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Opioids: Chapter 2

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So in the national opioid use guidelines the cluster 2 is a second phase of information where they’re just summarizing how is that the we monitor and start this trial so the principal is always hold true you want to start lodos you want to go slow and titrating up and looking at some optimal dose an optional dose doesn’t mean perfect doesn’t mean that the pain is

Completely gone but that the goals of the the functional outcomes that patient and and you have agreed on is is met or is actually getting towards and that we’re achieving some stability in the symptoms and sometimes when it’s during crisis pain it’s just simply stability of mood that may be the major outcome at least for the time being to achieve so during this

Time of course documenting the progress is key and that’s why those goals setting up front even before the trogot started so key i made reference in previous slides on how to establish some goals up front so that we know where to go with this therapy and just to re-emphasize this slide is making use of the other arms of pain management which isn’t just dealing

With the numeric rating score or use of a medication we need to see a patient move and function better need to build their confidence in going back to certain activities i won’t increase harm so physical therapy psychological therapies complementary therapies have a big role as well and obviously the other types of medications have their parallel use but finally

Just wanted to emphasize that in pain management particular self-management strategies to help overcome fears and to actually use even their medications better are so key and there’s a number of resources that other presentations are going to be addressing so here i wanted to just summarize the typical analgesic toolboxes they refer to it so there’s the general

Non-opioid group and then the appears that are available in bc so here in bc we are familiar with the butte rennes patch or the buprenorphine patch there’s also the fentanyl patch but those are not usually used in patients who have not been exposed to opioids at all the others are codeine hydromorphone morphine oxycodone and tramadol i would even put in here as a

New agonist so in this slide i just wanted to summarize there’s a number of factors that impact the way we choose which okay to start with if someone hasn’t been exposed to opioids at all obviously maximizing non-opioid management strategy is the way to go but we’re getting to the time where we’re making decision is start an opioid then many of them are appropriate

Most of the time as clinicians we start off with a short trial of the short acting ones to see if there’s even any effect and also if there’s any major side effects that will limit the way you can increase your doses the other factors of course includes cost coverage how compliant patient is of short duration and frequency of dosing versus single day dosing and then

Of course what their past experience was in the past with any medications in general and then lastly there are some some practical points like are they able to take the medications orally or we have to start considering patch forms what’s their digestive system and the liver system and clearance of these medications so some of these will play into our decision

These next two slides are pretty busy they just summarize some guiding principles as to the starting dosages on the various o periods available to us in bc so codeine tramadol morphine are located on this page and without going to all the details here really at the very far right of the slide is some suggested optimal maximum dosages like it is with the national

Opioid use guidelines document they do feel that the aural equivalent of morphine of 200 milligrams per day is what they call a watchful doh so you can see here that these are under or at about the equivalent of that dose to be the guided maximum for non-cancer pain it is accepted in the community that beyond that doesn’t quite make sense the diagnosis may be wrong

Or that there are other factors involved in these higher doses and we really need to review with vigilance especially at that time the second slide is also highlighting the medications particular oxycodone hydromorphone you’ll notice on these slides i have not put on buprenorphine or fentanyl patches but i will address the equivalent doses in the next slide this

Slide generally summarizes the accepted equivalences that has been understood in the the clinician community they are not hard and fast rules but they are just general guidelines and it really changes depending on how much and how long a patient’s been exposed to opioids also elderly age versus young ages is very different the reno liver function totally changes

These equivalences methadone in particular is a very variable medication to try to transition to because that really depends on how long you’ve been taking this medication

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Opioids: Chapter 2 By PracticeSupport