Fast Fact and Concept #20: Opioid Dose Escalation

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Title: Fast Fact and Concept #20: Opioid Dose Escalation

Author(s): Weissman, D.

This Fact Fact and Concept discusses guidelines for escalating opioids in the treatment of pain. The handout is suitable for discussion during teaching rounds or for discussion in a pain management teaching conference.

Educational Objective(s)
Understand common errors in opioid dose escalation. Review guidelines for opioid dose escalation.
A common question from trainees is how fast, and by how much, can opioids be safely dose escalated. I like to use the analogy of furosemide (Lasix) when discussing this topic. I have never seen a resident order an increase in Lasix from 10 mg to 11 mg, yet that is precisely what often happens with opioids, especially parenteral infusions. Like furosemide, dose escalation of opioids should be done on the basis of a percentage increase. In fact, this is reflexively done when opioid-non-opioid fixed combination products are prescribed; going from one to two tablets of codeine/acetaminophen represents a 100% dose increase. The problem arises when oral single agents (e.g. oral morphine) or parenteral infusions are prescribed. Increasing a morphine infusion from 1 to 2 mg/hr is a 100% does increase; while going from 5 to 6 mg/hr is only a 20% increase, and yet many orders are written, "increase drip by 1 mg/hr, titrate to comfort." Note: some hospitals and nursing units have this as a standing pre-printed order or nursing policy. In general, patients do not notice a change in analgesia when dose increases are less than 25% above baseline.

Reasonable guidelines include: for moderate to severe pain increase by 50-100%, for mild-moderate pain increase by 25-50%, irrespective of starting dose. When dose escalating long-acting opioids or opioid infusions, do not increase the long-acting drug or infusion basal rate more than 100% at any one time, irrespective of how many bolus/breakthrough doses have been used. These guidelines apply to patients with normal renal and hepatic function. For elderly patients, or those with renal/liver disease, dose escalation percentages may need to be reduced.

The recommended frequency of dose escalation depends on the half-life of the drug. Short-acting oral single-agent opioids (e.g. morphine, oxycodone, hydromorphone), not combination products, can be safely dose escalated every 2 hours. Sustained release oral opioids can be escalated every 24 hours, and for Duragesic® (Fentanyl transdermal), methadone or levorphanol, no less than every 72 hours is recommended.

References: 1. Physicians Desk Reference, 2000. 2. Improving End-of-Life Care: A resource guide for physician education. Weissman DE and Ambuel B. Medical College of Wisconsin, 1999. 3. Handbook of Cancer Pain Management. Wisconsin Cancer Pain Initative, 5th Edition, 1996.

Disclaimer Concerning Medical Information Health care providers should exercise their own independent clinical judgment. Accordingly, the official prescribing information should be consulted before any product is used.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Contact David E. Weissman, MD, FACP Palliative Care Program Director Medical College of Wisconsin (P) 414-805-4607 (F) 414-805-4608 [email protected]

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #20: Opioid Dose Escalation. September, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 7/2000

Format: Handouts

Purpose: Instructional Aid

Training: 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Adult, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment, Duragesic

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).