Duplicate therapy is a common occurance in practice. It is something that frustrates me quite a bit. There are quite a few reasons why it happens. Some of the most common reasons for duplicate opioids include:
- Hospital discharge: A patient is started on a new opioid during hospitalization, but their home opioid is inadvertently continued on the discharge medication list.
- Multiple prescribers: A primary care provider, pain specialist, surgeon, or emergency department physician each prescribe pain medications without realizing another opioid is already being used.
- PRN medications not discontinued: An older “as needed” opioid remains active in the electronic health record after a new analgesic is started.
- Incomplete medication reconciliation: Medication lists are copied forward between visits without verifying whether each medication is still needed.
- Different types of pain: I’ve had situations where a patient is prescribed one opioid for knee pain and another for back pain
Here’s the medication list and my take:
- Oxycodone 5 mg PO every 4 hours as needed for pain
- Hydrocodone/APAP 5/325 mg 1 tablet PO every 6 hours as needed for pain
- Morphine ER 15 mg PO twice daily
- Tramadol 50 mg PO every 6 hours as needed for pain
- Cimetidine 400 mg PO twice daily
- Sertraline 100 mg PO daily
- Lisinopril 20 mg PO daily
- Metformin 1000 mg PO twice daily
- Atorvastatin 40 mg PO at bedtime
- Furosemide 40 mg PO daily
- Potassium Chloride ER 20 mEq PO daily
- Aspirin 81 mg PO daily
- Senna 17.2 mg PO at bedtime
- Acetaminophen 1000 mg TID
- Phenytoin 300 mg daily
In this case scenario, you’ll clearly see that a PRN oxycodone and PRN hydrocodone represent duplicate opioids. With the scheduled acetaminophen at 3,000 mg daily, it makes the most sense to address the hydrocodone/acetaminophen combo and discontinue it. In addition, we also have an order of tramadol. I would like to see this discontinued as well. Tramadol can potentially increase the risk for seizures, and this patient likely has a seizure history with the phenytoin on board. I talk extensively on tramadol on this episode of the Real Life Pharmacology Podcast.
In addition to the duplicate opioid problem in this case scenario, cimetidine concerns me. It has tons of drug interactions. One of the riskiest ones that I notice is phenytoin (excellent board exam nugget). Via CYP inhibition, cimetidine can significantly increase the concentrations of phenytoin. I’d like to see a recent level for phenytoin and monitor for toxicity.
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