Breakthrough pain

[Hemegroup]

Looking for thoughts on this ... would you ever concurrently prescribe Tylenol #3 and Norco 5/325, with instructions to use one or the other for breakthrough pain? I've rotated in PM clinics where much stronger opiates were combined for regular w/breakthrough (such as Oxycontin with Percocet), so I saw no problem in writing for the T3 and Norco, but our county pharmacy protested. Thoughts?

[EMEDPA]

TYLENOL IN BOTH IS PROBLEMATIC IF THEY TAKE BOTH TOGETHER.

I don't work in pain management but have seen oxycodone 5 mg with vicodin for breakthrough used frequently.

[Hemegroup]

Right, I typically don't like patients taking more than 2 grams of acetaminophen a day ... I know that 4 grams is the stated danger zone, but new rules for people with chronic liver disease or CKD is 2 grams and I'd rather stay close to that mark for everyone. Incidentally, I heard word that there's going to be some new federal rules on the narc/tylenol combo products to go public shortly. Anyhow, two T3s and two Norco 5s in a 24-hr period keep it under the 2 gram mark.

[Joelseff]

If TC#3 or vicodin alone is inadequate for pain control, I would be more inclined to D/C the vicodin and TC#3 and go to 7.5/325 or 10/325 of Norco or if they are "breaking through" that I would D/C hydrocodone all together and go to oxy (percocet). I don't see the utility in using TC#3 AND Vicodin/Norco together. My time at Stanford Liver Tx service has got me buggin on how much APAP is out there so I RARELY write for Vicodin.

 

What I am beginning to understand in Pain Medicine, is that our primary goal needs to be ADEQUATELY treating their pain. If you are going to treat with narcs, regardless of schedule, you must write for one that achieves acceptable analgesia. My algo is something like:

NSAIDS->TC#3->Vico/Norco->Percocet->Oxy 15-30 IR->MS IR and so on...If you are changing a pt from one opiate to the other, make sure to calculate for equianalgesia.

[Hemegroup]

The utility is not raising their dose of Norco until it's absolutely necessary ... that was my goal. 'Low and Slow' is my motto.

[Joelseff]

because of hydrocodone? or apap? My approach in my practice is to get them appropriate analgesia asap (it also saves them from paging me at night complaining that they are still in pain lol) I can understand why you would want to start low and go slow though. I think I went to my SP on EVERY patient that broke through their Norco 10's during my first week in PM&R. I wish I can limit what I can write for pain to Norco being top dog. Unfortunately my pts come to me with dilaudid, duragesic, tapentadol and butrans and say "yah i am still at a 9 pain" and not ALL of them are seekers....ahhh i cant wait till i go back to IM in August!!!

 

edit: Oh have you tried Tramadol?

[Hemegroup]

In all my experience with Ultram, I've had one ... maybe two, patients tell me that it was effective for them. "It doesn't do a thing" has been pretty par for the course, almost absolutely! I read that tramadol was the same as codeine in comparison to morphine, both = to about 100 mg. Maybe there's a 'high' with codeine that's not present with tramadol?

[Hemegroup]

And sorry, in answer to your first question, for the hydrocodone.

[bradtPA]

For severe pain requiring breakthrough control, I typically will use a long acting agent with a short acting agent for breakthrough. Examples would be Opana ER with Opana, Oxycontin with oxycodone, Exalgo with dilaudid, fentanyl patch with fentora. For those on schedule IIIN, I just tell them to take an extra dose for breakthrough, or I will change then to a butrans patch.

[dm123]

I'm not a big fan of codeine for chronic type of pain. It seems OK for a few days like with teeth but long term tends to cause more GI plugs when compared to others for comparable and better pain control. Hydrocodone 10/325 sounds like a good fit for this person, maybe three to four times a day with the fourth broken in half for breakthrough. This would still fall into the Schedule III class, be cheaper, and involving less paperwork and if the patient is trustworthy, refills.

 

Hydromorphone, to me is kind of scary for long term. Tolerance seems to build faster.

