The Opioid Manager is designed to be used as a point of care tool for providers prescribing opioids for chronic non-cancer pain. It condenses key elements from the Canadian Opioid Guideline and can be used as a chart insert. Before You Write the First Script Patient Name: Pain Diagnosis: Date of Onset: Goals decided with patient:
Initiation Checklist Y N Date Are opioids indicated for this pain condition Explained potential benefits Explained adverse effects Explained risks Pt given info sheet Signed treatment agreement (prn) Urine drug screen (prn)
Opioid Risk Tool By Lynn R. Webster MD Item score
if female Item score
if male Item (check all that apply) 1. Family History of
    Substance Abuse: Alcohol Illegal Drugs Prescription Drugs 2. Personal History of
    Substance Abuse: Alcohol Illegal Drugs Prescription Drugs 3. Age (mark box if 16-45) 4. History of Preadolescent
    Sexual Abuse 5. Psychological Disease Attention Deficit Disorder, OCD, Bipolar, or Schizophrenia Depression
Total: Total Score Risk Category:
low risk 0-3 moderate risk 4-7 high risk 8+
Overdose Risk Patient Factors *Elderly
*On benzodiazepines *Renal impairment *Hepatic impairment *COPD
*Sleep apnea
*Sleep disorders *Cognitive impairment Provider Factors *Incomplete assessment *Rapid titration *Combining opioids and
sedating drugs
Failure to monitor dosing
*Insufficient information
given to patient and/or
relatives Opioid Factors *Codeine & Tramadol - lower risk
*CR formulations-higher doses than IR Prevention *Assess for Risk Factors

*Educate patients/families about risks & prevention *Start low, titrate gradually
monitor frequently

