# 072 Opioid Infusion Titration Orders, 2nd ed

FAST FACTS AND CONCEPTS #72

Author(s): David E Weissman MD

Introduction   This Fast Fact will discuss appropriate ways to write opioid infusion titration orders.
 

A bad example: ‘Morphine 2-10mg/hour, titrate to pain relief.’
What is wrong with this order?

  1. This order places full responsibility for dose titration upon the nurse.
  2. 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?).
  3. It poses the potential for overdosage by too zealous dose escalation and provides only one option for poorly controlled pain – increasing the continuous infusion rate.
  4. 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.

A better way to write this order: ‘Morphine 2 mg/hour and morphine 2 mg q 15 minutes for breakthrough pain (or 2 mg via PCA dose). RN may dose escalate the PRN dose to a maximum of 4 mg within 30 minutes for poorly controlled pain.’
 

Why is this better?

  1. 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.
  2. 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

  1. Principles of Analgesic Use in the Treatment of Acute and Cancer Pain. 5th Ed. Glenview, IL: American Pain Society; 2003. Available at: http://www.ampainsoc.org/pub/principles.htm.
  2. Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.32241.
  3. 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. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.18803.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006. Current version re-copy-edited April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE. Opioid Infusion Titration Orders. 2nd Edition. Fast Facts and Concepts. July 2006; 72. Available at: http://www.eperc.mcw.edu/fastfact/ff_072.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a 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.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain – Opioids