Are You Dealing with Acute, Chronic or Terminal Pain?

Conversions & Information for Pain & Symptom Control

Summary of the Most Significant Changes/Additions in the October 2011 BPM

If you have the 2008 edition...

The 2011 version is essentially the same format as the 10 page 2008 version.Listed are the most significant changes/additions.

• Page 2
  Duloxetine (Cymbalta) and tapentadol (nuycenta) were added to the neuropathic pain section, and there are changes in some of the maximum doses, formulations and brands available. In the nausea section, there are changes and additions in formulations and brands available, as well as some dosing changes.
• Page 3 only minor changes
• Pages 4-5
  Exalgo (hydromorphone) and Combunox (oxycodone/ibuprofen) were added to the mu agonist opioid analgesic chart, and a few of the values in the chart were changed. Propoxyphene was deleted as it has been withdrawn from the market due to risk of cardiac toxicity. The charts on page 5 with acetaminophen combinations were simplified as the per dose limit is now 325 mg. A new chart was added listing the transmucosal fentanyl products, along with starting dose and half-life and cautions. The Wong-Baker Faces Pain Rating Scale was moved onto the bottom of this page from page 7.
• Page 6
  Pearls 11 and 36 were deleted. Pearl 21 on half-life was changed to #36, and rewritten to include information on steady state. The information in pearl 23 regarding transmucosal fentanyl was moved to pages 5 and IV-2. Pearl 25 was moved to page IV-2. There are minor changes in some other pearls. 5 new pearls were added, on bioavailability, mu opioid analgesic ceiling, combining gabapentin and nortriptyline, analgesic drug potency and Methylnaltrexone (Relistor) for opioid-induced constipation.
  
• Page 7
  Vimovo (naproxen/esomeprazole DR) was added. There are numerous changes in column values containing starting dose, dosing schedule, daily maximum dose, and half-life, as well as numerous changes in brands available and formulations. Topical formulations of diclofenac and capsaicin are listed at the bottom of the page. The pain rating scale was moved to page 5.
• IV Page – Side 1
  On the IV/PO Equianalgesic chart, fentanyl transmucosal products were deleted and put in a separate chart below, along with how supplied, half-life and starting dose. This chart is identical to the one on page 5. Propoxyphene was deleted. There are only a few changes in the chart values. Exalgo (hydromorphone) was added to the controlled-release formulations chart which is now at the bottom of the page, moved from page   IV-2.
• IV Page – Side 2
  Oral meds were added to the Duragesic dose conversion chart. More caution information was added. The guidelines for administering naloxone (Narcan) for opioid-induced respiratory depression have changed. (see corrections below) Two new pearls were added, regarding IV acetaminophen and ziconotide (Prialt). The pearl regarding IONSYS was deleted, IONSYS was recalled due to a suspected product defect. There is a boxed caution regarding the transmucosal fentanyl products pertaining to the chart on the reverse side.

Corrections

• IV Page - Side 2
  Under Naloxone Guidelines, #3 Naloxone Administration: There are several typos involving mg and mL. However, the overall guidelines have changed. New guidelines are as follows: naloxone (0.4 mg/mL,1 mg/mL) - give 0.4-2 mg IV q2-3 min prn up to 10 mg; give IM/SC if IV route not available; supplemental IM doses last longer; may dilute 0.4 mg in 10 mL and give 0.5 mL in q1 minute increments to avoid abrupt cessation of pain control.

If you have the 2004 edition...

The 2011 version is essentially the same format as the 8 page 2004 version, with the addition of an IV page. There are format changes on pages 4/5, and numerous changes in the NSAID chart.

• Page 2
  There are several new meds under neuropathic pain, as well as some dosing and max changes. There are some additions and deletions in strengths and formulations amongst the antiemetics, as well as dosing changes. The agitation chart is essentially unchanged.
• Page 3 minor changes
• Pages 4-5
  There are some minor changes in the chart values, strengths, and formulations, and some brands are no longer available. Methadone information was removed and placed on side 2 of the new IV page.On page 5, the oxycodone/acetaminophen and hydrocodone/acetaminophen charts were simplified, reflecting the new limit on acetaminophen in combination drugs. A new chart was added listing the transmucosal fentanyl products, along with starting dose, half-life and cautions. The Wong-Baker Faces Pain Rating Scale was moved onto the bottom of this page from page 7.
• Page 6
  There are now 40 pearls. A few have been deleted, some reworded, some moved to other pages, and new ones added.
  
• Page 7
  There are numerous changes in the NSAID chart: a few meds added/deleted, changes in brands/formulations, and column values. Topical formulations of diclofenac and capsaicin are listed at the bottom of the page. Wong-Baker chart was moved to page 5.
• IV Insert – Side 1
  This sheet contains an IV/PO equianalgesic chart, plus an equation that is helpful in figuring out current to desired opioid dosage. There is a fentanyl transmucosal chart with starting dose, half-life and cost guidelines, and a controlled-release formulations chart with dosing and cost guidelines.
• IV Insert – Side 2
  This side contains naloxone/Narcan guidelines, Janssen’s oral/parenteral opioid to Duragesic chart and 7 pearls. Meperidine/Demerol equianalgesic doses are listed so that patients may be transitioned to a more appropriate med. Methadone values are given along with a strong caution regarding the serious risk of opioid toxicity. There is a boxed caution regarding the transmucosal fentanyl products listed on page IV-1.

