Introduction    This Fast Fact will illustrate poorly written opioid orders and provide preferred alternatives.

Scenario 1:  Episodic (non-continuous) moderate-to-severe pain

Bad Example:  ‘Oxycodone w/ acetaminophen (Percocet), 1-2 PO q 4-6hour PRN severe pain, and acetaminophen w/codeine (Tylenol #3) 1-2 PO q4-6 PRN moderate pain.’

Discussion:   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 opioids/non-opioid combination should be prescribed at a time:  assess for response and 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 based on patient report.  There is a very poor correlation of pain ratings between patients and clinicians.
4. Should both drugs be used, there is risk of exceeding 4 grams/day of acetaminophen.

Preferred order:  ‘Oxycodone w/ acetaminophen, 1-2 tabs PO q 4 hours PRN pain.’

Scenario 2:  Order for an oral long-acting opioid

Bad Example:  ‘Morphine extended-release 60 mg q 6 hours and transdermal fentanyl patch 25 mcg/hour, changed q 72 hours.’

Discussion: This order has two problems.  First, none of the oral long-acting products (e.g. MS Contin, OxyContin, Kadian) should be prescribed less than Q8h; Q12 is the FDA recommended starting interval, although many patients need a q8h 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.  While the oral long-acting products can be dose escalated every 24 hours, the transdermal fentanyl patch can only be safely dose escalated every 2-3 days.  Thus, it is a poor choice for poorly controlled pain

Preferred order:  ‘Morphine extended-release 150 mg q 12 hours.’  (The dose of 150 mg q12 hours is derived from the following equianalgesic relationships: morphine 60 mg q6 hours is 240 mg/day; transdermal fentanyl 25mcg/hr = approximately 60 mg/day of oral morphine.  240 +  60 = 300 mg or 150 mg q12 hours.  See Fast Fact #2.)

References

1. 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.
2. 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.
3. Drayer RA, et al. Barriers to better pain control in hospitalized patients. J Pain Sym Manage. 1999; 17:434-440.
4. Friedman FB. PRN analgesics: controlling the pain or controlling the patient? RN. 1983; 43:67-78.
5. 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.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006; 3rd Edition June 2015. Current version re-copy-edited April 2009; then again June 2015 and September 2016.