Guide or Resources for Prescribing Opioids in the Hospital

[MNCASC]

Anyone have a good guide, resource, or chart on how you treat pain for inpatients? In particular, opioid pain meds. I'm a new intern and am developing some experience but would like some good resources and advice.

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[Redpancreas]

@tantacles may know better than I do.

I'm sure there may be a comprehensive source but post some examples and we can weigh in. Oftentimes it's a few common scenarios you need to know as opposed to getting bogged down in a comprehensive source.

This helps a bit.

The prescription for pain management

Physicians can wield considerable influence to ease the suffering of patients in pain, starting with identifying the optimal drug and administering it before pain escalates.

acphospitalist.org

This is what the main stuff I knew as an intern.

Spectrum:
Tramadol - ensure no seizure hx or serotonergic contraindications (etc. bipolar 1, multiple other serotonin agents on board). also there's a lot of heterogeneity and doesn't work the same for everyone
Codeine - i dont use it often
Morphine - namely given as PRN q2 as continuation in ER is where I see it have its biggest role. look out for stacking in renal failure
Oxycodone- the king, x1.5 potency of morphine, longer dosing interval means its the take-home med, same stacking in renal failure
Fentanyl-IV short acting. Patient will tell you that IV med helped but then it started hurting again. One option in renal failure.
Dilaudid- I used this a lot in calpiphylaxis mainly seems to help more than fentanyl. That's the main use. Oftentimes its given to chronic pancreatitis patients coming in with their 20th pancreatitis "flare" s/p 3 celiac plexus blocks.

1.) The dose conversion tables are important. Put it on a laminated index card, hole punch it, and carry it on a ring.

https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/conversion-table.pdf

2.) If a patient has an indication for pain, treat it hard/fast if they're not chronically ill/old. If you under dose, they just get itchy and feel more pain. Use the EMR/Pharmacy for suspected pain seekers to figure out what their home dose is and limit them to that and figure out why they're in the hospital.


3.) Best use NSAIDs if no major contraindications for post-surgical/MSK pain. I think there's probably a study on this.
4.) CKD3B+/Old: Watch the morphine/oxycodone.
5.) Make sure you're prescribing each appropriate to half life. Don't dose morphine every 6 hours for example, it's half life is short.
6.) RX scheduled senna with opiates as you know.
7.) If you're going to need a PCA pump, it's best to consult pain if you're at a tertiary care center. They change their recommendations very frequently because its hard to keep up with the patient's demands.
8.) Make sure you're not discharging someone with more than 7 days worth of opiates and give them senna.

 

[chessknt]

The above should cover the basics you need to know.

Advanced additions you learn with more experience include SSRI, Neurontin, ketamine, precedex, topical agents etc but the mainstays are nsaid/opiate and knowing the different ones and their right time/place should be good enough for intern year. There is also a fair bit of regional variability (one place I worked used IVPB for every IV narcotic to avoid a euphoria).

One key tip would be to never use the opiate/acetaminophen combo pills, just schedule tylenol at your daily maximum dosage around the clock and have the opiate separate.

 

[AussieAg]

One key tip would be to never use the opiate/acetaminophen combo pills, just schedule tylenol at your daily maximum dosage around the clock and have the opiate separate.

This. Otherwise you see that patients (and nurses) jump straight to the PRN opioids instead of trying Tylenol first. My policy was that refusal of scheduled Tylenol would result in suspension of PRN opioids.

There is also a double-blind study of patients with acute orthopaedic pain in the ED that showed a combination of Tylenol + ibuprofen vs Norco resulted in greater improvement in pain.

 

[tantacles]

The above should cover the basics you need to know.

Advanced additions you learn with more experience include SSRI, Neurontin, ketamine, precedex, topical agents etc but the mainstays are nsaid/opiate and knowing the different ones and their right time/place should be good enough for intern year. There is also a fair bit of regional variability (one place I worked used IVPB for every IV narcotic to avoid a euphoria).

One key tip would be to never use the opiate/acetaminophen combo pills, just schedule tylenol at your daily maximum dosage around the clock and have the opiate separate.

Tons of great advice here and in the other parts of this thread.

One other tip:

In old people, start low and go slow.

Specifically, in a 50 year old with a hip fracture, 5 mg oxycodone for moderate pain and 10 mg oxycodone for severe pain is appropriate, and 4 mg iv morphine for breakthrough pain is appropriate.

In that 80 year old with a hip fracture? Do 2.5 mg oxycodone for moderate pain, 5 mg for severe pain, and 2 mg IV morphine for breakthrough.

Renal insufficiency? Use hydromorphone instead of morphine. the metabolite buildup from morphine can cause acute encephalopathy.

If a patient requires IV meds, don’t dose them less than q3. They wear off fast. I tend to schedule immediate release orals for no less than every 4 hours for similar reasons.

And finally, manage expectations! Your patients should not expect that you are going to use opiates to reduce their pain to zero in the hospital; The goal is to get their pain to a tolerable level so that they can get to the point where they can recover from the event or illness causing their pain 99% of the time.

 

[AlbinoHawk DO]

Try this:

Pain Management Guide: Evidence-Based Alternative Analgesia, 1st Edition Paperback – January 1, 2020​

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