That Extra Pain Medicine Didn T Help

That extra pain medicine didn’t help! What to do when your patient is getting opioids, but is still in pain Discussion Questions and Teaching Guide Discussion leader: ask the group the numbered, bolded questions. Guide the group to cover the key points bulleted below. 1. What are the most common reasons why a dose increase of an opioid may be ineffective?  The underlying disease may be worsening  The patient has pain that is unresponsive to opioids – for example some types of neuropathic (nerve) pain  The patient has developed tolerance to the analgesic effects of that particular opioid.  The most common reason: the dose increase was not adequate. 2. What are the principles that determine appropriate dose increases of opioids?  Base the dose increase on the patient’s pain intensity.  Base the calculations of the dose increase on the patient’s current 24-hour opioid intake.  Increase the current 24-hour opioid dose by 25-50% if the patient has mild (1-4/10) to moderate (5-6/10) pain. For moderate (5-6/10) to severe (7-10/10) pain, increase the 24-hour dose by 50-100%.  Divide the new 24-hour dose by the number of doses to be given each day. This is determined by the duration of the opioid. Most short acting preparations last 3-4 hours, so the 24 hour dose should be given in 6 divided doses. For a sustained release preparations that lasts 12 hours, the 24-hour dose would be divided into 2 doses.  Always plan for extra medicine for breakthrough pain (pain that occurs or “flares up” despite the regularly scheduled dose of opioid.) 3. How do you calculate the dose of opioid for breakthrough pain?  Use short acting preparations for breakthrough pain, ordered q 1-2 hours prn.  As a starting guide, make each dose of the short acting opioid equivalent to 10-20% of the 24 hour scheduled opioid dose.  For example, a patient taking 30 mg of sustained release morphine is taking 60 mg in 24 hours. Each breakthrough dose should be equivalent to 10-20% of that 60 mg dose, which is 6-12 mg. For the sake of simplicity, round to 5-10 mg morphine q 1-2 hours prn. 4. How would you increase the opioid dose of a patient with a pain score of 6/10 who is taking 90mg sustained release morphine q 12 hours and 4 doses per day of 15mg of morphine for breakthrough pain?  This patient is currently taking 240mg morphine per day (180mg from his scheduled dose and 60mg from his breakthrough). Since the patient has pain of moderate intensity, increase the current 24 hour dose by 50% (120mg.) Add the 120mg to the current 240mg dose for a new 24-hour dose of 360mg. Divide this into 2 daily doses of sustained release morphine, so the new order would read “180mg sustained release morphine q 12h.”  There should be short acting opioid for breakthrough pain which is 10-20% of the new 24-hour opioid dose, ordered q 1-2 hours prn. For a 24-hour dose of 360mg, this would be 36-72mg, which can be rounded to “35-70mg morphine q 1-2 hours prn.” 5. What special considerations exist for a patient who is getting inadequate relief from a preparation that contains an opioid and acetaminophen?  A patient who taking two tablets of an opioid/acetaminophen containing product q4 hours is taking the upper safe limit of acetaminophen in a day. Patients should not take more than 4000mg of acetaminophen in 24 hours. To increase the dose of opioid in this situation, it may be necessary to switch to a preparation that contains an opioid only. Oxycodone, morphine, hydromorphone and others are available as single entity preparations.  Hydrocodone, which is commonly used for acute post-op pain, is available only in combination with acetaminophen or an NSAID. So, if two tablets of hydrocodone/acetaminophen are ineffective for pain relief, it may be necessary to switch to a preparation that has a larger amount of hydrocodone relative to the acetaminophen content, or to switch to another opioid.

Dahl J, Stevenson K, Gordon D, Ó UW Board of Regents, 2000