 

If the pain gets bad for long enough period of time, the fentanyl patches seem to work well in keeping a constant blood level of med. Just keep heat off of them and stay away from hot tubs as the blood levels can jump. Most people like to sip wine in hot tubs, compounding the cracked heads when they get out and the cold air pushes all that peripheral blood inward and they inadvertently kiss the concrete.

 

The buccal mucosa stuff to me is a bit of overkill for the walking wounded. Way to hard to control blood levels. Several years back, I had to have a medical procedure done. My doc gave me a coupon for a free fentanyl lollipop (Actiqu). I was to put the thing in my mouth on the way to the surgical center. No directions came with the thing about it's parts. My wife was driving and I was sucking my brains out on the wrong end. When I got to pre-op, I was informed which end was the handle and which was the med. I don't remember much after that.

 

Opana ER with Opana instant release sounds good if the patient has insurance to cover them. They are relatively $$$.

 

After a person is tapered up (long half life and relatively low LD-50), methadone gives good pain relief without the buzz.

[Hemegroup]

This is all great advice, thanks. Although I'm still unsure of why I couldn't combine the two agents ... but the constipation point is a good one.

 

edited to note: I asked at SDN, and got a reply about two short-acting agents together not being optimally effective. Makes sense.

[bradtPA]

I generally stay away from codeine for pain. There are too many poor metabolizers out there that get no benefit from the med for me to use it when hydrocodone works more reliably.

[BlocDoc]

Looking for thoughts on this ... would you ever concurrently prescribe Tylenol #3 and Norco 5/325, with instructions to use one or the other for breakthrough pain? I've rotated in PM clinics where much stronger opiates were combined for regular w/breakthrough (such as Oxycontin with Percocet), so I saw no problem in writing for the T3 and Norco, but our county pharmacy protested. Thoughts?

 

I think most everyone missed his actual question but I did read through the posts rather quickly-

He is talking about Oxycontin and Percocet in one scenario and T3 and Norco in the second.

 

Oxycontin is, of course a sustained release preparation to be taken twice daily. Percocet (Oxycodone 5, 7.5 and 10 and acetaminophen 325), T3 (acet 325 and Codeine 30mg), and Norco (Hydrocodone 5, 7.5 and 10 /Acet 325) are all short acting preparations.

 

Often a patient taking a long acting drug will have breakthrough pain, a situation where the drug half-life and the clinical effects reach a trough level and the patient feels that "the drug is wearing off". At those times a break-through medication may be used which is obviously a quick-onset medication that bridges the clinical gap until the next dose of long-acting may be used. Thus, the use of a long and short -acting form of Oxycodone is appropriate. As an aside, limit the use of short-acting doses to 2-3 time a day. If it is insufficient, then the dose of the long-acting drug is likely insufficient.

 

However, the use of 2 short-acting medications is not supported in the literature and will create a number of potential clinical dangers, some of which have been discussed above.

When using a particular long-acting agent, always try to use a short-acting form of the same drug as they will potentiate each other best clinically, they tend to be better tolerated, negate any drug-drug interactions and tend to avoid large variations in chemical bioavailability.

 

Long-acting opioids are used to stay ahead of new pain events whereas the use of short-acting agents tends to create a "trying to keep pace with the pain" issue. This situation will increase the probability of psychological dependence and escalating drug doses/ frequency leading to at least pseudo-addiction if not outright addictions issues.

 

Maximum daily Acetaminophen doses is an important issue but becomes moot if one uses best medical practices in their use of long and short-acting opioids. Most all long-acting opoids have short-acting forms available for breakthrough use with the exception of fentanyl. In that instance, I have rarely needed a break-through agent but hydrocodone or oxycodone could be tried in all but the young and very old.

 

Regards to all...

[Contrarian]

For severe pain requiring breakthrough control, I typically will use a long acting agent with a short acting agent for breakthrough. Examples would be Opana ER with Opana, Oxycontin with oxycodone, Exalgo with dilaudid, fentanyl patch with fentora.

