[This section assumes that you know about the 4 A's:
Analgesia, Activities of daily living, Adverse side-effects, Aberrant behavior.]
1. Regardless of anything else you do in chronic pain patients, only change one thing at a time. Many overdoses occur from "stacking" numerous pain medications and other sedating medications together. Don't ever be in a hurry on this, regardless of your time pressures, patient distance for followup, the golf game, or anything else. My old theory is that the number of drug interaction problems is proportional to the third power of the number of medications. Once you get more than five medications on board, it is probably not an issue of whether, but rather what. While it may be okay to cover for opioid-related constipation, most of those medications don't interact because they aren't systemic. Covering for nausea or pruritus e.g. promethazine, is time-limited, but can be a problem too if the person is already taking other sedatives. Whether the issue is drug-interaction or simply cumulative medication side-effects, this presents a real problem for the foremost issue: function.
2. Start low, go slow. There are several reasons for this, but most of all safety. Also, when someone maintains no changes after taking more than 30 mg morphine equivalent, you need to question patient reliability. The medication that is the most notorious for accidental death is methadone, where the opioid naive should not start on more than perhaps 5 mg daily, and work up at a slow rate.
3. Methadone should have EKG check before initiation, and probably not be used in persons with cardiac dysrhytmias. There may be some debate on this, but if you are not experienced with adjusting methadone, believe the expert when they tell you to be careful. Methadone is becoming the leading cause of prescription death from accidental, prescribed overdose!
4. There are some truly "bad drugs" out there which you should avoid prescribing since they just don't work out well in the long run. I would suggest that the "absolute list" in chronic pain patients includes oral meperidine, carisoprodol and benzodiazepines. There is no standard of care manual that would disagree with me on this. The "due care needed" list ("addictionally speaking" in North Dakoa dialect) include the short-acting medications that are known to be the leading choices for those in the chemical dependency units: hydrocodone, oxycodone, hydromorphone and alprazolam. Additionally, any immediate-release sublingual fentanyl.
5. If you giving folks large dosages of pain medications in the day time, sedatives at night, you may also want to get a sleep study. Covering with stimulants in the daytime for excessive sedation may also signal the need for checking oxygen saturation. We do this all the time in our clinic. We also check for pupil reactivity. Poor response is an indication of excessive sedation.
Analgesia, Activities of daily living, Adverse side-effects, Aberrant behavior.]
1. Regardless of anything else you do in chronic pain patients, only change one thing at a time. Many overdoses occur from "stacking" numerous pain medications and other sedating medications together. Don't ever be in a hurry on this, regardless of your time pressures, patient distance for followup, the golf game, or anything else. My old theory is that the number of drug interaction problems is proportional to the third power of the number of medications. Once you get more than five medications on board, it is probably not an issue of whether, but rather what. While it may be okay to cover for opioid-related constipation, most of those medications don't interact because they aren't systemic. Covering for nausea or pruritus e.g. promethazine, is time-limited, but can be a problem too if the person is already taking other sedatives. Whether the issue is drug-interaction or simply cumulative medication side-effects, this presents a real problem for the foremost issue: function.
2. Start low, go slow. There are several reasons for this, but most of all safety. Also, when someone maintains no changes after taking more than 30 mg morphine equivalent, you need to question patient reliability. The medication that is the most notorious for accidental death is methadone, where the opioid naive should not start on more than perhaps 5 mg daily, and work up at a slow rate.
3. Methadone should have EKG check before initiation, and probably not be used in persons with cardiac dysrhytmias. There may be some debate on this, but if you are not experienced with adjusting methadone, believe the expert when they tell you to be careful. Methadone is becoming the leading cause of prescription death from accidental, prescribed overdose!
4. There are some truly "bad drugs" out there which you should avoid prescribing since they just don't work out well in the long run. I would suggest that the "absolute list" in chronic pain patients includes oral meperidine, carisoprodol and benzodiazepines. There is no standard of care manual that would disagree with me on this. The "due care needed" list ("addictionally speaking" in North Dakoa dialect) include the short-acting medications that are known to be the leading choices for those in the chemical dependency units: hydrocodone, oxycodone, hydromorphone and alprazolam. Additionally, any immediate-release sublingual fentanyl.
5. If you giving folks large dosages of pain medications in the day time, sedatives at night, you may also want to get a sleep study. Covering with stimulants in the daytime for excessive sedation may also signal the need for checking oxygen saturation. We do this all the time in our clinic. We also check for pupil reactivity. Poor response is an indication of excessive sedation.
