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Primary care physicians, pain physicians, and pharmacists
Estimated time to complete this activity: 1.25 hours
Release Date: July 3, 2012
Expiration Date: July 3, 2013
The goal when utilizing opioid therapy is to provide adequate pain relief, balanced with tolerable adverse events (AEs). Individual patients’ responses to different opioids can vary significantly. If gradual dose titration yields treatment-limiting AEs or poor analgesia, there is a change in the patient’s clinical status, drug-drug interactions suggest the need for an opioid with different pharmacokinetic properties, or there is a preference/need for a different administration route or formulation, opioid rotation—switching from one opioid to another—can be a therapeutic option. There are now many opioids and formulations to choose from when utilizing opioid rotation.
Physicians can reduce the risk of overdosing or underdosing as one opioid is discontinued and another is administered by selecting a safe and reasonably effective starting dose for the new opioid, followed by dose adjustment. This requires knowledge of an “equianalgesic dose table,” which provides broad estimates of the potency relationships between opioids, and guidelines for dose adjustments to individualize therapy for each patient.
The purpose of this educational activity is to provide physicians and pharmacists with the rationale, strategies, and best practices when considering opioid rotation to improve clinical outcomes for patients with chronic pain.
At the conclusion of the activity, the participant should be able to:
1. Identify the pitfalls and limitations of current equianalgesic tables in general, and for individual patients when rotating opioids
2. Utilize current equianalgesic tables by applying a 2-step guideline for safe and effective rotation
3. Assess patient factors that affect the choice of opioid and adjustment of therapy
4. Develop a strategy to incorporate new opioids and new formulations into the process of opioid rotation
5. Educate patients (and family or other caregivers) on recognizing opioid dose-related problems (eg, overmedication, AEs) and what to do about them (including responding to overdose crises)
- Opioid Rotation in Clinical Practice: Evidence and Guidelines—Then and Now
- Opioid Pharmacology and the Complexities of Equianalgesic Doses
- Applying Guidelines to Safe and Effective Rotation (including case presentations)
- Archived Q&A: Ask the Faculty
Ricardo A. Cruciani, MD, PhD
Director, Pain Division
Director, Institute for Noninvasive Brain Stimulation of New York
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
New York, New York
Lynn R. Webster, MD, FACPM, FASAM
Lifetree Clinical Research & Pain Clinic
Salt Lake City, Utah
In compliance with the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the University of Nebraska Medical Center, Center for Continuing Education (UNMC/CCE) to ensure balance, objectivity, independence, and scientific rigor in its continuing education activities. All faculty are expected to openly disclose any off-label, experimental, or investigational use of products/devices discussed in their presentation. All persons involved in the planning/content development are expected to disclose all relevant financial relationships within the last 12 months with pharmaceutical companies, biomedical device manufacturers or distributors, or others whose products or services may be considered related to the subject matter of the educational activity.
Disclosure of these commitments and/or relationships is included in these course materials so that participants in the activity may formulate their own judgments in interpreting its content and evaluating its recommendations. The following indicates the faculty and planning committee disclosure declaration information and the nature of those commercial relationships. Likewise, it is incumbent upon faculty to verbally disclose such interests/commitments at the beginning of their presentation at the educational activity.
Lynn R. Webster, MD, FACPM, FASAM, has disclosed the following: Consultant/Advisory Board: BioDelivery Sciences International, Inc.; Cephalon, Inc.; Covidien Mallinckrodt; Embryon, Inc.; Integrity Continuing Education, Inc.; Janssen Pharmaceutical K.K.; King Pharmaceuticals, Inc.; MedXcel; Medtronic, Inc.; Nektar Therapeutics; NeurogesX, Inc.; NeuroMed; ProStrakan, Inc.; Purdue Pharma L.P.; Xenoport, Inc. Research: Adolor Corporation; Alkermes, Inc.; Allergan, Inc.; Alpharma, Inc.; Ameritox; Anesiva, Inc.; Arcion Therapeutics, Inc.; Array BioPharma Inc.; AstraZeneca Pharmaceuticals LP; Cephalon, Inc.; Cervelo Pharmaceuticals, Inc.; Collegium Pharmaceutical, Inc.; CoMentis, Inc.; Durect Corporation; Elan Corporation; Elite Pharmaceuticals, Inc.; Endo Pharmaceuticals; Forest Pharmaceuticals, Inc.; Hoffmann-La Roche Inc.; Hisamitsu Pharmaceutical Co., Inc.; King Pharmaceuticals, Inc.; Nektar Therapeutics; NeurogesX, Inc.; Pain Therapeutics, Inc.; Penwest Pharmaceuticals Co.; Pfizer Inc.; Philips Respironics; Purdue Pharma L.P.; QRX Pharma Ltd.; Reckitt Benckiser Group plc; Recro Pharma, Inc.; Regeneron Pharmaceuticals, Inc.; Sucampo Pharmaceuticals, Inc.; Takeda Pharmaceutical Company Limited.; Torrey Pines Pharmaceutical, Inc; XenoPort, Inc.; ZARS Pharma, Inc.
