II. Preparations: Immediate Release Opioids for Moderate to Severe Cancer Pain (Opioid naive patients)

  1. See Opioid Analgesic
  2. Fentanyl 25-100 mcg IV or SQ every 2-3 hours
  3. Hydromorphone (Dilaudid) 0.5 to 2 mg IV or SQ (or 2 to 4 mg orally) every 3 to 4 hours
  4. Morphine Sulfate 2 to 10 mg IV or SQ (or 2.5 to 10 mg orally) every 3 to 4 hours
  5. Oxycodone 2.5 to 10 mg orally every 3 to 4 hours

III. Protocol

  1. Give Chronic Pain medication around-the-clock scheduled
    1. Use 'patient may refuse' approach
    2. Contrast with as needed dosing
  2. Help patients and family overcome reluctance to use Opioid Analgesics
    1. Reassure patient and family that Opioids are safe and are helpful
    2. Help to reduce stigma of Opioids and fear of addiction
  3. Start concurrent bowel regimen when starting Opioids
    1. See Bowel Regimen in Chronic Narcotic Use

IV. Protocol: Starting Opioid Analgesic (WHO Step 3)

  1. Choice drug: Morphine Sulfate
  2. Begin short acting Morphine Sulfate 5-10 mg q4h
    1. Daily Starting dose: 30-60 mg/day
  3. Dysphagia or otherwise not able to tolerate larger medication volumes
    1. Concentrated oral Opioid elixirs (Morphine, Hydromorphone, Oxycodone, Methadone) OR
    2. Buccal solutions

V. Protocol: Establishing maintenance dosing After 1 week

  1. Maintenance Pain Management
    1. Convert short acting Morphine to long acting Morphine
  2. Assess for persistent moderate to severe pain (pain score 4-9)
    1. Increase basal dose by 25-50% for moderate pain and 50-100% for severe pain
    2. Continue to dose until pain is relieved
    3. Pain relief should be goal, not fixed amount
    4. Morphine doses may need to exceed 600 mg/day
      1. High dose Morphine is safe as end of life analgesia
      2. Bercovitch (1999) Cancer 86:871-7 [PubMed]
    5. Change therapy when Opioid dose increases above highest tolerated dose
      1. Consider switching Opioids or rotating Opioids
      2. Decrease dose equivalents by 50-75% when making a medication change
  3. Assess rescue dosing for breakthrough pain
    1. Use immediate release form of Step 3 Opioid
      1. Short acting Morphine Sulfate
    2. Calculate rescue dose and interval
      1. Pearl
        1. Adjust short-acting, breakthrough pain dose when long-acting, basal dose is changed
      2. Dose
        1. One third of long acting agent dose in Morphine equivalents (if only 1 used) or
        2. Rescue doses represent 10-20% of 24 hour total dosing (in Morphine equivalents)
      3. Frequency
        1. One third of long acting interval
        2. Consider planned dose before turning or transfers
        3. Dose up to every 1-2 hours (or after peak effect anticipated) until pain relieved
          1. Expect peak effect of IV Opioids in 10 minutes
          2. Expect peak effect of SQ/IM Opioids in in 20-30 minutes
          3. Expect peak effect of oral Opioids in 60 minutes
    3. Example
      1. Sample patient uses 1000 mg oral Morphine equivalents every 24 hours
      2. Appropriate breakthrough Oxycodone dose would be 60-120 mg orally
        1. Typical Oxycodone dose of 5-10 mg would have no effect on this patient's breakthrough pain
  4. End-Of-Dose Pain (medications wear off early)
    1. First, try increasing long acting Opioid dose
    2. Next, consider short-acting agent timed to cover break-through pain
    3. Next, consider shortening the long-acting Opioid dose interval (for fast metabolizer)
      1. MS Contin may be dosed as often as three times daily
      2. Fentanyl Patches may be changed as often as every 48 hours

VI. Protocol: Prevent and treat Opioid Adverse Effects

VII. Resources

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