*Careful with benzodiazepines

*Higher risk of overdose - reduce initial dose by 50%, titrate gradually

*Avoid parenteral routes

*Adolescents + elderly - may need consultation *Watch for misuse
Stepped Approach to Opioid Selection Mild-to-Moderate Pain First-line: codeine or tramadol Severe Pain Second-line: morphine, oxycodone, or hydromorphone First-line: morphine, oxycodone, or               hydromorphone Second-line: fentanyl Third-line: methadone Initiation Trial A closely monitored trial of opioid therapy is recommended before deciding whether a patient is prescribed opioids for long term use. Suggested Initial Dose and Titration (Modified from Weaver M., 2007 and the eCPS, 2008) Notes: The table is based on oral dosing for CNCP. Brand names are shown if there are distinct features about specific formulations. Reference to brand names as examples does not imply endorsement of any of these products. CR = controlled release, IR = immediate release, NA = not applicable, ASA: Acetylsalicylic Acid Opioid Codeine (alone or in
combination with
acetaminophen or ASA) CR Codeine Tramadol (37.5 mg) +
acetaminophen
(325 mg) CR Tramadol IR Morphine CR Morphine IR Oxycodone CR Oxycodone IR Hydromorphone CR Hydromorphone Initial dose 15-30 mg q4h
as required 50 mg q12 1 tab q4-6h
prn up to 4/day a) Zytram XL 150 mg q24h
b) Tridural 100 mg q24h
c) Ralivia 100 mg q24h 5-10 mg q4h prn
max 40 mg/d 10-30 mg q12h
Kadian q24h - N.B. should
not be started in opioid naive patients 6-10 mg q6h prn
max 30 mg/d 10-20 mg q12h
max 30 mg/d 1-2 mg q4-6h prn
max 8 mg/d 3 mg q12h prn
max 9 mg/d Minimum time
interval for increase 7 days 2 days 7 days a) 7 days
b) 2 days
c) 5 days 7 days Minimum 2 days,
recommend: 14 days 7 days Minimum 2 days,
recommend: 14 days 7 days Minimum 2 days,
recommend: 14 days Suggested dose increase 15-30 mg/d up to max of
600 mg/d (acetaminophen dose
should not exceed 3.2 gm/d) 50 mg/d up to max of
300 mg q12h 1-2 tab q4-6h prn
up to max 8 tabs/day Max doses:
a) 400 mg/d
b) 300 mg/d
c) 300 mg/d 5-10 mg/d 5-10 mg/d 5-10 mg/d 10 mg/d 1-2 mg/d 2-4 mg/d Minimum daily dose before converting IR to CR 100 mg NA 3 tablets NA 20-30 mg NA 20 mg NA 6 mg NA
Initiation Trial Chart Date D / M / Y Opioid prescribed Daily dose Daily morphine equivalent More than 200 Less than 200 Watchful Dose
> than 200 Goals achieved: Yes, No, Partially Pain intensity Functional status: Improved, No Change, Worsened Adverse effects Nausea Constipation Drowsiness Dizziness/Vertigo Dry skin/Pruritis Vomiting Other? Complications? (Reviewed: Y/N) Other Monitoring 0 = None
1 = Limits ADLs
2 = Prevents ADLs
To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, download the Opioid Manager, and to provide feedback visit: http://nationalpaincentre.mcmaster.ca/opioidmanager Feb 2011
Patient Name: Maintenance & Monitoring Morphine Equivalence Table Opioid Morphine Codeine Oxycodone Hydromorphone Meperidine Methadone+Tramadol Equivalent
Doses (mg) 30 200 20 6 300 Conversion
to MEQ 1 0.15 1.5 5 0.1 Dose Equiv unreliable Transdermal
fentanyl 60-134 mg morphine=25 mcg/h
135-179 mg = 37 mcg/h
180-224 mg = 50 mcg/h
225-269 mg = 62 mcg/h
270-314 mg = 75 mcg/h
315-359 mg = 87 mcg/h
360-404 mg = 100 mcg/h
Switching Opioids: If previous
opioid dose was: High Moderate
or Low Then, SUGGESTED
new opioid dose is: 50% or less of
previous opioid
(converted to MEQ) 60-75% of previous opioid
(converted to MEQ)
Maintenance & Monitoring Chart Date D / M / Y Opioid prescribed Daily dose Daily morphine equivalent More than 200 Less than 200 Watchful Dose
> than 200 Goals achieved: Yes, No, Partially Pain intensity Functional status: Improved, No Change, Worsened Adverse effects Nausea Constipation Drowsiness Dizziness/Vertigo Dry skin/Pruritis Vomiting Other? Complications? (Reviewed: Y/N) Other Monitoring 0 = None
1 = Limits ADLs
2 = Prevents ADLs
When is it time to DECREASE the dose or STOP the opioid completely? When to stop opioids Examples and Considerations Pain Condition Resolved Patient receives definitive treatment for condition. A trial of tapering is warranted to determine if the original pain condition
has resolved. Risks Outweigh Benefits Overdose risk has increased.
Clear evidence of diversion.
Aberrant drug related behaviours have become apparent. Adverse Effects
Outweigh Benefits Adverse effects impairs functioning below baseline level.
Patient does not tolerate adverse effects. Medical Complications Medical complications have arisen (e.g. hypogonadism, sleep apnea, opioid induced hyperalgesia). Opioid Not Effective Opioid effectiveness = improved function or at least 30% reduction in pain intensity. Pain and function remains unresponsive.
Opioid being used to regulate mood rather than pain control.
Periodic dose tapering or cessation of therapy should be considered to confirm opioid therapy effectiveness.
How to Stop - the essentials How do I stop? The opioid should be tapered rather than abruptly discontinued. How long will it take to stop the
opioid? Tapers can usually be completed between 2 weeks to 4 months. When do I need to be more cautious
when tapering? Pregnancy: Severe, acute opioid withdrawal has
been associated with premature labour
and spontaneous abortion. How do I decrease the dose? Decrease the dose by no more than 10% of the total daily dose every 1-2 weeks. Once 1/3 of the original dose is reached, decrease by 5% every 2-4 weeks. Avoid sedative-hypnotic drugs, especially benzodiazepines, during the taper. Aberrant Drug Related Behaviour (Modified by Passik, Kirsh et al 2002) Indicator Examples * Altering the route of delivery • Injecting, biting or crushing oral formulations * Accessing opioids from
   other sources • Taking the drug from friends or relatives
• Purchasing the drug from the "street"
• Double-doctoring  Unsanctioned use • Multiple unauthorized dose escalations
• Binge rather than scheduled use  Drug seeking • Recurrent prescription losses
• Aggressive complaining about the need for higher doses
• Harassing staff for faxed scripts or fit-in appointments
• Nothing else "works"  Repeated withdrawal
 symptoms • Marked dysphoria, myalgias, GI symptoms, craving  Accompanying conditions • Currently addicted to alcohol, cocaine, cannabis or other drugs
• Underlying mood or anxiety disorders not responsive to
  treatment  Social features • Deterioration or poor social function
• Concern expressed by family members  Views on the opioid
 medication • Sometimes acknowledges being addicted
• Strong resistance to tapering or switching opioids
• May admit to mood-levelling effect
• May acknowledge distressing withdrawal symptoms * = behaviours more indicative of addiction than the others.
Everything Humanly Possible Centre for Effective Practice National Opioid Use Guideline Group (NOUGG) To access the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, download the Opioid Manager, and to provide feedback visit: http://nationalpaincentre.mcmaster.ca/opioidmanager
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