Latest / Pharmacy Podcast Network / Opioidology Part 2: Opioid Selection | Pain Pod

Transcript

Opioidology Part 2: Opioid Selection | Pain Pod · Pharmacy Podcast Network

• 0:05
  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy podcast Network.
• 0:21
  Speaker 2: This is the Pain Pod.
• 0:25
  Speaker 1: You want to see pain, look at me?
• 0:33
  Speaker 2: Welcome to the Pain Pod, the podcast for all things
• 0:38
  Speaker 2: pain management, hosted by the pain Guy, doctor Mark Grow.
• 0:48
  Speaker 2: We'll be collaborating with numerous pain management experts talking about
• 0:52
  Speaker 2: substance usage disorders, the latest treatment modalities, and most important
• 0:58
  Speaker 2: import focusing on the pain of our vasis as.
• 1:01
  Speaker 1: Leading providers of pain care.
• 1:05
  Speaker 2: And now here's our host, a man wanted in all
• 1:09
  Speaker 2: fifty states, a suburban city like mountain man without the beard,
• 1:16
  Speaker 2: from the hills of West Virginia and certified in weapons
• 1:21
  Speaker 2: of mass destruction response Yes, doctor Mary.
• 1:31
  Speaker 1: All right, welcome back everyone to the Pain Pod. So
• 1:35
  Speaker 1: here today in the Pain Pod, we are going to
• 1:37
  Speaker 1: be going over part two, the deuce of opioidology. So
• 1:44
  Speaker 1: Opioidology Part two. What we're going to dive into here
• 1:47
  Speaker 1: today in this episode of the Pain Pod is opioid selection.
• 1:51
  Speaker 1: So in the last episode, if you haven't checked it
• 1:53
  Speaker 1: out yet, highly recommend of course, but you know, we
• 1:57
  Speaker 1: went over the you know, the opioid story I'll opioid story,
• 2:01
  Speaker 1: all the ins and outs, the ups and downs, the
• 2:03
  Speaker 1: kidney punches here and there, the reality, the facts, right,
• 2:07
  Speaker 1: undeniable scenarios that not everyone enjoys, ultimately leading to hope
• 2:14
  Speaker 1: for a less loss of heartbeats overall. Right, But here
• 2:17
  Speaker 1: today we're gonna talk about a opioid selection. This is
• 2:20
  Speaker 1: you know, this is the next hot topic when it
• 2:22
  Speaker 1: comes to all things opioids, or as I'm saying, opioid ology. Right.
• 2:27
  Speaker 1: I actually posed this topic, this question on illustrious LinkedIn,
• 2:33
  Speaker 1: oh at least a year ago, if not more. I
• 2:36
  Speaker 1: just said, hey, folks, what's your opioid go to? What's
• 2:39
  Speaker 1: your opioid of choice prescription opiate of choice for your patients? Right? Crickets?
• 2:47
  Speaker 1: Literally no one answered, And you know, we got a
• 2:50
  Speaker 1: pair of respects to the reality that, hey, every patient
• 2:53
  Speaker 1: scenario is a different scenario, right, But what it'd imposed was, well,
• 2:57
  Speaker 1: you know what if you got a you know, a
• 2:58
  Speaker 1: healthy young lad you know, just has an accident or
• 3:02
  Speaker 1: something and it's you know, good general health, no concerns overall,
• 3:08
  Speaker 1: you know, what do you go with? Right? At some point,
• 3:10
  Speaker 1: we have our go tos, or we should have our
• 3:15
  Speaker 1: algorithms in our head or what we select for any
• 3:18
  Speaker 1: medical condition out there. But when it comes to the
• 3:20
  Speaker 1: opioid selection, boy, that's uh, that's like the the nice area, right,
• 3:26
  Speaker 1: that's what we've lived through based on what we talked
• 3:27
  Speaker 1: about on the previous episode of the Pain Pod for
• 3:30
  Speaker 1: the opioid story. All right, so enough chit chat. Let's
• 3:33
  Speaker 1: jump into opioid selection and start out here with you know, opioids.
• 3:38
  Speaker 1: If you're gonna go kick it off with opioid or
• 3:40
  Speaker 1: not to opioid, that is the question. How do we,
• 3:43
  Speaker 1: you know, distinguish opioids in general? Okay, I'll go over Yeah,
• 3:46
  Speaker 1: maybe a half a dozen different ways. Y'all will have
• 3:49
  Speaker 1: heard me before pontificate about opiate versus opioid. It's semantics,
• 3:54
  Speaker 1: it's words, it's terminology, it's philosophical, you name it. Tomato, tomato.
• 4:00
  Speaker 1: In the end, I want to eat the tomato, right. Well,
• 4:04
  Speaker 1: in the end, opioids are out there hopefully to help
• 4:08
  Speaker 1: our patients in pain, right, which could be any one
• 4:11
  Speaker 1: of us at any moment if we end up in pain.
• 4:14
  Speaker 1: But when we're talking about the poppy, you know what's
• 4:16
  Speaker 1: in the opium poppy? That would be the opiates. That's
• 4:19
  Speaker 1: what's natural feebane morphine coding the rest of them, the
• 4:23
  Speaker 1: rest of the gang, whether semisynthetic or fully synthetic, or opioids.
