Opioids from theory to practice
Opioids are one of the longest known and used drug groups. Due to their specific pharmacodynamic and pharmacokinetic actions, their use is often subject to uncertainty or hesitation on the part of both patients and physicians. In this algorithm, we will look at their use in practice in the role of the pain specialist and anaesthesiologist, in particular the setting of chronic medication - escalation and de-escalation of therapy, management of common side effects and adaptation of analgesia in the perioperative period.
Review
The algorithm presents a clinical case concerning titration of effective opiod treatment in a pre-op patient with chronic pain in the face of insufficient effect of maximal tramadol dose with acetaminophen. It guides the user through the management of adverse effects of transdermal buprenorphine, management of opioid induced constipation. Acute control of pain in the peri-operative period is covered, as is gradual withdrawal of opioids after surgical correction of the underlying condition.
Sources
OPAVSKÝ, Jaroslav. 2011. Bolest v ambulantní praxi: od diagnózy k léčbě častých bolestivých stavů. Praha: Maxdorf. Jessenius. ISBN 978-80-7345-247-6.
KOZÁK, Jiří; LEJČKO, Jan a VRBA, Ivan. Opioidy. 2nd, revised and expanded edition. Jessenius. Praha: Maxdorf, [2021]. ISBN 978-80-7345-664-1.
VAZZANA, M. et al., 2015. Tramadol hydrochloride: Pharmacokinetics, pharmacodynamics, adverse side effects, co-administration of drugs and new drug delivery systems. Biomedicine & Pharmacotherapy. Vol. 70, pp. 234–238. Available from: https://doi.org/10.1016/j.biopha.2015.01.022
HUDDART, Rachel et al., 2018. PharmGKB summary. Pharmacogenetics and Genomics. Vol. 28, no. 10, pp. 230–237. DOI 10.1097/fpc.0000000000000351. Available from: http://dx.doi.org/10.1097%2FFPC.0000000000000351
ALLEN-BRADY, Kristina and TUTEJA, Ashok K., 2019. Opioid-induced bowel disorder and narcotic bowel syndrome. In : Elsevier eBooks, pp. 463–475. DOI 10.1016/b978-0-12-813037-7.00033-9. Available from: https://doi.org/10.1016/B978-0-12-813037-7.00033-9
Learning targets
2. The student can perform rotation of strong opioids using the morphine milligram equivalent table.
3. The student will be able to explain opioid de-escalation therapy options.
4. The student will explain the meaning of basic pharmacodynamic and pharmacokinetic concepts.
Key points
2. Many side effects can be managed by changing the drug formulation or adding other medications.
3. When switching between opioids, we use an opioid rotation chart to correctly adjust the dose of the new medication.
4. A patient on chronic opioid therapy continues their regular treatment postoperatively, supplemented with top-up doses; however, not all opioids are suitable for these patients due to their pharmacodynamic qualities.
