please answer all the questions the attached 2 filed and make sure to answer questions correctly.

PAIN 708 Module 3 – Opioid Conversion Calculations

Case Homework

1. LK is a 43-year-old man who injured his back several years ago while unloaded a truck. He has had three back surgeries since his initial injury and is no longer a surgical candidate. At present, LK complains of pain in his sacral area, which he rates as a best of 2 and a worst of 4 on an average day (on a 1-10 scale; 0 = no pain, 10 = worst imaginable pain) while taking his pain medications.

Current medication regimen:

Oxycodone/APAP 10/325mg 2 tabs PO Q8h

Gabapentin 900mg PO Q8h

Desipiramine 75mg PO QHS

LK states he is content with his level of pain control and that it allows him to perform his desire activities of daily living. He enjoys the little “kick” he gets when he takes his two tablets of oxycodone/APAP every 6 hours.

As his prescriber, however, you are not as amused by the “kick.” You are also concerned about the amount of acetaminophen LK is getting per day (325mg x 8 tablets = 2.6g per day), since LK enjoys an alcoholic beverage or three on the weekends (alcohol use increases risk of acetaminophen and opioid toxicity). You decide to switch his oxycodone/APAP to Oxycodone ER.

What dosage regimen do you recommend? When can it be initiated? What educational tips should you give LK about his analgesics?

1. BC is a 48-year-old woman who injured her back in a motor vehicle accident recently, for which she required immediate surgical repair. Post-operatively she was started on intermittent sub-Q injections of morphine every 4 hours. It has been 5 days since surgery, and BC has been stabilized on a total daily dose (TDD) of 15mg subQ morphine. BC is ready for transfer to a rehabilitation facility, and it is anticipated that she will require chronic opioid therapy in the future.

What dosage regimen of long-acting oral morphine would you recommend and why? What dose of oral morphine should be made available to the patient for breakthrough pain?

1. FA is a 62-year-old man with colon cancer who underwent tumor debulking 3 days ago. Over the past 24 hours, he has received 3mg of IV hydromorphone. He has good pain control, and the attending physician would like to send him home on the equivalent regimen of long- and short-acting oxycodone. The physician anticipates FA will be able to taper down this dose significantly over the next few days.

What regimen would you recommend for this patient?

1. SJ is an 84-year-old woman with general debility, significant renal impairment and generalized aches and pains. She has been receiving morphine ER 30mg PO Q12h for the past several months with good success. Over the past couple of weeks, she has developed delirium, with both visual and auditory hallucinations. Other reversible causes have been ruled out, and you are concerned that the active metabolites of morphine are accumulating given SJ’s renal function and causing or contributing to the delirium.

Calculate an equivalent regimen using oxymorphone (generic long-acting and short-acting)

1. TS is a 72-year-old man with severe osteoarthritis pain. His prescriber has him on a regimen of morphine oral solution, 20mg Q4h around the clock. When TS remembers to take all six doses of morphine per day, his pain is very well-controlled. Unfortunately, when he forgets to take doses, he ends up in pain crisis.

His prescriber asks your help in converting TS from oral morphine to TDF. What do you recommend, and specifically how should the switch be timed?

1. DW is a 48-year-old man who just moved to the area for a new job. He has a 10-year history of chronic low back pain for which he receives 100mcg/hr TDF. Unfortunately, his new prescription plan does not cover TDF, and he has been referred to you for conversion to oral morphine.

What do you recommend?

1. KG is a 72-year-old woman with a 1-year history of postherpetic neuralgia. She has tried several adjuvant analgesics with minimal success; therefore, you decide to start methadone. She is not taking any other opioids. Her medications at this time include:

Lisinopril 10mg PO Qday

Hydrochlorothiazide 25mg PO Qday

Sertraline 50mg PO Qday

MVI with iron daily

What is your recommendation for starting methadone in this patient?

1. GH is a 42-year-old man who suffered an accident while working at a construction site. There was a cave-in, and he was crushed under an I-bean, requiring reconstruction of his left hip. This has left him with residual pain for which he takes MS Contin 60mg PO Q12h plus morphine IR 20mg Q4h as needed (takes 6 doses per day). You decide to switch him to methadone.

What would you recommend for his methadone dose, assuming you do a rapid switch?

1. AH is a 24-year-old woman with HIV-related neuropathy, receiving pregabalin 100mg TID. Oral hydromorphone was eventually added to her regimen after her pain progressed, and the patient did not tolerate antidepressant agents known to reduce neuropathic pain. Her pain never responded adequately to the hydromorphone, so her prescriber transitioned her to methadone, currently at 15mg PO TID. Unfortunately, AH’s prescriber suspects that methadone is responsible for the edema she is experiencing, and, in fact, worsening as methadone has been increased. The prescriber asks for your advice on transitioning AH to morphine.

Using a 1:3 ratio of methadone to oral morphine, what do you suggest?