Canada PCOC cheat sheet

Pain assessment: use a 0–10 numeric rating scale for adults; for patients unable to self-report, use the PAINAD (Pain Assessment in Advanced Dementia) tool, scoring 0–10 with ≥4 indicating moderate pain.

Breakthrough pain: define as a transient exacerbation of pain over controlled baseline; classify as incident (predictable/unpredictable), idiopathic, or end-of-dose failure; treat with short-acting opioid at 10–20% of total daily dose.

Opioid rotation: when switching opioids, use equianalgesic tables and reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance, then titrate.

Constipation prophylaxis: initiate a stimulant laxative (e.g., senna) plus an osmotic laxative (e.g., polyethylene glycol) when starting opioids; do not wait for constipation to occur.

Nausea in palliative care: first-line antiemetics include metoclopramide (prokinetic, for gastric stasis), haloperidol (for chemical/metabolic causes), and ondansetron (for serotonin-mediated nausea); choose based on suspected mechanism.

Dyspnea management: opioids are first-line for refractory dyspnea in palliative care; use low-dose morphine (e.g., 2.5–5 mg PO q4h) and titrate; oxygen only if hypoxemic.

Delirium screening: use the Confusion Assessment Method (CAM); positive if acute onset and fluctuating course plus inattention, and either disorganized thinking or altered level of consciousness.

Goals of care: document resuscitation status, preferred location of care, and substitute decision-maker; revisit at each transition and when prognosis changes.

Opioid starting doses in opioid-naïve adults: morphine 5–10 mg PO q4h or 2.5–5 mg SC/IV q4h; hydromorphone 1–2 mg PO q4h or 0.5–1 mg SC/IV q4h; titrate to effect.

Methadone: only for opioid rotation by experienced prescribers; equianalgesic conversion is nonlinear; typical starting dose when switching from high-dose morphine is 10% of the morphine daily dose or less, divided q8h–q12h.

Fentanyl transdermal: indicated for persistent severe pain requiring continuous opioid therapy; do not use for acute or postoperative pain; conversion from oral morphine: 100 mg/24h ≈ 25 mcg/h patch (varies by product).

Renal impairment: avoid morphine (active metabolites accumulate) and meperidine (normeperidine neurotoxicity); prefer hydromorphone, fentanyl, or methadone with dose adjustment.

Acetaminophen maximum: 3–4 g/day in healthy adults; reduce to ≤2 g/day in hepatic impairment, chronic alcohol use, or low body weight; check combination products for hidden acetaminophen.

NSAIDs: avoid in peptic ulcer disease, renal impairment (eGFR <30), heart failure, and anticoagulation; use lowest effective dose for shortest duration; monitor GI, renal, and cardiovascular effects.

Corticosteroids in palliative care: dexamethasone commonly used for appetite stimulation, bone pain, and cerebral edema; monitor for hyperglycemia, GI irritation, and myopathy; taper if used >2 weeks.

Anticholinergic burden: minimize in older adults; drugs such as dimenhydrinate, diphenhydramine, and oxybutynin can worsen cognition, constipation, and urinary retention.

First-pass metabolism: oral opioids undergo hepatic first-pass; morphine bioavailability ~30%, hydromorphone ~24%, oxycodone ~60–87%; this explains differences between oral and parenteral doses.

Half-life and steady state: steady state is reached after ~4–5 half-lives; methadone half-life is highly variable (8–59 hours), requiring slow titration and monitoring for accumulation.

CYP450 interactions: codeine and tramadol are prodrugs requiring CYP2D6 for analgesia; inhibitors (e.g., fluoxetine, paroxetine, bupropion) reduce efficacy; ultrarapid metabolizers risk toxicity.

Protein binding: methadone (~85–90%) and fentanyl (~80–85%) are highly protein-bound; hypoalbuminemia may increase free fraction and effect.

