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Assess pain using the pain scale. Pain is a subjective feeling: Ask the patient. If patient unable to communicate, assess pain based on behavioral cues.
Frequency of assessment: at time of initial interview and PRN (at least every hour when pain moderate to severe). The cause of the pain must always be properly addressed.
These suggestions are for symptom control only and are intended for the average adult. Individual patients might require a different dose or a different treatment approach. Patients who are already taking opioids will require higher doses to control new or worsening pain.
When the pain not expected to resolve shortly, medications should be administered “around the clock” and additional “PRN” or “rescue” doses should be available for breakthrough pain. Prescribe standing medication based on its half- life (3-4 hours for short-acting opioids) and rescue dose based on its time to onset (15-30 minutes for IV and 1 hour for oral).
Starting Dose for Opioid Naive Patients
Mild Pain: Non-opioids: acetaminophen 650-1000 mg PO q6h and /or ibuprofen 200-800 mg PO q6h should be tried first. Daily acetaminophen dose should not exceed 4 g/day in the adult, 3 g/day in the elderly, or 2 g/day in those with underlying hepatic dysfunction.
Moderate/ Severe Pain: Opioid +/- a co-analgesic. Starting doses are morphine 15-30 mg PO q4h, OXYcodone 10-20 mg PO q4h, HYDROmorphone 4-8 mg PO q4h. Co-analgesics such as acetaminophen, NSAID, anticonvulsants, antidepressants, and corticosteroids should be considered.
References: Goldstein, NE & Morrison, RS. Evidence-Based Practice of Palliative Medicine. Philadelphia, PA: Elsevier 2013. (01/15)
- Developed by The Benjamin and Lilian Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai, NY, NY.
Conversion: Current Opioid to Fentanyl Patch
Fentanyl patches must not be prescribed to opioid naive patients. Short-acting opioids should be used to titrate to pain control and then converted to the appropriate fentanyl patch dose.
For conversion between fentanyl patch and fentanyl IV, assume a 1:1 ratio (e.g.75 mcg/h fentanyl patch = 75 mcg/h fentanyl IV infusion.).
If converting to or from a fentanyl patch when pain well controlled, decrease the dose of new opioid by 25-50% to allow for incomplete cross-tolerance. You may need to titrate up rapidly for analgesia in the first 24 hrs. If converting to fentanyl patch, titrate up with short-acting opioids. If pain not controlled, you may choose not to decrease dose.
Since the fentanyl patch takes 3 days to achieve steady state, it is never appropriate to use fentanyl patches to titrate patients with moderate/severe pain.
Although there is technically not a maximum dose, it is usually not practical to prescribe more than four 100 mcg/h patches (400 mcg/h).
PRN dosing for fentanyl patches: The breakthrough dose of oral morphine for a patient on a fentanyl patch is roughly 1/3 fentanyl patch dose. As always, when starting an opioid-tolerant patient on a new opioid, you may need to decrease the calculated PRN dose by 25- 50% to account for incomplete cross-tolerance.
Do not apply external heat to a fentanyl patch as this can accelerate drug absorption and cause overdose. Do not prescribe fentanyl patches to patients with temperature over 39°C (102°F).
Place fentanyl patch along dry area of the body with adequate subcutaneous tissue (e.g. upper arm).
Conversion: Fentanyl Patch to Another Opioid
Opioids in Kidney and Liver Disease
1- Avoid sustained-release oral opioids and fentanyl patches in severe kidney disease (eGFR < 30). Note that even the “safest” opioids are not dialyzable.
2- Consult with an experienced clinician before initiating or adjusting dose of methadone.
Opioid Analgesic Equivalences
Opioid Titration
Calculate total amount of opioids used over past 24hrs and determine how well pain is controlled. If in mild to moderate pain, increase total dose by 25-50%; if in moderate to severe pain increase total dose by 50-100%. Short acting medications (morphine, HYDROmorphone, and OXYcodone) should be used to control moderate and severe pain. Long-acting preparations (e.g. sustained-release preparations of morphine or OXYcodone or transdermal fentanyl) should be started ONLY after the pain is controlled on short-acting opioids. Never use long-acting opioids to control acute pain.
PRN dosing for breakthrough pain (i.e. acute pain in patients with otherwise controlled pain): PRN dose is a short- acting opioid, dose is approximately 10% of the total 24 hour total daily dose. PRN should be available q 1-2 h (e.g., patient on long-acting morphine 60 mg PO q 12h, breakthrough dose = 10% of 120mg which equals short-acting morphine 15 mg PO q1h prn).
Patient Controlled Analgesia
- PCA is a safe and effective method for delivery of opioids for pain that is expected to resolve (e.g., post-operative pain) and for acute exacerbations of chronic pain (e.g., pathologic fracture in a patient with chronic pain from bone metastases). The patient self-delivers fixed doses of opioid by pressing a button (referred to as PCA dose). Patient must be alert to press the button, so this reduces the risk of overdose. The pump can also deliver a continuous dose (basal infusion). Pump has a lock out feature so patient can only receive a maximum amount of opioid each hour.
Bowel Regimen
Patients on opioid therapy need an individualized bowel regimen prescribed prophylactically at the time of initiation, and continued for the duration of opioid therapy. Maintain a high index of suspicion for bowel obstruction or fecal impaction. Rule out impaction with digital rectal exam or abdominal x-ray, if clinically suspicious. Always do rectal disimpaction if concerned for obstruction then proceed to treat with oral laxative.
STEP 1: Senna 2 tabs PO at bedtime. (Can titrate up to 8 Senna/day), PEG (miralax) PRN daily, and Bisacodyl suppository 10mg PRN daily
- STEP 2: Add Lactulose (or Sorbitol) 30 ml PO q24h. (Can titrate up to every 6 hrs)
- STEP 3: If constipated for 2 or more days, add Docusate mini-enema at bedtime (Docusate, PEG, Glycerine), Fleet mineral oil retention enema, or Sodium phosphate oral sol, 30 ml PO. If no results, add a high colonic tap water enema (nursing order).
- STEP 4: If constipated more than 3 days, call Palliative Care service for consideration of methylnaltrexone to treat opioid induced constipation. All steps need to be exhausted before methylnatrexeone is considered.
Opioid Overdose
Naloxone (Narcan) should be used only for life-threatening opioid-induced respiratory depression, an exceedingly rare occurrence in patients on chronic stable opioid doses. In order to minimize symptoms of opioid withdrawal (agitation, fever, emesis, and pain) when naloxone is needed, dilute 1 ampule (0.4 mg) with Normal Saline to a total volume of 10ml (1ml = 0.04 mg) and administer 1 ml IV q 1 min PRN. This careful titration will reverse respiratory depression without causing withdrawal. The half-life of naloxone (1 hour) is shorter than the half-life of opioid agonists; therefore additional doses or a continuous infusion of naloxone may be needed.