PT6 JAM - (opioid conversions)

4-6

short acting opioids typically dosed every _____ hours

8-12

long acting opioids typically dosed every ____ hours

short acting

for opioid naive patients, always use ______ opioids initially

pain assessment

first step of opioid conversion

breakthrough pain

pain above + beyond baseline coverage in state of controlled pain

nerve-based agents

consider addition of _____ if breakthrough pain is neuropathic in nature

volitional

provide breakthrough medications prior to ________ activities

10-15%

when initially calculating medications for breakthrough pain, use ______ of TDD of all opioids pt is taking

TDD = 40mg oxycodone ER

40mg x (______) = 4-5mg

type

incomplete cross tolerance is a concern only when changing opioid ______

25-50%

when converting opioids, must reduce TDD by _______

morphine -> oxycodone (ratio = 25:20)

TDD = 60mg morphine -> 48mg oxy

48mg x (______) = reduce by 12-24mg

new range = 24-36mg

75-100

fentanyl is _____x more potent than morphine + very quick acting

36

max concentration of fentanyl achieved around _____ hours

3-6

fentanyl takes _____ days to reach steady state

heat

do NOT apply ____ as it increases fentanyl absorption by 33%

morphine

fentanyl can only be converted to + from _______, so no need to to compensate for incomplete cross tolerance

QT prolongation

methadone has caution of _______

450

methadone

QTc = less than _____ = safe to use

450-499

methadone

QTc = _________ = monitor closely

500

methadone

QTc = _______ = avoid

2.5

lowest dose of methadone available

CYP3A4

methadone has caution with medications with ________ metabolism due to drug interactions

phenytoin, rifampin

CYP3A4 inducers = may need to increase methadone dose after one week of use

amiodarone, azoles

CYP3A4 inhibitors = reduce methadone dose by 25% immediately

hard change

when starting methadone, it is recommended to do a _______; ex: at next scheduled dose of opioid, use methadone

5-7

methadone can take _____ days for full response, so follow-up typically scheduled for week from first dose

fatigue

important first notable side effect of methadone which is why use is avoided in elderly living alone / those without a caregiver