• 4:28
  Speaker 1: In today's given world, we typically refer to everything as
• 4:31
  Speaker 1: opioid collectively, right, Whereas you know that would be the rectangle,
• 4:35
  Speaker 1: whereas the square would be the opiates, because it's very
• 4:37
  Speaker 1: specific to just what's in the poppy. Have we ever
• 4:40
  Speaker 1: had an opiate epidemic? Not really, but opioid crisis or
• 4:47
  Speaker 1: whatever other terms you want to use. That's more spot on. All, Right,
• 4:52
  Speaker 1: off my soapbox, onward to the pharmacology, the nerdy stuff, right,
• 4:55
  Speaker 1: regardless of who you are listening, Hey, this is important stuff.
• 4:58
  Speaker 1: So you know, obviously the most prescription opioids are exhibiting
• 5:02
  Speaker 1: their action on the MW. That's m U, the MW
• 5:06
  Speaker 1: opioid receptor, right, the MW opioid peptide receptors, technically the
• 5:11
  Speaker 1: long term right uh. And that could be broken down
• 5:13
  Speaker 1: into subcategories as well, you know, the first or second
• 5:17
  Speaker 1: depending on your point of view, I guess uh, involving
• 5:20
  Speaker 1: beta rest then where the restipoy depression comes into play.
• 5:23
  Speaker 1: But there's also delta opioid peptide receptors and Kappa opioid
• 5:29
  Speaker 1: peptoid receptors. Uh, so they come into play as well.
• 5:33
  Speaker 1: Kappa that comes into play for a couple of prescription
• 5:36
  Speaker 1: opioids because you know, the one of the potential effects
• 5:41
  Speaker 1: or side effects with kappa agonism would be the dysphoria
• 5:45
  Speaker 1: just pretty much the opposite of euphor you right, Dysphoia
• 5:49
  Speaker 1: is not feeling well generally speaking, another way to articulate
• 5:53
  Speaker 1: that one, whereas uphouri with the MW opioid receptor is
• 5:57
  Speaker 1: that hi feeling for lack of better terms. As well,
• 6:02
  Speaker 1: we also have things that you know throughout history as
• 6:04
  Speaker 1: things like the sigma receptor that sometimes debated along the way. Uh.
• 6:08
  Speaker 1: There's also research into the no susceptin orphan in peptide
• 6:15
  Speaker 1: receptor as well. And again that the subcategories of the
• 6:19
  Speaker 1: MEW receptor. The name of the game is typically MEW,
• 6:23
  Speaker 1: but there's other players in the ball field as well, Right,
• 6:26
  Speaker 1: it's the team that wins the game. Another way to
• 6:28
  Speaker 1: look at OPIOI, it's big picture again, we're zooming out
• 6:31
  Speaker 1: controlled substance classes. Sounds objective, right, Well, you know heroin
• 6:37
  Speaker 1: across upond in other countries is legal in the healthcare
• 6:40
  Speaker 1: supply chain here not so much. Uh. Then you have
• 6:43
  Speaker 1: you know, the vast majority of prescription opioids of course,
• 6:46
  Speaker 1: or C two's you know, or things like morphine hydro
• 6:49
  Speaker 1: code on oxy coda, you know, the whole gang, right.
• 6:52
  Speaker 1: C three's would be yourbut P and orphine dihydro coding
• 6:56
  Speaker 1: with ce do, dominifin or even aspirin.
• 6:59
  Speaker 2: Uh.
• 6:59
  Speaker 1: And then and of course, uh, your t's the you know,
• 7:03
  Speaker 1: con al with coding or coding with tyno however we
• 7:05
  Speaker 1: say it right. And then of course a couple just
• 7:07
  Speaker 1: the C fours uh tramaol and then petazis in the loxon.
• 7:12
  Speaker 1: So you know, the vast majority of though I see
• 7:14
  Speaker 1: twos along the way. All right, another way, and this
• 7:17
  Speaker 1: one gets me too. I already went on the soapbox
• 7:20
  Speaker 1: for the whole Uh, you know what the media does
• 7:22
  Speaker 1: with headlines for opiate versus opioid. But then what about
• 7:25
  Speaker 1: the origin or the development. So again in the poppy,
• 7:28
  Speaker 1: that's the opi. It's uh, the ban coding morphine. But
• 7:32
  Speaker 1: then you have your semisynthetics a lot of those guys, right,
• 7:34
  Speaker 1: and then you have your fully synthetic. We just make
• 7:37
  Speaker 1: them in labs. Right. And we'll see this a lot
• 7:40
  Speaker 1: from even federal regulatory agencies when the report now from
• 7:43
  Speaker 1: fancy good looking charts, and they'll say, oh, uh, you
• 7:47
  Speaker 1: know methadone or other fully synthetic or fentanel. Right, So
• 7:52
  Speaker 1: there's actually a lot of different fully synthetic opioids out
• 7:55
  Speaker 1: there prescription wise, butorphanol, fentonel I mentioned love orphan, my
• 8:00
  Speaker 1: parodine methodone. I mentioned that one ol, the saridine relatively
• 8:04
  Speaker 1: newer guy pentazesin to pentodlon tramadol. So you know that's
• 8:08
  Speaker 1: that's a hot nine right there. Right, you got a
• 8:11
  Speaker 1: whole baseball team lineup right there, not just one, certainly
• 8:14
  Speaker 1: not two. Right all right. In other episodes of the
• 8:18
  Speaker 1: Pain Pod, you've heard me whip out my wondrous medchim
• 8:22
  Speaker 1: I talk about getting pharmacologically nerdy. Right.
