Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The DIRE score calculator helps determine a patient's suitability for long-term opioid analgesia by assessing various aspects of their pain management and personal circumstances. This evaluation takes into account the following factors:

- Diagnosis: The nature and severity of the patient's medical condition.
- Intractability: The extent of treatments tried and the patient's engagement in their pain management.
- Psychological Risk: The impact of mental health on the patient's ability to undergo treatment.
- Chemical Health Risk: The patient's history or current use of substances.
- Reliability Risk: The patient's consistency in adhering to treatment plans.
- Social Support Risk: The stability of the patient's social environment and support system.
- Efficacy: The effectiveness of opioid treatment in improving pain and function.

Each factor is scored on a scale from 1 to 3. For Diagnosis, for example, a benign condition earns a 1, while an advanced condition earns a 3. This scoring continues through each factor:

- Intractability ranges from minimal effort in managing pain (1) to full engagement but inadequate response (3).
- Psychological Risk evaluates serious personality dysfunctions (1) to good communication and no significant psychological issues (3).
- Chemical Health Risk considers active substance abuse (1) to no history of chemical dependence (3).
- Reliability Risk scores numerous compliance issues (1) to high reliability (3).
- Social Support Risk ranges from chaotic lifestyle (1) to strong supportive relationships (3).
- Efficacy varies from poor function despite treatment (1) to considerable improvement and stable dosing (3).

The scores from each category are added together, resulting in a total score between 7 and 21. This total informs the interpretation:

- If the total score is 13 or less, the patient is deemed not suitable for long-term opioid analgesia.
- A total of 14 or more suggests the patient is a good candidate for such treatment.

This comprehensive scoring approach ensures that decisions related to opioid therapy are made with careful consideration of both potential benefits and risks.

The DIRE Score, or Diagnosis, Intractability, Risk, and Efficacy Score, is a clinical calculator used in the management of chronic pain patients who are being considered for long-term opioid therapy. This scoring system is designed to assess the patient's risk of opioid misuse and to determine the appropriateness of opioid prescription. 

The DIRE Score applies to adult patients with chronic non-cancer pain who are being evaluated for long-term opioid therapy. It is particularly useful in stratifying patients based on their risk of opioid misuse, thus aiding clinicians in making informed decisions about opioid prescription. 

The DIRE Score considers four main factors: Diagnosis (the nature and extent of the patient's pain condition), Intractability (the degree to which the pain is resistant to treatment), Risk (the patient's risk of opioid misuse or addiction), and Efficacy (the likelihood that opioid therapy will be effective for the patient's pain). 

There are no specific exclusion criteria for the use of the DIRE Score, but it should be noted that it is not intended for use in patients with cancer-related pain or in those who are already on long-term opioid therapy. It is also not a substitute for a comprehensive clinical assessment and should be used in conjunction with other clinical tools and

DIRE score for opioid prescription in chronic pain

The Prescription Opioid Misuse Index (POMI) is a tool designed to help pinpoint potential misuse of prescription opioids. It does this through responses to six specific questions that probe behaviors related to pain medication usage.

For each of the following questions, responses of "Yes" are scored as 1 point, while "No" responses score 0 points:

- Do you ever use more of your medication (take a higher dosage) than is prescribed for you?
- Do you ever use your medication more often (shorten the time between dosages) than is prescribed for you?
- Do you ever need early refills for your pain medication?
- Do you ever feel high or get a buzz after using your pain medication?
- Do you take your pain medication because you are upset, using it to relieve or cope with problems other than pain?
- Have you ever visited multiple physicians, including emergency room doctors, seeking more of your pain medication?

Once responses are collected, the scores for each question are summed. This total score can range from 0 to 6, providing a gauge for understanding an individual's behavior concerning prescription opioid use.

Interpretation of the total score is straightforward:

- A score of 2 or higher indicates that the criteria for prescription opioid misuse are met. This suggests there may be patterns of behavior pointing to the misuse of opioid medications.
- A score of 0 or 1 means the criteria for prescription opioid misuse are not met. This indicates that the individual's patterns of behavior typically do not suggest misuse according to the index.

The Prescription Opioid Misuse Index (POMI) is a clinical calculator used in the field of addiction medicine and pain management. It is specifically designed to assess the risk of prescription opioid misuse in patients who are being treated for chronic pain. The POMI is a valuable tool for clinicians as it helps to identify patients who may be at risk of developing opioid misuse behaviors, thus allowing for early intervention and prevention strategies. It is important to note that this calculator should not be used in patients who are not prescribed opioids or in those who are being treated for acute pain. The POMI is not designed to diagnose opioid use disorder, but rather to identify risk factors for misuse in a chronic pain population.

Prescription Opioid Misuse Index (POMI)

The Opioid Dose Conversion tool is designed to help users convert dosages between different types of opioids. Users provide two inputs by selecting the opioid type they are converting from and the type they want to convert to, each chosen from a preset list of options.

This tool operates using a predefined conversion factor table that relates each opioid type with one another. Depending on the "from" and "to" opioid selections, the tool computes a conversion factor indicating the equivalent dosage of the target opioid type necessary to achieve a therapeutic effect similar to the original opioid and dosage.

