II. Preparations: Immediate Release Opioids for Moderate to Severe Cancer Pain (Opioid naive patients)
- See Opioid Analgesic
- Fentanyl 25-100 mcg IV or SQ every 2-3 hours
- Hydromorphone (Dilaudid) 0.5 to 2 mg IV or SQ (or 2 to 4 mg orally) every 3 to 4 hours
- Morphine Sulfate 2 to 10 mg IV or SQ (or 2.5 to 10 mg orally) every 3 to 4 hours
- Oxycodone 2.5 to 10 mg orally every 3 to 4 hours
III. Protocol
- Give chronic Pain Medication around-the-clock scheduled
- Use 'patient may refuse' approach
- Contrast with as needed dosing
- Help patients and family overcome reluctance to use Opioid Analgesics
- Start concurrent bowel regimen when starting Opioids
IV. Protocol: Starting Opioid Analgesic (WHO Step 3)
- Choice drug: Morphine Sulfate
- Begin short acting Morphine Sulfate 5-10 mg every 4 hours
- Daily Starting dose: 30-60 mg/day
- Dysphagia or otherwise not able to tolerate larger medication volumes
V. Protocol: Establishing Maintenance dosing After 1 week
- Maintenance Pain Management
- Assess for persistent moderate to severe pain (pain score 4-9)
- Increase basal dose by 25-50% for moderate pain and 50-100% for severe pain
- Continue to dose until pain is relieved
- Pain relief should be goal, not fixed amount (no maximum Opioid dose in cancer)
- However, balance pain management with adverse effects (e.g. Constipation, sedation)
- Morphine doses may need to exceed 250 mg/day (although doses> 250 to 600 mg/day are less common)
- High dose Morphine is safe as end of life analgesia
- Bercovitch (1999) Cancer 86:871-7 [PubMed]
- Change therapy when Opioid dose increases above highest tolerated dose
- Assess rescue dosing for breakthrough pain
- Use immediate release form of Step 3 Opioid
- Short acting Morphine Sulfate
- Calculate rescue dose and interval
- Pearl
- Adjust short-acting, breakthrough pain dose when long-acting, basal dose is changed
- Dose
- One third of long acting agent dose in Morphine Equivalents (if only 1 used) or
- Rescue doses represent 10-20% of 24 hour total dosing (in Morphine Equivalents)
- For 100 mg MME/day, dose 15 mg Morphine IR every 4 hours prn
- Adjust the short-acting dose in 50% increments as needed
- Frequency
- One third of long acting interval
- Consider planned dose before turning or transfers
- Dose up to every 1-2 hours (or after peak effect anticipated) until pain relieved
- Pearl
- Example
- Sample patient uses 1000 mg oral Morphine Equivalents every 24 hours
- Appropriate breakthrough pain dosing
- Morphine Sulfate IR dose would be 100 mg orally
- Oxycodone dose would be 60-120 mg orally
- Typical Oxycodone dose of 5-10 mg would have no effect on this patient's breakthrough pain
- Use immediate release form of Step 3 Opioid
- End-Of-Dose Pain (medications wear off early)
- First, try increasing long acting Opioid dose
- Next, consider short-acting agent timed to cover break-through pain
- Next, consider shortening the long-acting Opioid dose interval (for fast metabolizer)
- MS Contin may be dosed as often as three times daily
- Fentanyl Patches may be changed as often as every 48 hours
VI. Protocol: Prevent and treat Opioid Adverse Effects
- See Opioid Adverse Effect Management
- See Bowel Regimen in Chronic Narcotic Use
- See Very Low Dose Naloxone Protocol for reversal
VII. Resources
- New Hampshire Hospice and Palliative Care Organization
VIII. References
- Abrahm (1999) Ann Intern Med 131:37-46 [PubMed]
- Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
- Cherny (2000) CA Cancer J Clin 50(2):70-116 [PubMed]
- Groninger (2014) Am Fam Physician 90(1): 26-32 [PubMed]
- Levy (1996) N Engl J Med 335:1124-32 [PubMed]
- Miller (2001) Am Fam Physician 64(7):1227-34 [PubMed]