Quick Consults

There are a number of opioid equianalgesic tables with variations in recommended conversion ratios. However, there are several problems with such tables: They do not consider incomplete cross-tolerance. Conversion charts are usually derived from single-dose studies in opioid-naive patients with well-defined pain problems such as post-surgery... 

Information is limited regarding the long-term use of polyethylene glycol (PEG). Some of the information available suggests that it is the most effective for the first 14 days of treatment. However, geriatric resources produced by the American Society of Consultant Pharmacists suggest continuing the use of PEG if it still meets your therapeutic... 

First, there is room to increase the Senokot dose to eight tablets daily at bedtime. If this is not effective, it is possible to introduce polyethylene glycol and decrease the daily Senokot dosage. Sennosides (such as Senokot) and osmotic laxatives (such as polyethylene glycol or Lactulose) have a different mechanism of action. If the response... 

Dyspnea is a common symptom in end-stage heart failure, and, in addition to optimizing cardiac medications, opioids can be very effective in reducing the sensation of air hunger. However, there is often some reluctance to prescribe opioids in patients with respiratory compromise, and there is some conflicting information about the safety of... 

Bisacodyl (Dulcolax) belongs to the same therapeutic class as sennosides (a stimulant laxative that acts on the intestinal wall to promote motility and bowel movement). The onset of action for bisacodyl tablets is approximately 10―12 hrs, and the bisacodyl suppository is approximately 15 minutes. If you are using the tablets, use a similar... 

Polyethylene glycol (PEG) is an osmotic laxative . It acts by absorbing more moisture into the stool, increasing the fecal volume, and inducing a laxative effect. The typical onset of action for Miralax is 1―2 days for constipation and 1―3 days for fecal impaction . It is contraindicated in severe inflammatory intestinal conditions and intestinal... 

Sennosides is a mixture of two naturally occurring plant glycosides (sennosides A and B). It works in the large intestine, acting directly on the submucosal plexus and the deeper myenteric plexus to stimulate propulsive waves. The typical onset of action for sennosides is 6―12 hours. Ideally, it should be taken at bedtime, with an expectation... 

Docusate is a surface-wetting agent, more commonly known as a stool softener . If prescribed, it should always be combined with a stimulant like Senokot. Current published literature indicates that patients usually respond as well to sennosides alone as they do when sennosides are combined with docusate. One of the few times when docusate... 

Many factors can contribute to poor patch adherence. Individual skin characteristics, such as skin oiliness or propensity to sweat, may interfere with adhesion. A particular brand of patch may not be suited to that individual, in which case, it may be worth trying a patch manufactured by another company. The following is a list of considerations... 

This is not a straightforward issue, as the evidence supporting one opioid over another is often based on the experience and advice of experts rather than on solid data from prospective, randomized, double-blind trials. Both morphine and hydromorphone (Dilaudid) have active metabolites that are known to accumulate in the context of renal insufficiency. 

Safety considerations when using opioids As health care providers taking care of palliative care patients, we need to educate patients and families about the safe use, handling and storage of opioids. This quick consult looks specifically at the safe handling of fentanyl.   For safety considerations when using opioids in general, please see:... 

Background on the Opioid Crisis The opioid overdose crisis refers to the rise in opioid overdose deaths. The crisis has resulted in prominent media coverage and has become a major Canadian health concern. Unfortunately, for many health care providers, patients and families, this has impacted perceptions regarding the usefulness of opioids...