View Full Version : [Neurology and Pain] SAFE Opioid Prescribing - Module V

Wed 28th May '14, 5:29pm
SAFE Opioid Prescribing - Module V: Everything You Always Wanted to Know About ER/LA-Opioids as a Drug Class

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Definition of Opioid Tolerant

“Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg of oral HYDROmorphone daily, or an equianalgesic dose of another opioid.” (Food and Drug Administration)

This history must immediately precede the intended course of PCA therapy. If a wash-out period of a week or longer has occurred since the above dosages were taken, reconsider whether the patient truly meets this definition of tolerance.

Definition of Opioid Naïve

Patients who do not meet the definition of opioid tolerant, who have not had narcotics doses at least as much as those listed above for a week or more, are considered to be opioid naïve.

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Wed 28th May '14, 5:32pm
For the therapeutic approach for the adverse effect of constipation please refer http://forum.tomhsiung.com/pharmacotherapy/201-%5Bpalliative-care%5D-management-of-constipation-in-palliative-care.html
For the therapeutic approach for the adverse effect of nausea and vomiting please refer http://forum.tomhsiung.com/pharmacotherapy/189-%5Bpalliative-care%5D-medication-therapy-for-nausea-and-vomiting-in-palliative-care.html , http://forum.tomhsiung.com/adverse-drug-effects-and-medication-safety/142-cinv-chemotherapy-induced-nausea-and-vomiting.html and http://forum.tomhsiung.com/adverse-drug-effects-and-medication-safety/116-cinv-the-degree-and-treatment.html

Wed 28th May '14, 5:58pm
1.Guanylate cyclase type-C (GC-C) agonist

Guanylate cyclase C (GC-C) agonist; activation of GC-C located on the luminal surface of intestinal epithelial cells leads to increased cyclic guanosine monophosphate (cGMP), anion secretion, fluid secretion, and intestinal transit

Appears to work topically rather than systemically; elevation in intracellular cGMP stimulates secretion of chloride and bicarbonate into the intestinal lumen, mainly through activation of the cystic fibrosis transmembrane conductance regulator (CFTR) ion channel, resulting in increased intestinal fluid and accelerated transit


Bulk producing laxative. Increase stool size. This causes a distention of the intestinal lumen, induces peristalsis, and decreases transit time through the intestine. The net result of these effects is an increased frequency of defecation. However, these class of agents should be limited in the palliative care patient population. Since patients ingesting bulk laxatives with relatively little activity and decreased fluid intake are at risk of forming an obstruction. Also they are not effective for severe constipation. And they have a grainy, unfavorable texture that may be nauseating to some patients.

3.Osmotic laxatives (osmotic and Saline) are indigestible sugars that cause an increase in fluid in the intestines to dilute sugars. The increase in water results in a softer stool and distention of the bowel, which stimulates peristalsis. The onset of action occurs within 24 to 48 hours.

4.Stimulant laxatives are considered first line in palliative care. However, due to their effect to induce colic, they are not recommended in bowel obstruction.

5.Surfactant laxatives (Stool softener) increase water penetration into the stool, thereby softening it and allowing easier passage through the bowel. Effects are seen within 24 to 72 hours.

6.Opioid receptor antagonists (topical)

Peripheral mu-opioid receptor antagonist; limited ability to cross blood brain barrier so doesn't abolish opioid-induced analgesia nor cause withdrawal symptoms but decreases opioid-induced constipation.

Wed 28th May '14, 9:18pm
For opioid conversion please refer