• 8:25
  Speaker 2: Uh.
• 8:25
  Speaker 1: There's the different structural classes of opioids, roughly about five
• 8:29
  Speaker 1: of them. Right. The vast majority of prescriptional opioids are
• 8:33
  Speaker 1: in the fenanthrene class. It means they're structures, their chemical
• 8:37
  Speaker 1: structure looks similar, very similar. Actually, there's also you know,
• 8:42
  Speaker 1: pentazesins a benzomorphine, methodone, diphenyl heptane, fentanyla me parodine, or
• 8:48
  Speaker 1: fenyl paparidines they can get their own group, and then
• 8:51
  Speaker 1: to pentodlon tramad all those cousins. They're fenyl propylamines. Okay,
• 8:55
  Speaker 1: everybody else though, finanthrenes the whole gang. Okay. Again, of
• 9:00
  Speaker 1: C two's there, but that's a different way to classify them,
• 9:03
  Speaker 1: because there's C threes there as well. I gotta take
• 9:05
  Speaker 1: a step further when it comes to distinguishing opioids overall. Right,
• 9:10
  Speaker 1: when a medicine name means something, it's phenomenal that that's
• 9:15
  Speaker 1: that's just huge, right, so we should probably point it out.
• 9:17
  Speaker 1: So here it lost in the shuffle. You know, the
• 9:20
  Speaker 1: names within prescription opioids matter. If it has an O,
• 9:25
  Speaker 1: N E in it. Think about oxycodone, that's always on
• 9:28
  Speaker 1: the tip of everyone's tongue, right, it means it has
• 9:30
  Speaker 1: a key tone group in it. You could practically draw
• 9:32
  Speaker 1: the structures based on the name. Yeah, if you're good, right,
• 9:36
  Speaker 1: and folks, this is a podcast. It's very visual, but
• 9:38
  Speaker 1: join me, okay, you know, let's all use our inner
• 9:41
  Speaker 1: Walt Disney and draw some cartoons in her head. But
• 9:43
  Speaker 1: if the name, the prescription opioid name has O N E.
• 9:46
  Speaker 1: If it has one and it has a key tone, right,
• 9:49
  Speaker 1: a little double bond with the O. If it has
• 9:51
  Speaker 1: C O D in it, that is not cash on delivery.
• 9:54
  Speaker 1: That is a three methoxy group. The three is just
• 9:57
  Speaker 1: talking about the position up top like ten. So, but
• 10:01
  Speaker 1: methoxy is the actual group. You know, oxygen with a
• 10:04
  Speaker 1: methyl on it. If it has hydro in it, alla,
• 10:07
  Speaker 1: hydro codone, hydromorphone means it's got some extra hydrogens. It's
• 10:11
  Speaker 1: the bottom line. So less double bonds. If it has
• 10:15
  Speaker 1: oxy in it, that means it has a hydroxyl group,
• 10:18
  Speaker 1: an oh group. Okay, So those four right there can
• 10:22
  Speaker 1: really distinguish, particularly the financeering class, the vast majority of
• 10:25
  Speaker 1: prescription opioids. Their names mean something. Folks also there, you know.
• 10:30
  Speaker 1: Another way is to say that there's mixed action opioids
• 10:33
  Speaker 1: out there, you know, and there were. By the way,
• 10:36
  Speaker 1: mixed action opioid is an opioid. Mixed action is the adjective, right,
• 10:43
  Speaker 1: tramadol to penthodol, lovorphanol and methodone they're all opioids, right,
• 10:47
  Speaker 1: they're mixed action they exhibit their effects via the opioid
• 10:52
  Speaker 1: MEU receptor one way, shape form or another, but they
• 10:55
  Speaker 1: also have things like serratonergic or norepinephrine or even NMDA
• 11:02
  Speaker 1: other opioid receptors as well. They have multiple mechanisms of
• 11:07
  Speaker 1: action mixed action opioids. Right, all right, before we jump
• 11:12
  Speaker 1: into the actual selection portion of this opioidology episode, you know,
• 11:17
  Speaker 1: if you think back to one of the very first
• 11:20
  Speaker 1: Pain Pod episodes was Opioid Madness. I believe it was
• 11:23
  Speaker 1: part one and part two. So in the end, you know,
• 11:25
  Speaker 1: we were basically doing a bracketology. Yeah, I was back
• 11:28
  Speaker 1: when COVID hit. We didn't have March madness. We had
• 11:30
  Speaker 1: enough madness in the world going on. But we you know,
• 11:33
  Speaker 1: here at the Pain Pot, we created opioid Madness, a
• 11:35
  Speaker 1: bracketology reviewing opioids to decipher what's the most interesting opioid ever.