Opioid receptor pharmacology: mu-receptor agonism produces analgesia, respiratory depression, miosis, and constipation; buprenorphine is a partial mu agonist with high affinity, reducing efficacy of full agonists.

Naloxone: opioid antagonist with short half-life (~30–90 min); may require repeat dosing or infusion for long-acting opioids; titrate to restore breathing, not full consciousness.

Renal clearance: hydromorphone metabolites are renally cleared; accumulate in renal failure; fentanyl has inactive metabolites and is preferred in renal impairment.

Pharmacogenomics: CYP2D6 and CYP2C19 polymorphisms affect opioid and antidepressant metabolism; consider testing when unexpected response or toxicity occurs.

Consent: obtain informed consent for treatment; in palliative care, consent may be verbal; document discussions of risks, benefits, and alternatives.

Capacity: assess decision-making capacity (understand, appreciate, reason, express choice); if absent, follow provincial substitute decision-maker hierarchy and best interests standard.

Confidentiality: disclose personal health information only with consent or as required by law (e.g., mandatory reporting of abuse, court order); use minimum necessary information.

Opioid prescribing regulations: in Canada, opioids are controlled under the Controlled Drugs and Substances Act; prescriptions must include patient name, drug, dose, quantity, directions, and prescriber information; some provinces require triplicate prescriptions or specific forms.

Medical Assistance in Dying (MAiD): legal in Canada under federal legislation; eligibility requires competent adult, grievous and irremediable condition, informed consent, and two independent assessments; pharmacists may participate in dispensing but have conscientious objection rights.

Advance care planning: document goals of care and substitute decision-maker; legally binding in some provinces (e.g., advance directives in Ontario), while others rely on substitute decision-makers.

Professional boundaries: avoid dual relationships; declare conflicts of interest; maintain patient privacy in all communications.

Mandatory reporting: report suspected child abuse, elder abuse, or neglect as required by provincial law; pharmacists may have duty to report impaired colleagues.

SBAR (Situation, Background, Assessment, Recommendation): structured handover tool to communicate urgent patient information concisely and reduce errors.

Teach-back method: ask patient to repeat instructions in their own words to confirm understanding; use for new medications and complex regimens.

Health literacy: use plain language, avoid jargon, limit to 3–5 key points per session, and supplement with written or visual aids; confirm understanding.

Interprofessional rounds: pharmacists contribute medication reconciliation, deprescribing recommendations, and identification of adverse drug events.

Conflict resolution: use 'I' statements, focus on patient goals, and escalate to shared decision-making or ethics consultation when values conflict.

Cultural safety: recognize power imbalances and historical trauma; ask about preferences for family involvement, traditional healing, and language needs.

Documentation: record communication with patients and families, including goals of care discussions, in the health record; use clear, objective language.

Telehealth communication: verify patient identity, ensure privacy, and have a plan for technical failure; document modality and participants.

Medication reconciliation: obtain best possible medication history (BPMH) at admission and discharge; compare with orders and resolve discrepancies; reduces adverse drug events.

Drug coverage in Canada: public plans vary by province; federal programs include NIHB for Indigenous peoples and CIHI for veterans; pharmacists should verify coverage and assist with special authorization requests.

Inventory management: use ABC analysis (A items high value/high use, C items low value) to prioritize stock control; maintain par levels for high-turnover items.

Sterile compounding: follow NAPRA standards; use ISO Class 5 environment for hazardous drugs; maintain beyond-use dates and documentation.

Opioid stewardship: implement take-back programs, prescribe naloxone kits with opioids, and monitor for aberrant behaviors using prescription monitoring programs (PMPs).

Quality improvement: use Plan-Do-Study-Act (PDSA) cycles to test changes; measure outcomes such as pain scores, constipation rates, and medication errors.

Emergency preparedness: maintain a plan for drug shortages; identify therapeutic alternatives and communicate with prescribers.

Billing and reimbursement: understand provincial fee schedules for pharmacist services (e.g., medication reviews, injections); document to support claims.