1. Opioids 
-Conjugated in liver and are excreted via kidney (90-95%). Worry at CrCl<30
-Dilaudid and fentanyl do NOT have toxic metabolites so they're better for ESRD patients. Most other opiates do.
-Need bowel regimen.
2. Fentanyl Patch
-Fentanyl patch takes 12-24 hours to reach full effect
-Lasts 24-72 hours
-Put on an area without a lot of adiposity (i.e. back)
2. Fentanyl Patch Conversion
-Simple rule: 1mg PO morphine is approx 1/2 mcg fentanyl
-25mcg/hr q 72 hours fentanyl patch is equivalent to the following
-Morphine 15mg IV or 50mg PO q 24 hours
-Dilaudid 3mg IV or 12 mg PO q 24 hours
-Oxycodone 30mg PO q 24 hrs
-Vicodin/tylenol 3 - 9 tables a day
-Norco 4-5 tabs q 24 hours
3. Methadone conversion rate depends on daily morphine equivalency dose. 
-Morphine <100mg/day (1:3)
100-300mg/day (1:5)
300-600 mg/day (1:10)
600-800mg/day (1:12)
800-1000mg/day (1:15)
>1000mg/day (1:20)
-Long and variable t-1/2 (12-120 hours).
-Drug drug interaction
-QT prolongation/torsades.
4. Basic IV to PO morphine conversion- 1:3 
5. Opioid equivalency chart 

6. Morphine peak effects + dosing
-IV peak effect 10 minutes, lasts 1-2 hours.
-SQ peak effect 20 minutes
-PO peak effect 30-60 minutes, lasts 3-4 hours.
-Dose at peak - so IV, dose, wait 10-15 mins, if they are still in pain, give more.
-Breakthrough pain - give 10% of total daily dose at once. Dose at peak.
7. Management of opioid side effects
-Constipation: softener + stimulant (colace + senna aka pericolase), miralax, sorbitol, bisacodyl. If no BM in 4 days consider enema
-Sedation: tolerance usually develops. Avoid sedatives/anxiolytics, consider adding CNS stimulants (caffeine, methylphenidate), reduce teh dose.
-Nausea/vomiting: reduce the dose or pick another drug. Antimotility agents (metoclopromide, prochlorperazine), scopolamine patch, haldol (potent dopaminergic antagonism at the CTZ). Haldol works after spinal anesthesia with local or morphine
-Pruritis: reduce the dose or pick another drug. Antihistamines, H2
-Delirium: reduce the dose or pick another drug. Antipsychotics (haldol, risperidone)
-Respiratory depression: sedation always precedes respiratory depression. Stop opiate, low dose naloxone to avoid withdrawal crisis. Dilute 0.4mg (1mL of 0.4mg/mL amp) in 9cc saline. Use 1cc q5 minutes until respirations improve. Also, bag-mask while you do this.
8. Short vs long acting
- Titrate inpatient meds until they are OK to go
- Take 24 hour total dose, convert to PO
- 80% long acting, 20% for breakthrough
9. Opiates for renal dysfunction
- Fenanyl is better
- Morphine is worse- glucuronidated to M6G, which is more potent and more emetic than morphine.
10. Benzos & opiates
- esp those who are glucuronidation (like lorazepam) compete with morphine for excretion, and can synergize the toxicities.