FAST FACT AND CONCEPT #72: Opioid Infusion Titration Orders

2nd Edition

Author: David E. Weissman, MD

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

Why?

• This order places full responsibility for dose titration upon the nurse.
• 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?).
• It poses the potential for overdosage by too zealous dose escalation and provides only one option for poorly controlled pain—increasing the basal rate.
• 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 5-10 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. 4 th 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.

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. Fast Facts and Concepts #72: Opioid infusion titration orders, 2 nd Edition. July 2006. End-of-Life / Palliative Education Resource Center: http://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.

Creation Date: 7/2002

Purpose: Instructional Aid, Self-Study Guide

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>opioids