Ricardo A. Cruciani, MD, PhD, has disclosed the following relevant financial relationships—Advisory Board: King Pharmaceuticals, Inc. Speakers Bureau: Covidien Mallinckrodt; Endo Pharmaceuticals; Forest Laboratories, Inc.; King Pharmaceuticals, Inc.; Pfizer Inc.
PharmaCom Group, Inc., staff members James W. Barrett, President; Angela T. Casey, Senior Editorial Director; Richard L. Abbot, Jr., Vice-President Educational Programming; and Maria F. DelCegno, Meetings Manager, have no relevant financial relationships to disclose. UNMC/CCE staff members Diane Frost, Program Associate; and Lois Colburn, Executive Director, have no relevant financial relationships to disclose.
This activity does contain information on commercial products/devices that are unlabeled for use or investigational uses of products not yet approved: investigational opioid molecules. Participants should note that the use of products outside currently FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for FDA-approved indications.
Disclaimer Statements:Accreditation/Method of Participation:
The content and views presented in this educational activity are those of the presenters. It should not be inferred or assumed that they are expressing the views of UNMC/CCE, PharmaCom Group, Inc., the commercial supporter of this activity (Mallinckrodt Inc., a Covidien company), or any other manufacturer of pharmaceuticals.
The material prepared is based upon a review of multiple sources of information, but it is not exhaustive of the subject matter. Therefore, health care professionals and other individuals should review and consider other publications and materials on the subject matter before relying solely upon the information contained within this educational activity.
It should be noted that the clinical recommendations made herein with regard to the use of therapeutic agents, varying disease states, and assessments of risk are based upon a combination of clinical trials, current guidelines, and the clinical practice experience of the participating presenters. The drug selection and dosage information presented in this activity are believed to be accurate. However, participants are urged to consult the full prescribing information on any agent(s) presented in this activity for recommended dosage, indications, contraindications, warnings, precautions, and AEs before prescribing any medication. Further, participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this activity.
The UNMC/CCE is accredited by the ACCME to provide continuing medical education (CME) for physicians. The UNMC/CCE designates this enduring activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This enduring activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME through the joint sponsorship of the UNMC/CCE and PharmaCom Group, Inc. Participants with any questions regarding continuing education earned through participating in this activity should contact Diane Frost at email@example.com or call 402.559.5145.
This program is accredited by the Nebraska Council for Continuing Pharmacy Education
(NCCPE). NCCPE is approved by the Accreditation Council for Pharmacy Education (ACPE) as
a provider of continuing pharmacy education (CPE). This CPE program is a knowledge-based
activity. ACPE UAN 128-999-12-103-HO1-P. Participants may earn 1.25 contact hours of CPE credit for
attendance of the entire CPE activity and the completion of an evaluation form.
CPE credits will be sent to your NABP eProfile account within 60 days of the program date. If you have any questions about CPE credits for this program, please call NCCPE at 402.420.1500.
In order to successfully complete this knowledge-based CME activity, the participant must complete the pre-assessment, attend/review the educational session, complete the activity post-assessment and evaluation, and complete the continuing education credit request form. Upon completing this activity as designed, UNMC/CCE will mail a CME credit letter to the participant in approximately 4 weeks.
This activity is jointly sponsored by the University of Nebraska Medical Center, Center for Continuing Education and PharmaCom Group, Inc.
This activity is funded through an educational grant from Mallinckrodt, a Covidien Company.
Please direct any technical questions to PharmaCom Group, Inc. at 203-323-5945
or email firstname.lastname@example.org.