Corrections

• Page 2 and 4/5
  Fentanyl transdermal (Duragesic) Conversion Chart: Janssen has revised the low conversion dose for the 25 mcg patch. The currently advised doses are PO morphine 60-134 mg and IM morphine 10-22 mg. On pages 4/5, this will change all the values in the second column of all three charts (#tabs or mLs QD to convert to fentanyl 25 mcg patch). Since the conversion chart was already conservative, it is unlikely that using the old values would pose any serious risk of overdose.

If you have the 2002 edition...

The 2011 version is essentially the same format as the 8 page 2002 version, with the addition of an IV page. The adjuvant section has been completely revised, there are some format changes on pages 4 and 5, and the NSAID chart has numerous changes.

• Page 2
  The adjuvant section has been revised to accommodate new information on meds for neuropathic pain. There are some additions and deletions in strengths and formulations amongst the antiemetics, as well as dosing changes. The agitation chart has minimal changes. (see fentanyl corrections below)
• Page 3 minor changes
• Pages 4-5
  On page 5, there are separate oxycodone/acetaminophen and hydrocodone/acetaminophen charts reflecting the new limit on acetaminophen in combination drugs. A new chart was added listing the transmucosal fentanyl products, along with starting dose, half-life and cautions. The Wong-Baker Faces Pain Rating Scale was moved from page 7 to the bottom of page 5. (see fentanyl corrections below)
• Page 6
  There are now 40 pearls. A few have been deleted, some moved to other pages, and new ones added. (see pearl 10 correction below)
• Page 7
  There are numerous changes in the NSAID chart: a few meds added/deleted, changes in brands/formulations, and column values. Topical formulations of diclofenac and capsaicin are listed at the bottom of the page. Wong-Baker chart was moved to page 5.
• IV Insert – Side 1
  This sheet contains an IV/PO equianalgesic chart, plus an equation that is helpful in figuring out current to desired opioid dosage. There is a fentanyl transmucosal chart with starting dose, half-life and cost guidelines, and a controlled-release formulations chart with dosing and cost guidelines.
• IV Insert – Side 2
  This side contains naloxone/Narcan guidelines, Janssen’s oral/parenteral opioid to Duragesic chart and 7 pearls. Meperidine/Demerol equianalgesic doses are listed so that patients may be transitioned to a more appropriate med. Methadone values are given along with a strong caution regarding the serious risk of opioid toxicity. There is a boxed caution regarding the transmucosal fentanyl products listed on page IV-1.

Corrections

• Page 2 and 4/5
  Fentanyl transdermal (Duragesic) Conversion Chart: Janssen has revised the low conversion dose for the 25 mcg patch. The currently advised doses are PO morphine 60-134 mg and IM morphine 10-22 mg. On pages 4/5, this will change the values in the second column of the analgesic conversion chart for converting to fentanyl patch (#tabs or mLs QD to convert to fentanyl 25 mcg patch). Since the conversion chart was already conservative, it is unlikely that using the old values would pose any serious risk of overdose.
• Pearl 10
  This pearl has been deleted (Roxanol droppers are not uniform in size, hence the dosage varies).

If you have the 1998 or 1999 edition...

The 2011 version incorporates the 4 pages with the 2 page How to Use BPM document, and then adds 4 more pages. The analgesic chart is now 2 pages with more information, including equivalent dose, conversion to Duragesic, dosing duration, onset, peak, half-life and cost guidelines. The NSAID chart is a full page with starting dose, dosing schedule, maximum daily dose, half-life, and cost guidelines, plus several topical formulations. There are 47 pearls, and more adjuvant meds with dosing directions. Newer nausea meds have been added. The Pros and Cons page is essentially unchanged. Wong-Baker FACES Pain Rating Scale has been added. An IV page has also been added, details below.

• IV Insert – Side 1
  This sheet contains an IV/PO equianalgesic chart, plus an equation that is helpful in figuring out current to desired opioid dosage. There is a fentanyl transmucosal chart with starting dose, half-life and cost guidelines, and a controlled-release formulations chart with dosing and cost guidelines.
• IV Insert – Side 2
  This side contains naloxone/Narcan guidelines, Janssen’s oral/parenteral opioid to Duragesic chart and 7 pearls. Meperidine/Demerol equianalgesic doses are listed so that patients may be transitioned to a more appropriate med. Methadone values are given along with a strong caution regarding the serious risk of opioid toxicity. There is a boxed caution regarding the transmucosal fentanyl products listed on page IV-1.

Corrections

• Fentanyl transdermal (Duragesic) Conversion Chart: Janssen has revised the low conversion dose for the 25 mcg patch. The currently advised doses are PO morphine 60-134 mg and IM morphine 10-22 mg. On pages 4/5, this will change the values in the second column of the analgesic conversion chart for converting to fentanyl patch (#tabs or mLs QD to convert to fentanyl 25 mcg patch). Since the conversion chart was already conservative, it is unlikely that using the old values would pose any serious risk of overdose.
• Pearl 13 in the 1999 edition, and the 12th pearl in the 1998 version have been deleted. Roxanol droppers are not uniform in size, hence the dosage varies.