CHRONIC PAIN SUFFERERS UNITE!
-Continual reevaluation of the patient receiving this drug is important, with special attention to the maintenance of pain control and the relative incidence of side effects associated with therapy. During chronic therapy, especially for non-cancer related pain, the continued need for the use of opioid analgesics should be periodically reassessed.
The US FDA requires a Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting opioid analgesics. The REMS consists of a medication guide and element to assure safe use. Additional information is available at www.fda.gov/REMS.
-This drug should be prescribed only by healthcare professionals knowledgeable in the use of potent opioids for the management of chronic pain.
-Patients should not consume alcoholic beverages while on morphine.
-When this drug is administered intravenously, an opiate antagonist and facilities for administration of oxygen and control of respiration should be available.
-This drug has been reported to be physically or chemically incompatible with various drug products. Specialized references should be consulted for specific compatibility information.
-Dose should be titrated based upon individual response to the initial dose.
-Extended-release capsules should be taken whole, not crushed, chewed, or dissolved; for patients who have difficulty swallowing, Kadian (R) and Avinza (R) may be opened and the contents of the capsule sprinkled on applesauce, immediately swallow without chewing.
-Patients considered opioid tolerant are those taking, for 1 week or longer, at least 60 mg of morphine daily, at least 30 mg of oral oxycodone daily, at least 8 mg or oral hydromorphone daily, or an equianalgesic dose of another opioid.
-The extended-release formulations should not be used for breakthrough pain or on an as needed basis.
-Use only the preservative free injectable formulations for preparations given via the epidural and intrathecal routes, and in neonates.
CDC December 2015 Guidelines
Morphine Equivalent Dose Adjustments
The dosing regimen of this drug should be adjusted for each patient individually, taking into account prior analgesic treatment experience. In the selection of the initial dose consider the following:
-Different formulations of this drug are not bioequivalent. When switching a patient from one form to another, consult the product labeling or local protocol.
-The degree of opioid tolerance of the patient
-The general condition and medical status of the patient
-Type and severity of the pain
-Risk factors for abuse, addiction, or diversion, including a prior history of abuse, addiction, or diversion.
-As needed "rescue doses" of immediate release oral formulations may be needed for patients with cancer pain. The need for more than 2 rescue doses per day may require a review of the controlled release dose.
-The parenteral morphine tartrate and sulfate salt formulations contain almost an equivalent amount of morphine base per milligram, and may be used interchangeably.
-Morphine sulfate controlled release oral formulations have not been shown to be bioequivalent; adjustment between these formulations should be done with caution and careful titration.
-This drug should be used with caution in patients greater than 50 years of age, debilitated patients, and patients with impaired respiratory function; doses may need to be reduced by up to half of the usual daily adult dose.
-Titrate dosage slowly upward, taking into consideration the dosages received for breakthrough pain, to meet the specific needs of the patient.
-Factors such as age, disease state, concomitant drug therapy, analgesic history, and tolerance to narcotics can have variable but important effects on dose and response. In some patients with severe, chronic pain, it may be necessary to exceed the usual dose. Doses should be maintained at the lowest effective dose.
-Dosage reductions may be required with concomitant CNS depressant therapy.
-Patients may initially experience drowsiness or increased sedation due to exhaustion that may be mistaken as excessive analgesia. Initial doses should be maintained for at least 3 days before any dose reduction, as long as sedation is not excessive or associated with unsteadiness, and confusion, and that respiratory activity and other vital signs are adequate.
-The daily dose should be gradually tapered to minimize or prevent withdrawal symptoms.
-Caution and reduced doses are recommended with concomitant use of other narcotic analgesics, general anesthetics, phenothiazine's, and other tranquillizers, sedatives/ hypnotics, tricyclic antidepressants, and other CNS depressants, including alcohol.