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Fast Fact and Concept #54: Opioid Infusions

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Title: Fast Fact and Concept #54: Opioid Infusions

Author(s): Elizabeth Weinstein ; Robert Arnold; David Weissman

Opioid infusions, either IV or SQ (Fast Fact #28: Subcutaneous Infusions), can provide smooth and efficient control of distressing pain or dyspnea in the imminently dying patient. Opioids correctly titrated to provide symptom relief will not cause respiratory depression (see Fast Facts #8: Morphine and Hastened Death). It is common for physicians to order an opioid infusion in the dying patient as follows: "start morphine infusion at 1 mg/hr, titrate to effect". This type of order is pharmacologically unsound and unsafe; hospitals should adopt clinical practice guidelines that meet current national standards. The following is a step by step approach to rational opioid infusion prescribing in the dying patient; the following information is most appropriate for morphine or hydromorphone (Dilaudid) infusions; a future Fast Fact will discuss these of methadone.

First, before starting an opioid infusion, calculate an equianalgesic dose of currently used opioids; then convert this to an equianalgesic basal rate. (Example: patient on MS Contin, 60 mg q12, now unable to swallow; 60 mg q 12 = 120 mg/24 hours po morphine = 40 mg IV morphine/24 hours = approximately 2 mg/hr IV infusion basal rate).

Second, if the current opioid dose is not effective, dose escalate the basal dose by 25-100% (see FF # 20).

Third, if the patient is opioid naïve or when increasing the basal rate above the current equianalgesic rate, give a loading dose when starting the infusion (Example: for a 1 mg/hr basal rate, give 2-5 mg loading dose). (see Portenoy reference for additional guidelines)

Fourth, choose a bolus (aka rescue or PCA dose). This can be a nurse initiated bolus dose when using a standard IV infuser, or a patient, nurse or family initiative bolus using a PCA device (Note: even though the dying patient may be unable to press the button, the nurse or family members can use the PCA device, depending on local hospital policy). Based on patterns of breakthrough pain, a bolus dose of 50% - 150% of the hourly rate is a place to start. For example, for a morphine infusion of 2 mg/hr, choose a starting bolus dose of 1-3 mg.

Fifth, choose a dosing interval. The peak analgesic effect from an IV bolus dose is 5-10 minutes; thus, the dosing interval (aka Lockout interval for a PCA device) should be in the range of 10-20 minutes.

Sixth, reassess for desired effect vs. side effects every 10-15 minutes until stable. Adjust bolus dose size every 30-60 minutes until desired effect is achieved.

Seventh, reassess the need for a change in the basal rate no more frequently than every 6-8 hours; use the number of administered bolus doses as a rough guide when calculating a new basal rate-however, never increase the basal rate by more than 100% at any one time. When increasing the basal rate, always administer a loading dose so as to more rapidly achieve steady-state blood levels.

The above guidelines should be thought of solely as a rough guide; differences in age, renal and pulmonary function and past responses to opioids must be considered when developing an appropriate analgesic treatment plan. When patients become anuric close to death, continuous dosing may be discontinued in favor of bolus dosing to prevent metabolite accumulation and agitated delirium.

References
Cancer pain relief and palliative care. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1990;804:1-75.
Levy M. Pharmacologic treatment of cancer pain. N Engl J Med 1996;335:1124-32.
Management of cancer pain: adults. Clin Pract Guideline Quick Ref Guide Clin 1994:1-29.
Portenoy, RK. Continuous Infusion of Opioid Drugs in the Treatment of Cancer: Guidelines for Use. J Pain Symptom Manage 1986;1: 223-228.
See Fast Fact #28: Subcutaneous Infusions for References regarding subcutaneous infusions.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #54 Weissman DE. Opioid Infusions in the Imminently Dying Patient. November, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

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.

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: 11/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 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
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

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


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).