would otherwise be a hypocrite - I have bladder cancer with granulomatous cystitis and have been maintained on Nucynta for three years. Straight narcotics did not help at all and made me less than functional.

I think there is a role for narcotics, but it was way over done in the 90s up to about 5 years ago. I do find it odd, however, that MANY of those who were saying "there is no limit for opioids" and were passing out those meds in high doses are now on the lecture circuit saying they knew that narcotics were bad all along and did not contribute to the crisis. Two of the leading "experts" nationally on opioid abuse were a couple of the biggest offenders! Reformed ***** syndrome.
 
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