Fast Fact and Concept #70: PRN Range analgesic orders

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Title: Fast Fact and Concept #70: PRN Range analgesic orders

Author(s): Deb B. Gordon; David E. Weissman

PRN range orders (e.g. 2-6 mg IV morphine Q2h PRN) are designed to provide flexibility in dosing to meet an individual's unique analgesic needs. However, range orders have been shown to be a source of medication errors. It is critical that physicians, nurses, and pharmacists share a common understanding of how to implement PRN range orders and that they demonstrate consistency in this interpretation.

Reasonable range--range orders must be large enough to provide appropriate options for dose titration, but small enough so that appropriate reassessment is done in a timely manner. A good rule is that a range order should be in the range of 100-200% of the base dose (2 - 6 mg).

Initial dose selection--for the opioid naïve patient, the first dose administered should be the lowest dose in the range; if the patient is opioid tolerant, or has received recent doses with inadequate pain relief and tolerable side effects, a dose on the higher end of the range can be administered.

Dose escalation--for moderate to severe pain increase the dose by 50-100%; for mild pain (fine tuning) increase by 25%. Do not increase a prn the dose by > 100% at one time; e.g. increasing from 2-4 mg is a 100% dose increase; from 2-6 mg is a 200% dose increase. Be knowledgeable about the onset, peak, and duration of the specific opioid ordered. Doses of short acting opioids can be increased at subsequent dosing intervals (Q 1-2 hours) while long acting opioid products should be increased no more frequently than every 24-72 hours depending on the specific product.

Dose modification

References: Debra B. Gordon, RN. Adapted with permission from: Pain Management Fast Facts- 5 Minute Inservice. UWisconsin Hospital and Clinics. Weissman DE, Ambuel B and Hallenbeck J. Improving End-of-Life Care: A resource guide for physician education. Medical College of Wisconsin, 2002. Handbook of Cancer Pain Management.Wisconsin Cancer Pain Initiative, 5th Edition.1996.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for Fast Facts and Concepts #70 PRN Range Analgesic Orders. Gordon DB and Weissman DE. June 2002 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: 6/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

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).