Question 10: In your practice, how do you determine which opioid to prescribe?

Raymond Sinatra, MD: Yeah, I'm going to actually reserve that for Commander Burke. Neil, can I ask you one question? How do you in your practice determine which opioid to prescribe in a patient who you feel would benefit from that class of drug? There are a variety of factors that go into that decision making process?

Neil Jobalia, MD: There certainly are and most of it ... I view the whole class of long acting opioids as equal between methadone, Duragesic, OxyContin, MS-Contin or Kadian. I know that because the population I treat is a chronic pain population that I want to use a long acting opioid along with something for incident or breakthrough pain. Beyond that, it's more based on patient factors and my preference. In my experience I've found that OxyContin seems to be the best tolerated of the opioids. And since patients starting out are somewhat reluctant ... at least most of them are somewhat reluctant to be started on pain medication I like to choose one that they're going to tolerate well just so that they don't become I guess prejudiced against the class as a whole.

Raymond Sinatra, MD: When you mean better tolerated ... you mean side effect profile ... what particular ... nausea, constipation?

Neil Jobalia, MD: Mostly sedation, maybe dysphoric effects, hallucinations or just unsteady feeling ... if you deal with a geriatric population you certainly don't want to give them something that's going to make them more likely to be off balance and fall. Constipation, itching, nausea, all of those come into play. But again, I look at those as a class effect and try to pick the one that I think is going to be the best tolerated so that they can at least get some of the benefits without having some of the negative side effects from the medication.

Again, in my experience OxyContin has been the best tolerated, but there's other factors such as cost. As you know, Medicare prescription reimbursement is a huge issue currently and I make it an issue in my practice and I try to use methadone in those patients because it's cheap and it's long acting, they can afford it. However, unfortunately it's ... it seems to have more unpleasant effects and they have trouble tolerating that medication and then I'm left with a little bit of a quandary because all of the other long acting opioids are about ... pretty close to equivalent when it comes to the paying for them out of pocket. So there certainly are factors which will lead me to one versus another, but I try ... I pretty much view them all as equal and I use a variety of them in my practice.