Here's a glance at how you can interpret these results and perform conversions:

- **Codeine to Other Opioids:**
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 1.15
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.0625
  - To Hydrocodone: Conversion factor is 0.15
  - Continue similarly for other drugs.

- **Fentanyl (buccal or sublingual) to Other Opioids:**
  - To Codeine: Conversion factor is 0.87
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.054
  - To Hydrocodone: Conversion factor is 0.13
  - Continue similarly for other drugs.

- **Fentanyl Transdermal to Other Opioids:**
  - To Codeine: Conversion factor is 16
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 18.5
  - To Hydrocodone: Conversion factor is 2.4
  - Continue similarly for other drugs.

- **Hydrocodone to Other Opioids:**
  - To Codeine: Conversion factor is 6.67
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 7.7
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.42
  - Continue similarly for other drugs.

- **Hydromorphone to Other Opioids:**
  - To Codeine: Conversion factor is 33.3
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 38.5
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 2.08
  - Continue similarly for other drugs.

- **Methadone to Other Opioids:**
  - To Codeine: Conversion factor is 31.33
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 36.15
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 1.96
  - Continue similarly for other drugs.

- **Morphine to Other Opioids:**
  - To Codeine: Conversion factor is 6.67
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 7.7
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.42
  - Continue similarly for other drugs.

- **Oxycodone to Other Opioids:**
  - To Codeine: Conversion factor is 10
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 11.54
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.625
  - Continue similarly for other drugs.

- **Oxymorphone to Other Opioids:**
  - To Codeine: Conversion factor is 20
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 23.1
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 1.25
  - Continue similarly for other drugs.

- **Tapentadol to Other Opioids:**
  - To Codeine: Conversion factor is 2.67
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 3.08
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.167
  - Continue similarly for other drugs.

- **Tramadol to Other Opioids:**
  - To Codeine: Conversion factor is 1.33
  - To Fentanyl buccal or sublingual (mcg): Conversion factor is 1.54
  - To Fentanyl transdermal (mcg/hr): Conversion factor is 0.083
  - Continue similarly for other drugs.

These conversion factors allow practitioners to translate dosages across different opioid medications accurately. The purpose of these conversions is to ensure patient safety and maintain equivalent analgesic effects when switching opioid drugs. Each conversion must be carefully considered alongside clinical judgment, as individual patient response may vary.

The Opioid Dose Conversion calculator, also known as the Opioid Equianalgesic calculator, is a tool used in the management of patients who are on opioid therapy for pain control. This calculator is used to convert the dose of one opioid to the equivalent dose of another opioid, allowing for safe and effective switching between different opioids. It is particularly useful in patients with chronic pain, cancer pain, or those undergoing palliative care. 

The calculator takes into account the potency of different opioids and the patient's current opioid dose to provide an equivalent dose of a different opioid. It is important to note that this calculator should not be used in opioid-naive patients, as it assumes a degree of opioid tolerance. Additionally, the calculator does not account for individual variations in opioid metabolism and response, so clinical judgment is still required in dose adjustments.

Opioid Dose Conversion

The Corrected QT Interval (QTc) calculator is an essential tool in evaluating heart health by analyzing the heart's electrical activity. This is done using inputs such as the QT interval (in milliseconds), heart rate (in beats per minute), and a formula choice to compute the QTc value.

To begin, the calculator determines the RR interval, which is the period between heartbeats, by using the formula RR = 60 / heartRate. This step accounts for variations in heart rate when calculating the QTc.

Depending on the formula selected by the user, the adapted QTc is computed through different methods:

- Bazett's Formula: QTc is derived by dividing the QT interval by the square root of the RR interval.
- Fridericia's Formula: QTc involves dividing the QT interval by the cube root of the RR interval.
- Framingham's Formula: QTc is calculated by adding the QT interval to 154 multiplied by (1 - RR).
- Hodges' Formula: QTc adds the QT interval to 1.75 times the difference between heart rate and 60.

After calculating the QTc, the result is rounded to the closest integer. The interpretation of this QTc value is categorized into specific ranges to assess its clinical significance, as follows:

- Short QTc: Below 350 ms, which may indicate abnormally rapid heart repolarization.
- Normal QTc: From 350 to 430 ms, considered typical and healthy.
- Borderline QTc: Between 431 and 450 ms, slightly outside the optimal range.
- Prolonged QTc: From 451 to 500 ms, which can suggest a potential risk for arrhythmias.
- Severely Prolonged QTc: Over 500 ms, indicating a significantly elevated risk for heart-related events.

Understanding whether a QTc falls into the normal or one of the abnormal categories can help in diagnosing conditions involving heart rhythm irregularities.

The Corrected QT Interval (QTc) Calculator is a tool used to adjust the QT interval (a measure of ventricular depolarization and repolarization on an ECG) for heart rate. The QT interval varies with heart rate, and correcting it provides a standardized measurement to assess the risk of arrhythmias like Torsades de Pointes. This is crucial in clinical settings, especially when monitoring patients on medications that may prolong the QT interval.

Opioids for pain

Guidelines

Key sources