How Do You Know When the Papaya Is Ripe?

Yesterday I was at Trader Joe’s and I picked up a papaya. It’s a very aromatic fruit in case you haven’t had it. And as I was checking out, the friendly cashier asked me,

“How do you know when the papaya is ripe?”

“You can tell when it feels soft like a ripe avocado. And you can also smell the fragrance.”

I might have taught someone something I’ve known for a long time, and it felt nice. I just didn’t think it was a question, because I knew the answer all this time.

And I said to myself, what if I know something about opioid dosing that others haven’t asked Or maybe they’ve been dosing based on assumptions they haven’t yet challenged or reconsidered?

So I figured I would write about a question that I think is common knowledge as a pain pharmacist—but may be very helpful for someone who’s trying to learn more about opioid dosing. Or maybe you’re just curious and happened to google “how do I dose opioids like a pain pharmacist” at 3AM.

What do you look for when you review opioid fill history?

I’m very fortunate to live in a country where there’s a centralized opioid fill history system called the Prescription Drug Monitoring Program. The record tells me important information like:

• The quantity

• The prescriber

• The exact date an opioid or controlled substance was filled

Now, if you’re reading this and you live outside of the U.S., I imagine you could call the pharmacy to verify. (Leave a comment and let me know how it’s actually done!)

A sensible follow up question if you’ve read this far is: Why? Why do I need to review this ALL THE TIME?

This step is essential because it tells you what baseline the patient is at.

The dosing of opioids can be very different depending on whether a patient is opioid naive or opioid tolerant. Just imagine this: a patient has been on OxyContin 20 mg every 8 hours for chronic pain. If you prescribe oxycodone 5 mg every 8 hours as needed for acute pain without checking their fill history, you end up underdosing. That’s because you haven’t accounted for their baseline opioid requirement.

Dosing the opioid as accurately as you can is the technical reason to check the fill history every time. But what if I told you there’s also an emotional reason?

Do you remember the time you were getting multiple messages from nurses that the patient was in so much pain? You were frantically reaching out to the pain team (if you’re lucky to have one) just to get some answers—so the patient, nurses, and yourself could all be at peace? I’ve answered enough consults in my career to know: Giving the opioid fill history some thought has helped prevent or resolve many situations that could’ve escalated.

If you’re the cashier who’s reading this, thank you for being so curious about the papaya. Your question gave me the inspiration to write this newsletter.