The Opioid Manager is designed to be used as a point of care tool for providers prescribing opioids for chronic non-cancer pain. It condenses key elements from the Canadian Opioid Guideline and can be used as a chart insert.
Before You Write the First Script
Patient Name:
Pain Diagnosis:
Date of Onset:
Goals decided with patient:
Initiation Checklist
Y
N
Date
Are opioids indicated for this pain condition
Explained potential benefits
Explained adverse effects
Explained risks
Pt given info sheet
Signed treatment agreement (prn)
Urine drug screen (prn)
Opioid Risk Tool
By Lynn R. Webster MD
Item score
if female
Item score
if male
Item (check all that apply)
1. Family History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
2. Personal History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
3. Age (mark box if 16-45)
4. History of Preadolescent
Sexual Abuse
5. Psychological Disease
Attention Deficit Disorder,
OCD, Bipolar,
or Schizophrenia
Depression
Total:
Total Score Risk Category:
low risk 0-3
moderate risk 4-7
high risk 8+
Overdose Risk
Patient Factors
*Elderly
*On benzodiazepines *Renal impairment *Hepatic impairment *COPD
*Sleep apnea
*Sleep disorders *Cognitive impairment
Provider Factors
*Incomplete assessment *Rapid titration *Combining opioids and
sedating drugs
Failure to monitor dosing
*Insufficient information
given to patient and/or
relatives
Opioid Factors
*Codeine & Tramadol - lower risk
*CR formulations-higher doses than IR
Prevention
*Assess for Risk Factors
*Educate patients/families about risks & prevention
*Start low, titrate gradually
monitor frequently
*Careful with benzodiazepines
*Higher risk of overdose - reduce initial dose by 50%, titrate gradually
*Avoid parenteral routes
*Adolescents + elderly - may need consultation *Watch for misuse
Stepped Approach to Opioid Selection
Mild-to-Moderate Pain
First-line: codeine or tramadol
Severe Pain
Second-line: morphine, oxycodone, or hydromorphone
First-line: morphine, oxycodone, or hydromorphone
Second-line: fentanyl
Third-line: methadone
Initiation Trial
A closely monitored trial of opioid therapy is recommended before deciding whether a patient is prescribed opioids for long term use.
Suggested Initial Dose and Titration
(Modified from Weaver M., 2007 and the eCPS, 2008) Notes: The table
is based on oral dosing for CNCP. Brand names are shown if there are distinct features about specific formulations. Reference to brand names as examples does not imply endorsement of any of these products. CR = controlled release, IR = immediate release, NA = not applicable, ASA: Acetylsalicylic Acid
Opioid
Codeine (alone or in
combination with
acetaminophen or ASA)
CR Codeine
Tramadol (37.5 mg) +
acetaminophen
(325 mg)
CR Tramadol
IR Morphine
CR Morphine
IR Oxycodone
CR Oxycodone
IR Hydromorphone
CR Hydromorphone
Initial dose
15-30 mg q4h
as required
50 mg q12
1 tab q4-6h
prn up to 4/day
a) Zytram XL 150 mg q24h
b) Tridural 100 mg q24h
c) Ralivia 100 mg q24h
5-10 mg q4h prn
max 40 mg/d
10-30 mg q12h
Kadian q24h - N.B. should
not be started in opioid naive patients
6-10 mg q6h prn
max 30 mg/d
10-20 mg q12h
max 30 mg/d
1-2 mg q4-6h prn
max 8 mg/d
3 mg q12h prn
max 9 mg/d
Minimum time
interval for increase
7 days
2 days
7 days
a) 7 days
b) 2 days
c) 5 days
7 days
Minimum 2 days,
recommend: 14 days
7 days
Minimum 2 days,
recommend: 14 days
7 days
Minimum 2 days,
recommend: 14 days
Suggested dose increase
15-30 mg/d up to max of
600 mg/d (acetaminophen dose
should not exceed 3.2 gm/d)
50 mg/d up to max of
300 mg q12h
1-2 tab q4-6h prn
up to max 8 tabs/day
Max doses:
a) 400 mg/d
b) 300 mg/d
c) 300 mg/d
5-10 mg/d
5-10 mg/d
5-10 mg/d
10 mg/d
1-2 mg/d
2-4 mg/d
Minimum daily dose
before converting IR to CR
100 mg
NA
3 tablets
NA
20-30 mg
NA
20 mg
NA
6 mg
NA
Initiation Trial Chart
Date
D / M / Y
Opioid prescribed
Daily dose
Daily morphine equivalent
More than 200
Less than 200
Watchful Dose
> than 200
Goals achieved: Yes, No, Partially
Pain intensity
Functional status: Improved, No Change, Worsened
Adverse effects
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
Complications?
