Introduction     This Fast Fact will discuss appropriate ways to write opioid infusion titration orders. See Fast Fact # 34 for further information on the appropriate symptom management during a ventilator withdrawal.

A bad example: ‘Morphine 2-10mg/hour, titrate to pain relief.’  This order is commonly written for terminally ill patients and in the context of terminal ventilator withdrawals.

What is wrong with this order?

1. It 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.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006; 3rd Edition May 2015. Current version re-copy-edited April 2009; then again May 2015.