FAST FACT AND CONCEPT #74: Oral Opioid Orders — Good and Bad Examples

2nd Edition

Author: 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, 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

1. 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.
2. Drayer RA, et. Al. Barriers to better pain control in hospitalized patients. J Pain Sym Manage 1999; 17:434-440.
3. Friedman FB. PRN analgesics: controlling the pain or controlling the patient? RN 1983; 67-78.
4. Principles of Analgesic use in the treatment of acute and cancer pain. 4 th Ed. American Pain Society. 1999; Page 31;

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 #74: Oral opioid orders, 2nd Edition. July 2006. End-of-Life / Palliative Education Resource Center: http://www.eperc.mcw.edu.

Creation Date: 8/2002

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>opioids