(Reviewed: Y/N)
Other Monitoring
0 = None
1 = Limits ADLs
2 = Prevents ADLs
To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, download the Opioid Manager, and to provide feedback visit:
http://nationalpaincentre.mcmaster.ca/opioidmanager
Feb 2011
Patient Name:
Maintenance & Monitoring
Morphine Equivalence Table
Opioid
Morphine
Codeine
Oxycodone
Hydromorphone
Meperidine
Methadone+Tramadol
Equivalent
Doses (mg)
30
200
20
6
300
Conversion
to MEQ
1
0.15
1.5
5
0.1
Dose Equiv unreliable
Transdermal
fentanyl
60-134 mg morphine=25 mcg/h
135-179 mg = 37 mcg/h
180-224 mg = 50 mcg/h
225-269 mg = 62 mcg/h
270-314 mg = 75 mcg/h
315-359 mg = 87 mcg/h
360-404 mg = 100 mcg/h
Switching Opioids:
If previous
opioid dose was:
High
Moderate
or Low
Then, SUGGESTED
new opioid dose is:
50% or less of
previous opioid
(converted to MEQ)
60-75% of previous opioid
(converted to MEQ)
Maintenance & Monitoring Chart
Date
D / M / Y
Opioid prescribed
Daily dose
Daily morphine equivalent
More than 200
Less than 200
Watchful Dose
> than 200
Goals achieved: Yes, No, Partially
Pain intensity
Functional status: Improved, No Change, Worsened
Adverse effects
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
Complications?
(Reviewed: Y/N)
Other Monitoring
0 = None
1 = Limits ADLs
2 = Prevents ADLs
When is it time to DECREASE the dose or STOP the opioid completely?
When to stop opioids
Examples and Considerations
Pain Condition Resolved
Patient receives definitive treatment for condition. A trial of tapering is warranted to determine if the original pain condition
has resolved.
Risks Outweigh Benefits
Overdose risk has increased.
Clear evidence of diversion.
Aberrant drug related behaviours have become apparent.
Adverse Effects
Outweigh Benefits
Adverse effects impairs functioning below baseline level.
Patient does not tolerate adverse effects.
Medical Complications
Medical complications have arisen (e.g. hypogonadism, sleep apnea, opioid induced hyperalgesia).
Opioid Not Effective
Opioid effectiveness = improved function or at least 30% reduction in pain intensity.
Pain and function remains unresponsive.
Opioid being used to regulate mood rather than pain control.
Periodic dose tapering or cessation of therapy should be considered to confirm opioid therapy effectiveness.
How to Stop - the essentials
How do I stop?
The opioid should be
tapered rather than abruptly discontinued.
How long will it take to stop the
opioid?
Tapers can usually be
completed between 2 weeks to 4 months.
When do I need to be more cautious
when tapering? Pregnancy:
Severe, acute opioid withdrawal has
been associated with premature labour
and spontaneous abortion.
How do I decrease the dose?
Decrease the dose by no more than 10% of the total daily dose every 1-2 weeks. Once 1/3 of the original dose is reached, decrease by 5% every 2-4 weeks. Avoid sedative-hypnotic drugs, especially benzodiazepines, during the taper.
Aberrant Drug Related Behaviour
(Modified by Passik, Kirsh et al 2002)
Indicator
Examples
* Altering the route of delivery
• Injecting, biting or crushing oral formulations
* Accessing opioids from
other sources
• Taking the drug from friends or relatives
• Purchasing the drug from the "street"
• Double-doctoring
Unsanctioned use
• Multiple unauthorized dose escalations
• Binge rather than scheduled use
Drug seeking
• Recurrent prescription losses
• Aggressive complaining about the need for higher doses
• Harassing staff for faxed scripts or fit-in appointments
• Nothing else "works"
Repeated withdrawal
symptoms
• Marked dysphoria, myalgias, GI symptoms, craving
Accompanying conditions
• Currently addicted to alcohol, cocaine, cannabis or other drugs
• Underlying mood or anxiety disorders not responsive to
treatment
Social features
• Deterioration or poor social function
• Concern expressed by family members
Views on the opioid
medication
• Sometimes acknowledges being addicted
• Strong resistance to tapering or switching opioids
• May admit to mood-levelling effect
• May acknowledge distressing withdrawal symptoms
* = behaviours more indicative of addiction than the others.
Everything Humanly Possible
Centre for Effective Practice
National Opioid Use Guideline Group (NOUGG)
To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, download the Opioid Manager, and to provide feedback visit:
http://nationalpaincentre.mcmaster.ca/opioidmanager
Subject: