Opioid Manager Template (Page 2 of 2) in pdf

Maintenance & Monitoring

Maintenance & Monitoring Chart

Morphine Equivalence Table

D / M / Y D / M / Y

D / M / Y

Opioid

Equivalent

Conversion

Date

Doses (mg)

to MEQ

Opioid prescribed

Morphine

Daily dose

Codeine

200

0.15

Daily morphine equivalent

Oxycodone

1.5

More than 200

Watchful Dose

Hydromorphone

> than 200

Less than 200

Meperidine

300

0.1

Goals achieved

Yes, No, Partially

Methadone & Tramadol

Dose Equivalents unreliable

Pain intensity

60 – 134 mg morphine = 25 mcg/h

Transdermal

Functional status

Improved, No Change, Worsened

135 – 179 mg = 37 mcg/h

fentanyl

Adverse effects

Nausea

180 – 224 mg = 50 mcg/h

225 – 269 mg = 62 mcg/h

Constipation

270 – 314 mg = 75 mcg/h

Drowsiness

0 = None

315 – 359 mg = 87 mcg/h

Dizziness/Vertigo

360 – 404 mg = 100 mcg/h

1 = Limits ADLs

2 = Prevents ADLs

Dry skin/Pruritis

Switching Opioids:

Vomiting

If previous opioid

Then, SUGGESTED

Other?

dose was:

new opioid dose is:

Complications?

(Reviewed: Y/N)

50% or less of previous opioid

High

Aberrant Behaviour

(Reviewed: Y/N)

(converted to morphine equivalent)

Urine Drug Screening (Y/N)

60-75% of the previous opioid

Moderate or low

(converted to morphine equivalent)

Other Medications

When is it time to Decrease the dose or Stop the Opioid completely?

Aberrant Drug Related Behaviour

(Modified by Passik,Kirsh et al 2002).

Indicator

Examples

How to Stop – the essentials

When to stop opioids

Examples and Considerations

*Altering the route of delivery

• Injecting, biting or crushing oral formulations

How do I stop?

The opioid should be

*Accessing opioids from

• Taking the drug from friends or relatives

tapered rather than abruptly discontinued.

other sources

• Purchasing the drug from the “street”

Pain Condition Resolved

Patient receives definitive treatment for condition. A trial of tapering is warranted

• Double-doctoring

to determine if the original pain condition has resolved.

How long will it take to stop the

• Multiple unauthorized dose escalations

Unsanctioned use

opioid?

Tapers can usually be completed

Risks Outweighs Benefits

Overdose risk has increased.

• Binge rather than scheduled use

between 2 weeks to 4 months.

Clear evidence of diversion.

• Recurrent prescription losses

Aberrant drug related behaviours have become apparent.

Drug seeking

• Aggressive complaining about the need for higher doses

When do I need to be more cautious

• Harassing staff for faxed scripts or fit-in appointments

Adverse Effects

when tapering? Pregnancy:

Adverse effects impairs functioning below baseline level.

• Nothing else “works”

Outweighs Benefits

Patient does not tolerate adverse effects.

Severe, acute opioid withdrawal has been

Repeated withdrawal symptoms

• Marked dysphoria, myalgias, GI symptoms, craving

associated with premature labour and

Medical complications have arisen (e.g. hypogonadism, sleep apnea,

spontaneous abortion.

Medical Complications

• Currently addicted to alcohol, cocaine, cannabis or other drugs

opioid induced hyperalgesia)

Accompanying conditions

• Underlying mood or anxiety disorders not responsive to treatment

How do I decrease the dose?

Opioid effectiveness = improved function or at least

• Deteriorating or poor social function

Opioid Not Effective

Decrease the dose by no more than 10% of

Social features

30% reduction in pain intensity

• Concern expressed by family members

the total daily dose every 1-2 weeks. Once

Pain and function remains unresponsive.

one-third of the original dose is reached,

• Sometimes acknowledges being addicted

Opioid being used to regulate mood rather than pain control.

Views on the opioid

• Strong resistance to tapering or switching opioids

decrease by 5% every 2-4 weeks. Avoid

Periodic dose tapering or cessation of therapy should be considered to confirm

medication

• May admit to mood-leveling effect

sedative-hypnotic drugs, especially

opioid therapy effectiveness.

• May acknowledge distressing withdrawal symptoms

benzodiazepines, during the taper.

= behaviours more indicative of addiction than the others.

National Opioid Use Guideline Group (NOUGG)

To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain and to download the Opioid Manager visit

Opioid Manager Template Page 2

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