• 11:41
  Speaker 1: The winner of that bracketology, if you want to call
• 11:44
  Speaker 1: it a winner, just saying, you know, I had the
• 11:46
  Speaker 1: most to cover educationally, but it was the most interesting
• 11:49
  Speaker 1: was upan orphine at the time. Right, Lots of much
• 11:53
  Speaker 1: ado on various episodes of the Pain Pod in that regard,
• 11:56
  Speaker 1: but you know, when you look at the pain management
• 11:59
  Speaker 1: options as far as indications anyway, you know, you have
• 12:03
  Speaker 1: your you know, you know, the buckle or bugle formulation,
• 12:06
  Speaker 1: you have the transdermal patch, and you have the injection, right,
• 12:10
  Speaker 1: but they come with their baggage too, like, for instance,
• 12:13
  Speaker 1: the you know, the trans mucosal versions, the dental concerns
• 12:18
  Speaker 1: overall that we've learned throughout the years that it's you know,
• 12:21
  Speaker 1: just something that's not going to come up in clinical trials,
• 12:24
  Speaker 1: but in post marketing we start catching on to that
• 12:26
  Speaker 1: as well. And then the concerns with the transnormal patch
• 12:30
  Speaker 1: of like any waning effects not lasting the full seven days.
• 12:33
  Speaker 1: You know, that's by far not always, but something of concern.
• 12:37
  Speaker 1: Both of those products are for chronic pain only, whereas
• 12:39
  Speaker 1: the injection would be for really any severe pain along
• 12:43
  Speaker 1: the way. But again it depends on the scenario for
• 12:46
  Speaker 1: a patient. So let's go into the big picture here.
• 12:49
  Speaker 1: What we're here for, you know, for opioid selection, what
• 12:52
  Speaker 1: do we base our clinical decisions on? Typically guidelines? Right,
• 12:57
  Speaker 1: alas the title is a guide, a guideline doesn't mean
• 13:01
  Speaker 1: it's always the answer in pain management, and I believe
• 13:04
  Speaker 1: multiple episodes of the Pain Pod. We've covered things like
• 13:07
  Speaker 1: the CDC opioid guideline. Right, you're like, I remember that
• 13:11
  Speaker 1: one Oh boy came in hot, didn't You had the
• 13:13
  Speaker 1: author even on on one of the episodes, the pharm
• 13:15
  Speaker 1: d author anyway, right, yep. So you know they're with
• 13:19
  Speaker 1: statements like, oh, you know the twenty twenty two guideline
• 13:22
  Speaker 1: update for opioids from the CDC. Their first recommendation was
• 13:25
  Speaker 1: non opioid therapies are effective for many common types of
• 13:28
  Speaker 1: the cut pain and you know, compared to an opioid
• 13:33
  Speaker 1: even so, you know it gets tricky there. But alas
• 13:37
  Speaker 1: when it comes to selection, there's nothing specific, right, that's
• 13:42
  Speaker 1: where we get the individual guidelines along the way. We
• 13:45
  Speaker 1: even't you know, in our wild and wonderful state of
• 13:46
  Speaker 1: West Virginia, we had the SAMP guy have the SAMP
• 13:49
  Speaker 1: guidelines see if an effective management of pain. It's the
• 13:52
  Speaker 1: first time that we know of since the nineteen eighties
• 13:55
  Speaker 1: who Ladder that we had clinical treatment algorithms. Okay, these
• 13:58
  Speaker 1: have been shared worldwide wide coming from little old West Virginia.
• 14:02
  Speaker 1: A stoplight approach to no susceptive, neuropathic and mixed pain.
• 14:05
  Speaker 1: Because we're human in life happens, right, but they still
• 14:08
  Speaker 1: don't go into directly the specific medical conditions because that
• 14:12
  Speaker 1: does matter for a patient. Right. That being said, all
• 14:16
  Speaker 1: the guidelines, you know, it makes me think of the
• 14:18
  Speaker 1: sign that says, oh this is a drug free workplace,
• 14:20
  Speaker 1: but it's you know, the signs in a pharmacy, your
• 14:24
  Speaker 1: honor objection. There's literally medications aka drugs everywhere, right, So
• 14:30
  Speaker 1: how do we go into actually selecting? You know, I
• 14:32
  Speaker 1: did this back in the day with end sads, where
• 14:35
  Speaker 1: you know, if I if I have more conversations or
• 14:38
  Speaker 1: a ten more talks or whatever on end sids. There's
• 14:41
  Speaker 1: so much to talk about when it comes to end
• 14:42
  Speaker 1: SAIDs lass. We'll have it here on the pain pot
• 14:45
  Speaker 1: as well, but hey, you know which one where do
• 14:49
  Speaker 1: we start? Right? So we made like a Baker's dozen
• 14:51
  Speaker 1: for the in sid selection, but it got to think
• 14:53
  Speaker 1: of for opio it's what do we take into account?
• 14:55
  Speaker 1: So here a dozen things. Here's our meat and potatoes, folks,
• 14:59
  Speaker 1: ding ding ding. Opioid selection factors. Okay, first up is
• 15:02
  Speaker 1: the patient opioid experience or opioid naive. You know, they
• 15:05
  Speaker 1: had they utilized prescription opioids or quite frankly any opioids
• 15:11
  Speaker 1: in the recent past, you know, and you got to
• 15:15
  Speaker 1: kind of dial it in as well too, Like you know,
• 15:17
  Speaker 1: our oldest son when he had eartubes, I couldn't help,
• 15:20
  Speaker 1: but know us, they give him fetnyl because it was
• 15:21
  Speaker 1: a procedure, and what hospital doesn't, Right, he's still opioid
• 15:26
  Speaker 1: naive at this point, right, Like that that was a
• 15:28
  Speaker 1: while ago and it was in a procedure, so all right.