 

Agree with the above...

I see LOTS of patients in Behavioral/Addiction Medicine issues seeking pain relief.

 

A few thoughts...

 

Headaches... I don't prescribe opiates for ANY headaches. Triptans or Barbituates for acute headache termination only and refer to pain specialist. Will refer the "sane" ones to Headache Specialist as soon as HE gets his clinic up and running...:wink:

 

Back/Neck muscular pain... I prescribe Flexeril, Methocarbomol, baclofen, Skelaxin and Capzasin Crm and Ibuprophen or Acetamenophen or LidoPatch/Flector Patch.

 

Joint Pain... Voltaren Gel

 

Toothache... I RARELY if at all prescribe opiates for toothaches. Have found a Dental Block for immediate relief followed by short-term, SCHEDULED high dose NSAIDs to be effective (800mg po q 6 hr scheduled so patient never gets BACK in pain waiting for a PRN dose to kick in). Alternate, is to offer Dental block, if patient agrees (filter for DSB and a sign that they REALLY want relief) give 2 vicodin now, swab with orajel, do block, then schedule nsaids.

 

Will prescribe Toradol but no longer that 3-4 days...

 

I prescribe Tramadol sparingly and short-term in patients I don't want to give vicodin to. If I have to prescribe Vicodin...

 

When I prescribe hydrocodone/aceteminophen (Vicodin)... I often start off SCHEDULED (for example: 2 tabs po TID x 3 days... then 2 tabs BID x 3 days... then 1-2 tabs BID PRN x 3 days # 40... 0-refills). I want to know if they are having continued pain so NO refills. I want to know that they are following my instructions so NO early refills, NO excuses about "running out" of tabs.

 

Don't forget about hydrocodone/Ibuprophen (Vicoprofen) in patients you are leery about using acetaminophen on. I use this for our recent tylenol OD suicidal gesture/attempt patients. and our Hepatitis/ETOH liver dz patients.

 

I will prescribe the "Oxy" products (Oxycodone/acetaminophen, Oxycodone/Ibuprophen. Oxycodone/ASA, OxyContin) in this Substance Abusing/Dependent population as last resort but only on a VERY short term.

 

OxyContin 20-80mg BID with 10-30mg of OxyCodone TID PRN for "Break-thru" has always been sufficient to date

 

I will convert to methadone if long term is needed. Scheduled Methadone works well and I usually use divided TID daily doses. Ex:

 

Methadone TID dosing (0900, 1500, 2100)

25mg/day (10-10-5)

30mg/day (10-10-10)

40mg/day (15-15-10)

50mg/day (20-20-10)

60mg/day (20-20-20)

70mg/day (25-25-20)

80mg/day (30-30-20)

 

 

YMMV...

 

Contrarian

[dm123]

I'm sorry if this seems a bit off topic but the following relates to a pet peeve. Tramadol works by its effect on the neuro transmitter serotonin, the feel good neuro transmitter. It is not unlike Lyrica and others indicated for nerve pain. Cymbalta, an SSRI and Lilly's principal money maker, and still on patent, recently received an indication as an adjunct in treating musculo-skeletal pain, menstrual pain and other types of pain. I about fell out of my chair. These drugs are not addictive in the sense people crave the high but they do have a significant "withdrawal syndrome" (from a package insert) associated with them. Once people get started on them, stopping causes most times severe symptoms and they feel they needed the drug so they stay on them for life. I can see a need for SSRIs in depression but don’t like the marketing for pain.

 

Another concern is the possibility of serotonin syndrome or serotonin storm, a life threatening condition. If someone ends up on Ultram (tramadol), Lyrica, Cymbalta or its competitor Effexor, Prozac, eat chocolate, bananas, maybe take Dextromethorphan (street name poor man’s PCP) for cough and some other OTC supplements the worst could happen. To me, it just seems to be over reaching with a drug that could easily be over prescribed and dangerous.