Fast Fact and Concept #74: Oral opioid orders: good and bad examples

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Title: Fast Fact and Concept #74: Oral opioid orders: good and bad examples

Author(s): David E. Weissman, MD

The following will illustrate poorly written opioid orders, explanations and preferred alternatives.

SCENARIO #1 Episodic (non-continuous) moderate-severe pain

Bad Example: Oxycodone w/ acetaminophen (Percocet) 1-2 po q4-6 prn severe pain and acetaminophen w/codeine (Tylenol #3) 1-2 po q4-6 prn moderate pain.

Explanation: This order has several problems: 1) the duration of short-acting opioids is typically 3-4 hours; rarely 6 hours; studies document that when given a range, nurses and doctors are most likely to give the lowest dose at the longest interval, leading to inadequate analgesia; 2) only one opioid-non-opioid combination should be prescribed at a time, assess for response, then change to different product if the first agent does not produce the desired effect; 3) the use of descriptors (mild, moderate, severe) allows for subjective interpretation of pain severity by the nurse, rather than judging pain severity directly from the patient; there is a very poor correlation of pain ratings between the patient and nurse or patient and doctor; 4) should both drugs be used, there is risk of exceeding 4 grams/day of acetaminophen.

Preferred order: Oxycodone w/ acetaminophen 1-2 po q 4 hours prn pain

SCENARIO #2 Order for oral long-acting opioid

Bad Example: MS Contin 60 mg q 6 hour and Duragesic Patch 25 ug q 72 hours

Explanation: This order has two problems. First, none of the oral long-acting products (ex. MS Contin, Oxycontin, Oramorph SR, Kadian) should be prescribed less than Q8h; Q12 is the preferred dosing interval. Second, there is no rationale for using two different long-acting products at the same time. Prescribe only one drug, then dose escalate to desired effect or unacceptable toxicity. Remember to always prescribe a prn product for breakthrough pain. Remember, while the oral long-acting products can be dose escalated every 24 hours, the Duragesic Patch can only be safely dose escalated every 2-3 days--thus, it is a poor choice for poorly controlled pain.

Preferred order: MS Contin 150 mg q 12 hours. (The dose of 150 q12 is derived from the following equianalgesic relationships: MS 60 q6 = MS 240 mg/day; Fentanyl 25 ug = MS 60 mg/day. 240 + 60 = 300 or 150 mg q12).


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Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing Fast Facts and Concepts #74 ORAL OPIOID ORDERS-GOOD AND BAD EXAMPLES. Ajmal Gilani, MD; Albert Hinn, MD; Peter Lars Jacobson, MD 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: 8/2002

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

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