• 15:32
  Speaker 1: After that, the second thing would be opioid risk assessments
• 15:35
  Speaker 1: always always, it's it's one of the biggest risk reduction strategies,
• 15:38
  Speaker 1: of course, best practices. And then of course third thing
• 15:42
  Speaker 1: would be age. You know, it's pediatric, adult, geriatric, older patients.
• 15:47
  Speaker 1: You know, also we want to know what's going on
• 15:49
  Speaker 1: with the patient. Is it acute, sub acute chronic, you know,
• 15:52
  Speaker 1: subecuting between acute and chronic, of course, and then what
• 15:57
  Speaker 1: is the actual painful medical condition or situation? Right, that's
• 16:00
  Speaker 1: our first five. Then we dive to some specifics. Like
• 16:04
  Speaker 1: the sixth thing I would say would be renal and
• 16:06
  Speaker 1: hepatic function. I mean maybe it could even divide those out,
• 16:09
  Speaker 1: but we'll put them together. It makes a nice dozen
• 16:12
  Speaker 1: in the end, right, The seventh thing would be pregnancy
• 16:14
  Speaker 1: or lactation status if the patient's female. Of course, you
• 16:18
  Speaker 1: know that's going to come into play. Also, drug drug
• 16:21
  Speaker 1: interactions of concern that are out there, you know those
• 16:24
  Speaker 1: are you're getting into the PDPK, the pharmacological scenarios there too.
• 16:27
  Speaker 1: With those last three or so, don't get into some
• 16:31
  Speaker 1: patient preferences, like if there is any of that is
• 16:34
  Speaker 1: dosage frequency, you know they want it multiple times a
• 16:37
  Speaker 1: day or just once a day, or you know what's
• 16:39
  Speaker 1: going on there. Formulation preference, you know, or folks ok
• 16:43
  Speaker 1: with an injectable or okay with a patch of transdermal
• 16:47
  Speaker 1: topical you name it in this case transnormal or oral
• 16:51
  Speaker 1: along the way. Of course, in any clinical scenario, we
• 16:55
  Speaker 1: got to account for cost concerns. And then the last
• 16:59
  Speaker 1: thing at three in there would be the ten out
• 17:01
  Speaker 1: a dozen would be the final opioid selection factors. What
• 17:04
  Speaker 1: else is being utilized? What's the other parts currently or
• 17:08
  Speaker 1: intended for the diverse treatment plan overall non opioids, you know,
• 17:12
  Speaker 1: a djuvenan's non form complimentary selections, you name it, overall
• 17:16
  Speaker 1: interventionally even everything all together, So that that's the twelve okay,
• 17:20
  Speaker 1: that's twelve things overall. Again, dive a little bit deeper
• 17:24
  Speaker 1: just into those we mentioned the opiid risk assessments. When
• 17:28
  Speaker 1: selecting those, there's two questions asually recommend to folks. It's
• 17:32
  Speaker 1: one of them is already answered because it's the first
• 17:34
  Speaker 1: opioid selection recommendation we have here. I'll be his patient
• 17:38
  Speaker 1: opioid naive or experienced. And then whether you as the
• 17:41
  Speaker 1: clinician or a teammate or the patient will be conducting
• 17:44
  Speaker 1: the you know, the screening overall. That's really that right,
• 17:48
  Speaker 1: there's a them out there, but that'll narrow it down
• 17:51
  Speaker 1: for you now based on the risk screening. You know,
• 17:55
  Speaker 1: then it's like, hey, what do we do? You know,
• 17:57
  Speaker 1: when there's a screening for a higher risk, some things
• 18:00
  Speaker 1: will take into a comfort opioid selection would be on
• 18:02
  Speaker 1: the risk side would be well, there's you know, the
• 18:04
  Speaker 1: abuse to turn formulation. There's some newer ones in the
• 18:07
  Speaker 1: in the kettle in the oven for the future where
• 18:10
  Speaker 1: they're looking at, you know, you know, just reducing the
• 18:13
  Speaker 1: risk overall. But currently this is right now, there's basically
• 18:19
  Speaker 1: four options that are out there for the abuse to
• 18:21
  Speaker 1: turn formulation opioids. There's one hydro codone product that's long
• 18:26
  Speaker 1: acting tablet. There's three oxycodone options. I mean, unless you've
• 18:31
  Speaker 1: you know what, if you've lived under a rock, you
• 18:33
  Speaker 1: still know about oxycon let's be real, the extent release tablet.
• 18:36
  Speaker 1: There's also ex tamza, the extent release capsule, and relatively
• 18:40
  Speaker 1: new it would be the roxy bond the immediate release tablet.
