Fast Fact and Concept #72: Opioid Infusion Titration Orders

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Title: Fast Fact and Concept #72: Opioid Infusion Titration Orders

Author(s): David E. Weissman

The following will illustrate a poorly written opioid order for titration of infusion analgesics, explanation and preferred alternative.

Bad example: MS 2-10mg/hour, titrate to pain relief

Explanation-Why is this a bad example?

a) This order places full responsibility for dose titration upon the nurse.

b) It provides no guidance regarding how fast to titrate (e.g. every hour, every shift?) or dose titration intervals (e.g. for poorly treated pain, should the dose be raised from 2 to 3 mg, 2 to 10 mg, other?).

c) It poses the potential for overdosage by too zealous dose escalation and provides only one option for poorly controlled pain-increasing the basal rate.

d) Given that it takes at least 8 hours to achieve steady-state blood levels after a basal dose change, it makes no pharmacological sense to dose escalate the basal dose more frequently than q 8 hours.

Preferred: MS 2 mg/hour and MS 2 mg q 15 minutes for breakthrough pain (or 2 mg via PCA dose) and RN may dose escalate the prn dose to a maximum of 4 mg within 30 minutes for poorly controlled pain.

This order is preferred as it provides a basal rate and a breakthrough dose; the breakthrough dose has a peak effect within 10 minutes, thus, if the breakthrough dose is inadequate it can be safely increased, as often as every 15-30 minutes, to achieve analgesia, without a need for rapid upward titration of the basal rate.

Reassess the need for a change in the basal rate no more frequently than every 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.

References: Principles of Analgesic use in the treatment of acute and cancer pain. 4th Ed. American Pain Society. 1999. Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Management of Cancer Pain. Clinical Practice Guideline No. 9; AHCPR Publication No. 94-0592.Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service, 1992, 1994.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for Fast Facts and #72 Opioid infusion titration orders Weissman DE. July 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: 7/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide

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).