This workshop provides a practical framework for opioid decision-making in palliative care, with a focus on assessing pain, initiating opioids, adjusting therapy, and managing side effects.
Pain Assessment and Communication
Effective opioid management begins with a thorough pain assessment using standardized scales and mnemonics. Providers should explore:
- Descriptive mnemonics: Examples include PQRSTU, OLD CARTS, and SOCRATES to assess location, timing, quality, and response to treatment
- Real-world application is emphasized—two patients with the same “6/10” pain score may have vastly different functional impacts and treatment needs.
- Therefore, Intensity over time: NOW, WORST, BEST, and GOAL scores are important to give context to patient’s pain score
Opioid Selection and Dosing
Different opioids vary in potency, metabolism, and administration routes. Key principles:
- Start low, especially in opioid-naïve patients (e.g., morphine 2 mg IV PRN; oxycodone 5 mg PO PRN)
- Use long-acting opioids (or scheduled short-acting) for persistent or constant pain, with short-acting agents for breakthrough pain
- For opioid tolerant patients PRN dosing should be 10–15% of the total daily dose (TDD), scheduled based on duration of action
Conversion and Titration
Conversion: Refer to the equianalgesic table for specific guidance:
- Special Exceptions:
- Fentanyl patch (e.g., 25 mcg/hr IV ≈ 50 mg oral morphine per day after 48 hrs of consistent use)
- Methadone conversions, which are nonlinear and based on total daily oral morphine equivalents (OME) and patient age.
Titration: Increase by 25–50% for mild-moderate pain and 50–100% for severe pain
Side Effect Management
Common opioid-related side effects and their treatments include:
- Constipation: Always anticipate; use stimulant laxatives (senna, bisacodyl)
- Itching: consider opioid rotation or treat with antihistamines like diphenhydramine or hydroxyzine
- Sedation: precedes respiratory depression; stimulants or dose adjustment may be useful
- Nausea/Vomiting: dopaminergic agents such as haloperidol or prochlorperazine are first-line
- Naloxone: for overdose, start with 0.04 mg IV push q1min up to 0.8 mg