Lecture 04 : Week 07

[Music] this is week seven lecture number four namaste in in this week we also studied about how to prescribe end is essential narcotic drugs again we are emphasizing this subject because safe prescription of essential narcotic drug is our moral responsibility and if it is prescribed safely your patients also will be benefited with good pain relief without causing any adverse effect or side effect of the drug so few of the slides may be repetion or content may be reputation of the previous subject but this is we want to emphasize that how to use end safely first and for foremost the purpose of this lecture is to lay down guidelines for op prescription there are each and every Department should lay down a guideline whenever you are prescribing ends or opioids to your patient the certain guideline needs to be followed so this guidelines is for the cancer pain management and breakthrough pain management how to do op op rotation from one opio to another opid how to convert from oral to the transdermal opods and how to manage opio induced side effects so all the guideline should contain all these points in detail secondly the purpose is also to make clinician aware about the ndps amendment ndps act it is a narcotic drug and psychotropic uh substance act it was uh introduced in clinical in uh India in 1985 and then amended in 2015 which is a very important Amendment as far as palea care physicians are concerned and all clinicians who are practicing palea care or who are going to subscribe e narcotic drugs to the patient should know about this NDP s act and its amendments the scope of this guideline is also to standardize prescription of Ops across the hospital service it is not only restricted to your department but even other department who prescribes op should follow this guideline and to prevent and actively manage the opio related side effect the main focus of the guideline uh can be extended by even management of its side effect and prevention of the side effects so when you are P managing pain in longterm long-term pain means chronic pain usually observe in cancer pain HIV patients and few of the non-cancer patient also has a chronic pain like low back pain shoulder pain Sur uh cervical pain Etc here the goal is to reduce the suffering due to pain improve the fun functionality of the patient and improve the quality of life of the patient so whenever you are using opioids for long term for many months or even years many many of our patients are on morphine or other opiates for one year 1 and a half year so what are the best practices for patient with mild to moderate pain whose pain is not controlled by non op given orally and regularly low do step three opats should be started so oral morphine less than 30 Mig per day may be used alternatively instead of codin or tradol sometimes step to drug like codin and tradol codin is a very good anales but severe constipation is noted with codin and nowadays it is not available except in the syrup form for cuff syrup and all that two they are misusing for Addictive purpose tradol available across the counter but it does have side effects like uh irritation gastritis NOA vomiting so you can use instead of this you can start morphine less than 30 MGR per day immediate release and slow release oral formulation of morphine oxicodone and hydromorphone can be used for dose titration other these two drugs are not available in our s our setup the titration schedules for both types of formulation should be supplemented with oral immediate release opes given as needed and transdermal Fantan and vinorine are alternative to op oral op as I said patients who cannot swallow we can put it them on trans dermal fanil of course it is very costly drug cannot be aford canot many of our patient cannot afford buprenorphine tablet buprenorphine is alternative which is available in Indian market it has its own limitation after certain dose you cannot increase the dose because it will not be effective in giving pain relief to Patient so it has got a sealing effect because it is partially Agonist and partially antagonist against the morphine receptor after certain dose it will not be effective secondly incidence of noia vomiting is also reported of course it doesn't have must constipation with whenever you are using buprenorphine either drug may be preferred step three appeared for some patients for patient unable to swallow they are effect they are an effective noninvasive method of op delivery so patient who are not able to swallow you can give transdermal pentanal or buprenorphine can be given sublingually this we discussed in previous lecture on wh ler always to be drugs to be given by mouth by clock by letter attention to detail and individualized treatment how does one start oral morphing uh start with immediate release click quick release then switch over to constant release one thing about constant release tablet means morphine S tablet you should re remember that it should not be crushed most of our head and neck cancer patients are with r tube so we give immediate release tablet which can be crusted mixed into the water and uh give it through the r tube but this sustain release tablet cannot be crust it will lose it Effectiveness so patient who are on Rice tube and who are given tablet in crust form they should not be given sustain release tablet they are always put on the immediate release T So initially you can start with a immediate release tablet every 4 hour and increase the dose 5 mgram at a time till the pain is relieved and rescue dose mey breakthrough pain intermittently if patient get sudden pain you can give extra dose of morphine again we discuss this that Counseling of the patient explain each and every medicine properly with timings with its side effect and what are the changes patient should bring in the diet and lifestyle when they are on morphine how to start sustain relma is uh like converting immediate release dose multiplied by three is the sustained relas dose so breakthrough pain dose is four hourly dose of the morphine so if patient is on 10 mgam 4 hourly and he gets intermittently very severe pain one extra tablet of 10 migam he take take he can take during that time whenever he's getting a pain episode intermittently principles of opio Maintenance therapy so maintenance you can switch over to extended release rescue dose is always prescribed rescue dose is always immediate release tablet because it has to act very fast patient just got up from the back and he strain his back bed he got up from the bed and he had sudden pain in the back because of the vertebral metastasis that time he can again sit down take one immediate release tablet one extra tablet of morphine and his pain will be relieved within 20 to 30 minutes so any time when you want to increase the dose it should be 33 to 50% increase from the previous dose and fanil should be uh should be used only in opio tolerant patients means patient who are tolerating opio properly they will tolerate fanil otherwise fanil also causes lots of NOA vomiting before prescribing fanil one should keep in mind that patient's pain should be adequately treated treated or controlled by Morphin then the same dose can be converted into fental patch if the pain is poorly controlled it it is given for the stable pain if pain