Question

Case Study - Grandmother Seventy-five-year-old Esther, an active grandmother who fractured her hip while hiking with her senior outing group, is a new patient on the 10th floor orthopedic unit of University Hospital at the OSU Wexner Medical Center. A nurse practitioner has examined Esther and prepared her admission orders (prescriptions and care instructions). The nurse practitioner entered the orders into the electronic medical record, which includes a Computerized Physician Order Entry system (CPOE). The prescription orders have just been received by the pharmacist in the hospital pharmacy for review. Esther’s medications are as follows: • Current Prescriptions: o To prevent blood clots: Warfarin Sodium (Coumadin) 5mg once daily o For high blood pressure: Metoprolol Tartrate (Lopressor) 25 mg twice daily o For GERD (heart burn): Esomeprazole Magnesium (Nexium) 40 mg capsules once daily • Current Over-the-Counter Medications: o Analgesic (pain medicine): Acetaminophen (Tylenol) 325 mg as needed o Nutritional supplement for depression: St. John’s Wort 450mg tablets once daily • New Inpatient Prescriptions on admission: o Opioid analgesic for moderate to severe pain: hydromorphone hydrochloride (Dilaudid) 1 mg IV every 4 hours as needed for pain o All current medications (see above) ordered upon admission to the hospital After discharge from the hospital and a stay at a skilled nursing facility (SNF) for rehabilitation, Esther is discharged from the SNF and her son takes her prescriptions to the community pharmacy (CVS). A. New Prescriptions upon discharge from the SNF: o Opioid analgesic for moderate to severe pain: oxycodone/acetaminophen (Percocet) 5/325 mg every 6 hours as needed for severe pain o Resume all home medications

1. a) What is the max number of Percocet tablets per day that can be legally prescribed for Esther? (Hint: The law is given in morphine equivalent doses (MED). Percocet has oxycodone and you will need to do some math; you can ignore the acetaminophen component in this calculation. References C, D, and E will be helpful.) Please show your math. b) What is the maximum number of days supply that may be included in her Percocet prescription?

Reference:

Answer 1

The max number of Percocet tablets per day that can be legally prescribed for Esther is 12 tablets or upto 50 morphine equivalent doses (MED).

Total daily dose of opioid is calculated in 2 steps:

FIRST STEP - Determine the total daily amount of opioid the patient takes.(5 mg of oxycodone 6 hourly = 5*4= 20 mg)

SECOND STEP- Convert to morphine milligram equivalents (MME)—multiply the dose of opioid by the conversion factor

Conversion factor of oxycodone is 1.5 So, 20*1.5 = 30 morphine equivalent doses (MED).

  The maximum number of days supply that may be included in her Percocet prescription is 7 days. Prescription is refilled after 7 days only if the doctor prescribes opioid again. This is applied to patients who are started on opioids for the first time.