• 18:44
  Speaker 1: That's a little bit of a change or shift there
• 18:46
  Speaker 1: because it's an ADF products an IR. You know, cute
• 18:49
  Speaker 1: utilization there as well too, So all right, but those
• 18:54
  Speaker 1: those are some options, and coming in to selection, I
• 18:56
  Speaker 1: had that. I think it was the seventh thing as
• 18:58
  Speaker 1: far as U selection overall, possibly sixth, but the you know,
• 19:04
  Speaker 1: renal and hepatic function, So let's concentrate on the renal.
• 19:07
  Speaker 1: If somebody's got chronic kiddeing disease. In the realm of
• 19:11
  Speaker 1: prescription opioids, you're typically avoiding things like codine, maparodine, morphine.
• 19:17
  Speaker 1: Oh no, you usually want to avoid insets probably common
• 19:20
  Speaker 1: clinical sense at this point, you know, use caution with
• 19:24
  Speaker 1: oxycodon tramadol, and you know, as far as preferences, it's
• 19:28
  Speaker 1: not every patient scenario, but there's other things out there,
• 19:30
  Speaker 1: like you know, fentanyl, bupan, orphine, hydromorphone methodone, you name it,
• 19:35
  Speaker 1: some other non opioids as well too. All right, let's
• 19:39
  Speaker 1: kick it up a notch here. Let's just take those
• 19:42
  Speaker 1: twelve opioid selection factors. And by the way, this is
• 19:45
  Speaker 1: not a specific science. This is a recommendation overall to
• 19:49
  Speaker 1: wrap our heads around this. Okay, we'll have this listed out.
• 19:53
  Speaker 1: If you already started writing them down, my bad. We'll
• 19:56
  Speaker 1: have them online for you. Okay, this stuff's all is
• 20:00
  Speaker 1: available at ping guy dot us. But we'll have them
• 20:02
  Speaker 1: in show notes as well too. But utilizing these twelve
• 20:05
  Speaker 1: opiate selection factors for different cases, we'll go through a couple. Okay,
• 20:11
  Speaker 1: right off the bat, let's do acute pain and we'll
• 20:14
  Speaker 1: do kidney stones. Why not, because you know I had
• 20:17
  Speaker 1: an all episode on that one right back in the day.
• 20:20
  Speaker 1: Oh too soon, literally always. So here's answers to those
• 20:24
  Speaker 1: twelve things. So it's patient opio had experience from naive
• 20:27
  Speaker 1: naive low risk assessment, forty year old adult. It's acute nephroleithiasis,
• 20:33
  Speaker 1: kidney stone pain, healthy normal renal hepatic function. It's male,
• 20:41
  Speaker 1: no drug drug interactions, no preference as far as dosage,
• 20:44
  Speaker 1: frequency or formulation or cost. Also utilizing finaso pyridine and
• 20:50
  Speaker 1: was provided intramuscular contora LAC in the hospital as well.
• 20:54
  Speaker 1: So what we're going to do is as far as
• 20:55
  Speaker 1: you know upon discharge for this patient, well, you know,
• 20:59
  Speaker 1: some questions. It's not like he did an answer, folks,
• 21:01
  Speaker 1: but questions I'm gonna be utilizing EAR with or without
• 21:04
  Speaker 1: IR is the you know, the patient was opioid naive,
• 21:08
  Speaker 1: so you know, we think in IR along the way
• 21:10
  Speaker 1: there if you're thinking, you know, it was a low
• 21:13
  Speaker 1: opioid risk assessment, but if you're worried about the general
• 21:16
  Speaker 1: supply in society, you know, would an abuse to turn
• 21:19
  Speaker 1: formulation be in stock at the pharmacy for like an
• 21:22
  Speaker 1: acute situation like this, you got some options things like
• 21:25
  Speaker 1: you know, T three or two or four or whatever,
• 21:29
  Speaker 1: you know, coding would see the metifit hydro code on, oxycodon, morphine, tramaol, pentadol.
• 21:35
  Speaker 1: I'd pose this to you guys, what any thoughts on hydromorphone,
• 21:38
  Speaker 1: love orphanol or oxymorphone If you're cranking it up a
• 21:41
  Speaker 1: notch or so based on the distinguishing opioids there. You know,
• 21:46
  Speaker 1: when I was in the patient seat, not the driver's seat,
• 21:49
  Speaker 1: I received T three and most would say like, oh
• 21:52
  Speaker 1: what it was? Good golly, isn't that like that's that's
• 21:55
  Speaker 1: down there. The M and ME of coding is zero
• 21:56
  Speaker 1: point one five good golly. Well, you know what, when
• 22:00
  Speaker 1: you multiplied out by the dose, it's pretty similar to
• 22:03
  Speaker 1: like a hydro code on a sement if five three
• 22:05
  Speaker 1: twenty five, just a tad bit under so you know.
• 22:08
  Speaker 1: But again, different clinicians will have different answers, but we
• 22:11
  Speaker 1: all want to be in the same ballpark, right, all right,
• 22:14
  Speaker 1: what about let's kick it up to a sub acute scenario.
• 22:18
  Speaker 1: We're gonna have a patient with a broken femur ouch.
• 22:22
  Speaker 1: They are opioid experienced because you know, this is subacute,
• 22:25
  Speaker 1: not quite chronic pain, not a that three months yet.