is poorly controlled fanil will not act so if patient pain increases day by day the fanil patch will not act because once you apply the P it will it will act for 72 hours and you cannot change the dose in that case intermittently again you have to give Morphin along with fanil patch to relieve the pain specific indications for the fanil patch are the patient who cannot swallow who has got poor compliance to the tablets many of the patient doesn't like to swallow tablet so in or they have many plenty of tablet to swallow then by giving pet you can reduce few tablets which uh spare few tablets which he doesn't have to swallow so poor compliance patient patient with renal failure in which morphine action can be prolonged you can prescribe re uh fental P patch then patient having severe constipation with morphine or severe NOA vomiting hallucination in this patient you can switch over to fanel page it is too costly about uh 1 25 microgram patch cost about 550 rupees but of course it action lasts for 72 hours means for 3 days where you should apply pentanal page this is the training it should be given to the all nurse is in our uh setup wherever uh in whatever hospital we are using pentanal patch all nurses and all uh doctors paramedical staff should be given how to apply pentan patch because they feel the patch should be applied on the area where there is a pain here it is wrongly applied on the nipple so it should always be applied on the flat skin dry skin and skin without air hair it need not be applied to the area where it is pain it can be applied any other way like uh on the front of the chest on the side of the arm back of the chest or back of the lumber region in the back uh on on back side of the lumber region so this is the way you should apply the patch tradol and morphine there is no comparison tradol is a weak opid Morphin is a strong opid definitely more potent and very highly effective in cancer pain management whenever a patient is given morphine how you will monitor them first of all is analgesia satisfactory means you are giving adequate dose of the morphine does after pain relief patient activity has increase have we achieved the balance between pain relief and adverse effect his adverse effect are under control like constipation is manageable nausea vomiting is manageable he's not too sleepy he's able to do his routine and all or whether is there any abuse potential so every time he comes you check how much morphine he has taken has he taken extra dose of morphine are there any missing pills uh has his pain is stable or is he taking Morphin from some other prescriber all these things you have to evaluate to check on the abuse potential of the patient how you can detect the uh potential uh addiction potential be detected first of all op checklist which is this is filled up during the first visit of the patient and by tools as I had uh uh said in previous previous lecture that by using the tools and this questionnaire where there is a history of family uh Addiction in family alcoholism illegal drugs uh prescript rtion prescription drugs alcohol abuse illegal drugs all this history needs to be taken and given a score how we how do we assess the patient's adherance to prescription first check whether patient is taking morphine from only one doctor and one designated Pharmacy and not from the multiple sub prescript prescription monitoring program where you have to pel count you have given 100 tablets to of morphine to the patient when he comes back exactly how many he should suppose he comes back after 15 minutes 15 days how many tablet he should have used how many should be remaining with him with where are the empty rappers and all such things are the it is called prescription monitoring program double check on the stolen medicine if the pills are missing check with the relatives check with the patient check with the patients family doctors or any friend in the uh in in his group lastly urine analysis can be taken up which will measure the morphine into the urine if he has taken very large dose it can be detected in the urine test this is how we write the prescription of the morphine like tablet morphine 10 mg immediate release one tablet 4H hourly right then we write one one one one and ra night two do the middle night middle of the night dose is combined over here in the last dose here we write timings 700 a.m. 1100 a.m. 300 p.m. 700 p.m. and 11 p.m. then if suppose we are giving it for 15 days here we write the number of tablets um like for 15 days it will be 90 tablets this is the complete and with this you have to write tablet Bodil five Mig two tablet at night suppose for 15 days means 30 tablets this is the way we write the morphin prescription so number of tablet has to be return so the pharmacist also counts the tablet and give it to the patient which are the abant uh Behavior patient keeps on asking for Morphin frequently frequent visit to you then uh uh there is suddenly he from instead of one tablet he takes four tablets 4 hourly repeated visit approach to other doctor we come to know from the pharmacist we come to know that he has come very frequently to take the medicine and all such thing so these are the symptoms which causes shows abant Behavior on long-term adverse effect very few adverse effect has been noted uh which which can be severe constipation with FAL inection dryness of mouth tooth decay increase incidence of fall and dizziness hypogonadism increase pain sensitivity and sleep or disorder breathing can be detected in this patient so again we are emphasizing on evaluation of the patient consider alternative whenever you are in suspicious of that patient is not using their Morphin properly discontinuing opioids may be difficult uh explain to the patient then you have to taper off over a period of 10 15 days then it can be discontinued take time to talk clearly and Screen patient for depression and other psychiatric disorder before starting opioids don't give oper to relatives first time at least patient should be seen by you evaluate the patient and just don't give away with any other person so evaluation of the patient uh don't start op without evaluation op rotation you should have some alternative op uh available otherwise uh don't continue op in patients who show no progress toward treatment and goal is opioid rotation don't assume that patient knows how to use opioid you have to tell them each and every steps always trust the patient but always verify in in your own way whether he's using morphine properly so here we talked about CR and Sr tablet should not be crushed this was amended in 2014 and there uh and in this amendment it was in ENT introduce essential narcotic drugs which has got uniform law Central law law as far as prescription procurement and sale of this end is concerned throughout India so if you have proper guideline it is safe to use narcotics you should have knowledge of ndps act and you should have knowledge of uh how patient behaves when they are on morphine and it is responsibility of all treating doctor or prescribing doctors to check repeatedly that the morphine is used properly for pain management and not misuse or abuse by patient so it should not be misused by patient and should be used properly by for pain management only thank you very much [Music] [Music] [Music]