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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).

References:

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.

Drayer RA, et. Al. Barriers to better pain control in hospitalized patients. J Pain Sym Manage 1999; 17:434-440.

Friedman FB. PRN analgesics: controlling the pain or controlling the patient? RN 1983; 67-78. Principles of Analgesic use in the treatment of acute and cancer pain. 4th Ed. American Pain Society. 1999; Page 31.

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

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).