• 22:28
  Speaker 1: But we'll say they have an opioid risk assessment of
• 22:31
  Speaker 1: moderate because they have a family history of concerns. Our
• 22:34
  Speaker 1: forty five year old male, this is subacute. Like I mentioned,
• 22:41
  Speaker 1: you know, normal renal and hepadic function. As far as
• 22:46
  Speaker 1: drug dra interactions, they're also utilizing stalopram. They prefer daily
• 22:50
  Speaker 1: oral medications and they are alert to the concept of
• 22:53
  Speaker 1: cost concerns and they're also utilizing in approx and as well,
• 22:57
  Speaker 1: so same questions you want er and IR. This is
• 22:59
  Speaker 1: a different scenario that it's opioid experienced. It's not needing
• 23:04
  Speaker 1: it yesterday, So perhaps an ADF could be ordered, particularly
• 23:07
  Speaker 1: with that opioid risk assessment being moderate. So there we'd
• 23:11
  Speaker 1: be thinking perhaps even the hydro code on er product
• 23:14
  Speaker 1: the hysingla or OxyContin or extanza by the way, taking
• 23:17
  Speaker 1: that one with food morphine er of course, and then
• 23:21
  Speaker 1: either u trans or bealbuka. But then you know other options.
• 23:27
  Speaker 1: The list goes on, but which one would you pick? Right,
• 23:31
  Speaker 1: We're gonna have variability, but that's where that question comes in,
• 23:34
  Speaker 1: of like what's our go to? That's the case, folks, right,
• 23:39
  Speaker 1: we'd be remiss not to mention two or three chronic
• 23:42
  Speaker 1: pain situations. So fifty five year old female patient with fibermialogia,
• 23:47
  Speaker 1: opioid naive, low opioid risk assessment score, you know, healthy
• 23:53
  Speaker 1: renal hepatic function, no pregnancy or electation, drug DRIG interactions,
• 23:58
  Speaker 1: wondering about serotonin with any treatments for fibromyalgia because the
• 24:03
  Speaker 1: patient's utilizing delox team, and of course the big one
• 24:06
  Speaker 1: for fibromialogia exercise exercise, exercise, right, so perhaps in this case, uh,
• 24:13
  Speaker 1: you know, continue that exercise, right, maybe having a mixed
• 24:17
  Speaker 1: action opioid. Now, patient's currently utilizing delox team, so you
• 24:21
  Speaker 1: got that serotenergic and orb different effects. So tramadol perhaps
• 24:26
  Speaker 1: could be the dans and why a concern because of that,
• 24:30
  Speaker 1: you know, serotonin Perhaps depentadol could be in many cases,
• 24:35
  Speaker 1: you know, the better selection overall with its lack of
• 24:39
  Speaker 1: the serotonergic concerns along the way as well too, if
• 24:41
  Speaker 1: the patient's continuing both, right, all right, what about the
• 24:45
  Speaker 1: chronic pain patient chronic pain with ostio arthritis and it's worstening.
• 24:49
  Speaker 1: Let I say it's worstening for this patient. We're making
• 24:51
  Speaker 1: up in the sky. Okay, patient with worsening austi arthritis,
• 24:56
  Speaker 1: opiate naive, low risk score. It's an older patient over
• 25:00
  Speaker 1: sixty five, No concerns, even though on age of reno
• 25:05
  Speaker 1: and hepatic function. They're also using les center prolence and
• 25:08
  Speaker 1: the stat and they're they're they're rich, they're not worried
• 25:13
  Speaker 1: about the cost of whatever you got. Talk as far
• 25:15
  Speaker 1: as the other treatments that are already in place would
• 25:18
  Speaker 1: be exercise, tai chi and topical DIKLOPHINEC. So when an
• 25:23
  Speaker 1: opioid is appropriate in this scenario, what would somebody do?
• 25:28
  Speaker 1: So for the selection here, we'd want to look to
• 25:30
  Speaker 1: the guidelines. I've got them on paying guy dot Us
• 25:32
  Speaker 1: under resources. There's the ACR and the a R s
• 25:36
  Speaker 1: I twenty nineteen guidelines. You could just remember there's two
• 25:39
  Speaker 1: OA guidelines. Right. The only opioid on those guidelines recommended,
• 25:44
  Speaker 1: not right out of the gate, but later on, would
• 25:46
  Speaker 1: be Tramadall right, begs the question then about one want
• 25:49
  Speaker 1: to well it depends. All well, it just wasn't reviewed
• 25:52
  Speaker 1: years back when those guidelines were made, right all right,
• 25:57
  Speaker 1: So since were talking about gudelines, let's talk about chronic
• 25:59
  Speaker 1: lower back pain. How could we go over opioid selection
• 26:01
  Speaker 1: without chronic lower back pain? Right, So we have a
• 26:04
  Speaker 1: fifty five year old male opioid naive lower opioid risk score,
• 26:11
  Speaker 1: got chronic lower back pain. Drug drug interactions of concern
• 26:15
  Speaker 1: would be involving the other medicines and use of selicoxib
• 26:18
  Speaker 1: and dual oxetine, so gainly of that serotonin potential concern.
