Opioid Manager Template

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OPIOID MANAGER
OPIOID MANAGER
Goals decided with patient:
Initiation Checklist
Opioid Risk Tool
Y N
Date
By Lynn R. Webster MD
Are opioids indicated for this
The Opioid Manager is designed to be used as a point of care tool for providers
Item score
Item score
pain condition
if female
if male
prescribing opioids for chronic non cancer pain. It condenses key elements from
Explained potential benefits
the Canadian Opioid Guideline and can be used as a chart insert.
Item (circle all that apply)
A
Explained adverse effects
Before You Write the First Script
1. Family History of
Explained risks
Substance Abuse:
Alcohol
1
3
Patient given information sheet
Patient Name:
Illegal Drugs
2
3
Signed treatment agreement (as needed)
Prescription Drugs
4
4
Pain Diagnosis:
2. Personal History of
Urine drug screening (as needed)
Date of Onset:
Substance Abuse:
Alcohol
3
3
Illegal Drugs
4
4
Overdose Risk
Stepped Approach to Opioid Selection
Prescription Drugs
5
5
- Start low, titrate gradually,
Opioid Factors
Provider Factors
monitor frequently
Patient Factors
3. Age (mark box if 16-45)
1
1
Mild-to-Moderate Pain
- Incomplete assessments
- Codeine & Tramadol - lower risk
- Careful with benzodiazepines
4. History of Preadolescent
- Elderly
- CR formulations - higher doses than IR
Severe Pain
- Rapid titration
First- line: codeine or tramadol
3
0
- Higher risk of overdose - reduce initial
- On benzodiazepines
Sexual Abuse
- Combining opioids and
dose by 50%; titrate gradually
Second-line: morphine, oxycodone or hydromorphone
First-line: morphine, oxycodone or hydromorphone
- Renal impairment
Prevention
5. Psychological Disease
sedating drugs
- Hepatic impairment
- Avoid parenteral routes
- Assess for Risk Factors
Attention Deficit Disorder,
- Failure to monitor dosing
2
2
- COPD
Second-line: fentanyl
- Adolescents; elderly - may need
Obsessive-Compulsive Disorder,
- Educate patients /families about risks
- Sleep apnea
- Insufficient information
consultation
or Bipolar, Schizophrenia
& prevention
Third-line: methadone
- Sleep disorders
given to patient and/or
- Watch for Misuse
- Cognitive impairment
relatives
Depression
1
1
Total
Total Score Risk Category:
B
Initiation Trial
Low Risk: 0 to 3, Moderate Risk: 4 to 7, High Risk: 8 and above
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 e-CPS, 2008)
Initiation Trial Chart
Notes: The table is based on oral dosing for CNCP.
Brand names are shown if there are some distinct features about specific formulations. Reference to brand names as examples does not imply endorsement of
D / M / Y D / M / Y D / M / Y D / M / Y
CR = controlled release, IR = immediate release, NA = not applicable, ASA: Acetylsalicylic Acid
any of these products.
Date
Opioid prescribed
Minimum time
Suggested
Minimum daily dose
Opioid
Initial dose
interval for increase
dose increase
before converting IR to CR
Daily dose
7 days
Codeine (alone or in
15-30 mg q.4 h.
15-30 mg/day up to maximum of
Daily morphine equivalent
100 mg
combination with
as required
600 mg/day (acetaminophen dose
More than 200
Watchful Dose
acetaminophen or ASA)
should not exceed 3.2 grams/day)
> than 200
Less than 200
50 mg/day up to maximum of
50 mg q.12 h.
2 days
CR Codeine
NA
Goals achieved
Yes, No, Partially
300 mg q.12 h.
Pain intensity
1-2 tab q. 4-6 h. as needed
Tramadol (37.5 mg) +
1 tablet q.4-6 h.
7 days
up to maximum 8 tablets/day
3 tablets
Functional status
Improved, No Change, Worsened
acetaminophen (325 mg)
as needed up to 4/day
Adverse effects
Nausea
Maximum doses:
a) 7 days
a) Zytram XL
®
: 150 mg q. 24 h.
b) Tridural
: 100 mg q. 24 h.
a) 400 mg/day
b) 2 days
Constipation
CR Tramadol
NA
c) Ralivia
: 100 mg q. 24 h.
b) 300 mg/day
c) 5 days
Drowsiness
0 = None
c) 300 mg/day
1 = Limits ADLs
Dizziness/Vertigo
5-10 mg q. 4 h. as needed
7 days
5-10 mg/day
IR Morphine
20-30 mg
2 = Prevents ADLs
maximum 40 mg/day
Dry skin/Pruritis
10-30 mg q.12 h.
CR Morphine
Vomiting
Minimum 2 days,
5-10 mg/day
Kadian
®
: q.24 h.
recommended: 14 days
NA
Other?
Kadian
®
should not be started in
opioid-naïve patients
Complications?
(Reviewed: Y/N)
5-10 mg q. 6 h. as needed
7 days
5 mg/day
IR Oxycodone
Aberrant Behaviour (Reviewed: Y/N)
20 mg
maximum 30 mg/day
10-20 mg q.12 h.
Minimum 2 days,
Urine Drug Screening (Y/N)
CR Oxycodone
10 mg/day
NA
recommended: 14 days
maximum 30 mg/day
Other Medications
IR Hydromorphone
1-2 mg q. 4-6 h. as needed
1-2 mg/day
7 days
6 mg
maximum 8 mg/day
To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain
3 mg q. 12 h.
CR Hydromorphone
Minimum 2 days,
2-4 mg/day
NA
maximum 9 mg/day
recommended: 14 days
and to download the Opioid Manager visit
Feb 2011

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