Opioids are a cornerstone of pain management in inpatient palliative care. They are often necessary to relieve moderate to severe pain, especially when non-opioid options are insufficient or inappropriate due to disease progression or patient-specific factors.
When to Consider Opioid Therapy
- Patients with moderate or severe cancer-related pain, that may not be candidates or insufficiently controlled by Non-Opioid Analgesics
- Pain rapidly changing in the context of worsening pain or other complex comorbidities and/or interfering with function, sleep, or quality of life
Key Considerations for Opioid Use
- Etiology of pain (cancer-related versus non-cancer related)
- History of opioid use, opioid naïve versus opioid tolerant (>60mg OME for at least 1 week) and any Adverse Effects experienced
- Renal or hepatic dysfunction: some opioids have toxic metabolites (e.g., morphine in renal failure)
- Route of administration:
- PO preferred when feasible
- IV/SQ often needed for NPO, vomiting, or impaired absorption
- Transdermal options for stable, chronic and persistent pain
- Insurance and formulary access in the inpatient setting
Opioid Rotation
Read more >> Opioid Conversion
- May be indicated when:
- Route of administration is changing (e.g. loss of oral route)
- Side effects limit dose increases and/or pain is uncontrolled despite escalation
- Organ dysfunction (e.g. renal insufficiency/failure) alters metabolite clearance
- Insurance, formulary access in the inpatient setting and/or patient preference
- Requires careful use of opioid conversion tables (link opioid pocket card) and clinical judgment
- Incomplete cross-tolerance reductions (25-50%) should be applied when pain is relatively controlled on current regimen or currently experiencing adverse effects (e.g. allodynia, hyperalgesia, neurotoxicity) that may be contributing to uncontrolled pain experience.
Medication Classes and Drug Selection
Coming soon…
Opioid Tapering
- Important when transitioning off opioids if pain is resolved or to minimize side effects
- Taper slowly to prevent withdrawal
- General rule is to taper by 10% of total daily dose per week for 4-6 weeks, then recalculate to 10% of total remaining daily dose per week thereafter.
- Note: the likelihood of withdrawal is related to the percentage decreases (not mg) and to closer a patient approaches discontinuation