Fast Fact and Concept #020; Opioid Dose Escalation

2nd Edition

Author: David E. Weissman, MD

A common question from trainees is how fast, and by how much, can opioids be safely dose escalated. I like to use the analogy of furosemide (Lasix) when discussing this topic. I have never seen a resident order an increase in Lasix from 10 mg to 11 mg, yet that is precisely what often happens with opioids, especially parenteral infusions. Like furosemide, dose escalation of opioids should be done on the basis of a percentage increase. In fact, this is reflexively done when opioid-non-opioid fixed combination products are prescribed; going from one to two tablets of codeine/acetaminophen represents a 100% dose increase. The problem arises when oral single agents (e.g. oral morphine) or parenteral infusions are prescribed. Increasing a morphine infusion from 1 to 2 mg/hr is a 100% does increase; while going from 5 to 6 mg/hr is only a 20% increase, and yet many orders are written, “increase drip by 1 mg/hr, titrate to comfort.” Note: some hospitals and nursing units have this as a standing pre-printed order or nursing policy.

In general, patients do not notice a change in analgesia when dose increases are less than 25% above baseline.

There is a paucity of clinical trial data on this subject. A common formula used by many practitioners includes:

• moderate to severe pain increase by 50-100%, irrespective of starting dose
• mild-moderate pain increase by 25-50%, irrespective of starting dose.

When dose escalating long-acting opioids or opioid infusions, do not increase the long-acting drug or infusion basal rate more than 100% at any one time, irrespective of how many bolus/breakthrough doses have been used. These guidelines apply to patients with normal renal and hepatic function. For elderly patients, or those with renal/liver disease, dose escalation percentages should be reduced.

The recommended frequency of dose escalation depends on the half-life of the drug. Short-acting oral single-agent opioids (e.g. morphine, oxycodone, hydromorphone), can be safely dose escalated every 2 hours. Sustained release oral opioids can be escalated every 24 hours, and for Duragesic â (Fentanyl transdermal), methadone or levorphanol, no less than every 72 hours is recommended.

See related analgesic Fast Facts:

#18 Oral opioid dosing intervals

# 51 Opioid combination products

# 70 PRN range orders

# 74 Good and Bad analgesic orders

References:

Hanks G, Cherny NI and Fallon M. Opioid analgesic therapy. In Oxford textbook of Palliative Medicine, 3 rd Ed. Doyle D, Hanks G, Cherny N and Claman K eds. Oxford, 2005

Improving End-of-Life Care: A resource guide for physician education . 3 rd Edition. Weissman DE, Ambuel B. and Hallenbeck J. Medical College of Wisconsin, 2001.

Handbook of Cancer Pain Management. Wisconsin Cancer Pain Initiative, 5th Edition, 1996.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Opioid dose escalation. Fast Fact and Concept #20; 2nd Edition, July 2005. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.

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.

Keyword(s): Pain>opioids

Purpose: Instructional Aid

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care