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