Appendix 2: Palliative opioid prescribing tool

Twelve Steps
1. Opioids are the drugs of choice for pain and dyspnea in advanced disease
2. Opioids are safe in cardiopulmonary disease but - start low, go slow
3. Persistent symptoms require regular dosing i.e. short-acting opioid q4 hours
4. Not all opioidsare the same and inter-individual analgesia/side effects vary widely
5. Opioids with few or no active metabolites preferred in those with renal failure or frailty
6. Always order breakthrough when regular dosing: 10%of total daily opioid dose qlh pm
7. lf3 or more breakthroughs used in 24 hours increase the regular dose
8. Titrate dose to the best possible symptom controlwith fewest side effects
9. When you prescribe an opioid, prescribe a laxative
10. When titrating, increase regular opioid dose by 25%and recalculate breakthrough dose
11. If side effects are intolerable, consider switching opioid
12. Educate patient/family re control of symptoms and safety of opioids

Opioid Dosing
Opioid Oral SC Starting p.o. Starting p.o. Active
dose dose dose - opioid dose-frail Metabolites
Calculating a breakthrough dose: 10'.lfo of the total daily regular opioid dose ql h prn. na'ive* older adult/
Example: morphine 50mg q4hr total daily dose SOX 6= 300mg. 300/10 = 30mg qlhr pm CRF
Calculating a new dose by number of breakthrough doses used: add 24 hour total Tylenol #3 2tabs n/a avoid avoid +++
regular dose + total breakthroughs used = total daily opioid dose. Divide this by dosing (acetaminophen/codeine)
intervals and this is new regular dose. Recalculate breakthrough dose. Example: Morphine 10mg 5mg 5-lOmg q4h 2.5-Smg q4hr +++
hydromorphone 12mg q4h, with4 breakthroughs of8mg ql h. Total daily opioid dose is (12 Hydromorphone 2mg 1mg 1-2mgq4hr 0.5-lmg q4hr ++
X6) + (4X 8) = 104mg. New dosing is 104/6co 16mg q4hrwith breakthrough oflOmg qlhr Oxycodone 7.5mg n/a 5-lOmg q4hr 2.5 -Smg q4h 0
pm Fentanyl transdermal"" SEE THE FOOTNOTE BELOW 0
Methadone*"" 1mg 0.5mg 2-Smg q8hr 1mg q12hr 0
Switching to Sustained Release: titrate short-acting to optimal dose. Add total regular Consult POCT
dose+ breakthroughs (if used) = total daily dose.Total daily dose /2 = Opioid SR q12hours.
Younger patients may metabolize rapidly and require q8hr dosing.
I
Opioid Rotation: add up total regular dose + breakthroughs (if used)= total daily dose. Footnotes
Total daily dose Xmorphine conversion factor= total daily morphine equivalents. Daily • Opioid naive: the patient has NOT had 5 daysof continuous opioid exposure
morphine equivalents/ conversion factor to new opioid = total daily new opioid dose. (i.e. short-acting q4hr po,sc; long-acting q12hr; transdermal)
Reduce 25-50%in me of tolerance to previous opioid. Divide by dosing interval. Example: •• Fentanyl transdermal patch is NOT recommended for opioid-na'fve patients.
Tylenol #312 tabs/day= 60mg morphine equivalents per day = 12 mg ofhydromorphone Previous opioid should be continued for first'l2 hours ofFentanyl patchas absorption is
per day = 9mg hydromorphone per day (reduced fortolerance) = 1.5 mg hydromorphone delayed.
po q4hr, hydromorphone 1mg qlhr prn for breakthrough Recommended conversion from morphine to fentanyl is as follows:
Oral to Parenteral: depending on the opioid may have to rotate to eitherhydromorphone Fentanyl 25mcg patch/hr = 50mg morphine/day orally
or morphine forsc. Add up regularoral doses+ breakthroughs (if used)= total daily oral Fentanyl 25mcg patch/hr = 100mg morphine/day orally in CRFand frail older adult
dose.Total daily oral dose/2 = total daily parenteral dose. Example: Morphine SR 120mg po c.alculate breakthrough dose based on morphine equivalents of the patch. Lowest dose
ql 2hX2 = 240mg total daily morphine dose po = 120mg total parenteral morphine dose patch = 12mcg/hr
= 20mg s.c q4h regular, morphine 12mg sc ql h pm for breakthrough.
••• Need special license to prescribe. Variable half life and dosing.

References
Opioid Side Effects
Dyspnea in advanced Disease: a guide to dinical management. OUP 2006
Adverse Effect Management
American Pain Society (2008) Principles of Analgesic Use in the Treatment of Acute and
Cancer Pain Sedation Tolerance develops in2-5days. If not, rotate opioid. If symptom
controlled, reduce dose.
American Geriatrics Society (2009): The management of persistent pain in older persons.
Nausea Common in first week. Metoclopramide 10mg qid Of
Canadian Pain Society (2008) Managing Pain: The c.anadian Healthcare Professional's
haloperidol 0.5mg bid. Consider rotation if persists.
Reference
Constipation Always. Stimulant laxative (senna) +/- Osmotic laxative (PEG, lactulose)
For further symptom management advice, discharge planning and patient/family Opioid Induced ! LOC, myodonus, hallucinations, delirium. Rotate opioid, consider
resources visit Palliative Care Companion on the Clini<al Page ofthe Intranet... Neurotoxicity hydration, treat concurrent infection.
http://phcconnect/programuervices/palliative_care/page_62358.htm Pruritis Consider rotation if persists
Respiratory Rare. Rapid tolerance after 2-5 days regular dosing.
depres~on Sedation always precedes. Pinpoint pupils, unrousable, RR<8, not dying
Treatment- Lew dose naloxone: dilute 1ml (0.4mg/ml) naloxone in9ml
saline. slow IVpush(0.5-1ml q2min)

Acknowledgement: Romayne Gallagher thanks the other members of the Palliative Outreach and Consult Team for their help in creating this
online resource: Nicki Apostle MD, Veo Bunderla RN MSN, Ella Garland RN BSN, Donald Ginsberg MDCM, Kate McNamee Clark RN BSN,
Pat Richardson RN BSN, Timothy Sakaluk MD and Simin Tabrizi RN MSN.

Appendix to: Gallagher R. The use of opioids for dyspnea in advanced disease. CMAJ 2011. DOI:10.1503/cmaj110024.
Copyright © Palliative Outreach and Consult Team of the Hospice Palliative Care Program
at Providence Health Care, Vancouver, British Columbia