• 26:23
  Speaker 1: The person is very frugal and isn't concerned about what formulation,
• 26:27
  Speaker 1: but want's the easiest dosage possible. Okay, so what do
• 26:31
  Speaker 1: we base our opioid selection on. Well, we've got the
• 26:34
  Speaker 1: two main guidelines. We have actually two or three, but
• 26:39
  Speaker 1: we'll say there was ACP in twenty seventeen, there's the
• 26:42
  Speaker 1: WHO in twenty twenty three. We also have a Department
• 26:46
  Speaker 1: of Veterans Defense. Overall, what we're looking at here though,
• 26:52
  Speaker 1: if you're escalating to the scenario where a patient would
• 26:55
  Speaker 1: be a candidate for prescription opioid, would you be looking
• 26:58
  Speaker 1: at based on those guidelines, tramadol or even transdermal bup
• 27:01
  Speaker 1: and orphine? Some questions there? Right, they do have that dueloxteen,
• 27:05
  Speaker 1: so you know sarahtonin syndrome is not a major concern
• 27:10
  Speaker 1: unless it's a major concern. Right, So again, just because
• 27:14
  Speaker 1: they're not in the guidelines, what would we be looking
• 27:15
  Speaker 1: at their transdermal The person's fine with it, So you
• 27:18
  Speaker 1: got to look at coverage? What about kick it up to?
• 27:22
  Speaker 1: What about methadone? I leave that to you folks. Low cost, right,
• 27:27
  Speaker 1: but has its concerns, It has its baggage, it's it's
• 27:30
  Speaker 1: got a pay extra for its baggage on any air
• 27:32
  Speaker 1: playing any air line on this planet. Quite frankly, so
• 27:36
  Speaker 1: it's not easy, right, all right, we've banged the drum, folks.
• 27:39
  Speaker 1: So opioid selection we you know, we went over difference
• 27:42
  Speaker 1: as an opioids, went over the selection factors. I'll run
• 27:45
  Speaker 1: through them again here One opioid experience through opioid naive.
• 27:48
  Speaker 1: Two opioid risk assessment results three age four is it acute? Subcute? Chronic? Five?
• 27:54
  Speaker 1: What's the condition? Six? Reno hepatic function? Seven pregnancy or
• 27:58
  Speaker 1: electation status? Eight, Drug drig interaction concerns, nine, dosage frequency preference, ten,
• 28:04
  Speaker 1: formulation preference, eleven, cost concerns the almighty dollar, and last
• 28:08
  Speaker 1: but not at least twelve what else do we have
• 28:10
  Speaker 1: going on for the diverse pain management treatment plan? Right?
• 28:15
  Speaker 1: So what's your go to opioid? I bet you might
• 28:20
  Speaker 1: not be able to answer still, and that's okay. But
• 28:24
  Speaker 1: for each of these scenarios and many others, we would
• 28:28
  Speaker 1: want to have our ducks in a row. It involves guidelines,
• 28:31
  Speaker 1: It involves the experience and reasonable and risk reduction strategies.
• 28:35
  Speaker 1: You know, we don't want to end up in scenarios
• 28:36
  Speaker 1: where like hey, left lane is closed thousand feet ahead
• 28:39
  Speaker 1: and right lanes closed five hundred feet ahead. What are
• 28:41
  Speaker 1: you gonna do? Right? Want to have our ducks in
• 28:43
  Speaker 1: a row. We always want to use our clinical judgment
• 28:46
  Speaker 1: monitor in the ongoing no matter what, and document the
• 28:49
  Speaker 1: heck cut of everything. Right. This is sincly though, and
• 28:51
  Speaker 1: we also want to use our best practices you know,
• 28:53
  Speaker 1: this is something from other pain Pot episodes, but patient
• 28:56
  Speaker 1: education and then adherence and diversion monitoring as well. In
• 29:00
  Speaker 1: the end, when it comes down to a people, respect
• 29:03
  Speaker 1: what you inspect, not what you expect, follow up with
• 29:06
  Speaker 1: our patients who care about how much we care, not
• 29:11
  Speaker 1: necessarily how much we know, but how much we care.
• 29:14
  Speaker 1: That being said, it comes on to what we know
• 29:17
  Speaker 1: as well, because we want to be able to help
• 29:18
  Speaker 1: our patients with the best in this case opioid selections overall. So, folks,
• 29:23
  Speaker 1: I hope that this episode of the Pain Pod Opioidology
• 29:26
  Speaker 1: port deuce opioid selection. I hope it helps not just you,
• 29:32
  Speaker 1: but your patients, our patients, our society overall. Okay, I'm
• 29:36
  Speaker 1: happy to keep in touch, folks. Reach out to me
• 29:38
  Speaker 1: A paying guy dot us you get literally message me
• 29:40
  Speaker 1: in my phone, vibrate the whole nine yards, you know,
• 29:43
  Speaker 1: feel free And as always, folks, thank you for listening
• 29:46
  Speaker 1: to the Pain Pod and I hope you have a
• 29:49
  Speaker 1: great day every day.
• 29:51
  Speaker 2: If you'd like to join Mark on the Pain Pod,
• 29:54
  Speaker 2: send us an email. To publish, you're at Pharmacy podcast
• 29:58
  Speaker 2: dot com. Make sure to share the show and subscribe
• 30:02
  Speaker 2: on your favorite podcast directory. Thanks for listening.