TABLE 13.
Practical tips for prescribing opioids
| Opioid-naïve | |
| Mild to moderate pain | Start codeine 30 mg to 60 mg tid (all doses refer to oral route administration) |
| If a dose of codeine 180 mg/day is inadequate and it is determined that the use of a stronger opioid is necessary, discontinue codeine and replace with a stronger opioid as described below for moderate to severe pain | |
| Moderate to severe pain | |
| Option 1 | Start continuous-release morphine 10 mg to 15 mg q12h with regular morphine 5 mg q4h prn for breakthrough pain control up to three doses per 24 h as a start |
| Option 2 | It is also reasonable to start with a short-acting form of a stronger opioid such as morphine sulphate 5 mg, oxycodone 2.5 mg to 5 mg or Percocet* first and then transfer to a continuous release form once the initial dose requirement is established |
| Titrate dose every three to five days according to analgesic requirements and limiting side effects | |
| Patient already on an opioid with moderate to severe pain and poor pain control | Initiate a trial of increased dose, titrating in increments appropriate to the agent and the dose until adequate pain relief or limiting side effects are encountered |
| Reasonable dose increments in mg (start with q12h dosing; occasionally, more frequent dosing may be required, eg, q8h or q6h); morphine continuous release: 15, 30, 60, 75, 90, 120,150,180, 200, 230, 260; oxycodone continuous release: 10, 20, 30, 40, 50, 60, 70, 80, 100, 120, 140; hydromorphone continuous release: 3, 6, 12, 18, 24, 30, 36, 42, 48, 54, 60 | |
| Duragesic (in μg/h) : 25, 50, 75, 100, 125, 150, 175, 200 | |
| If one agent fails, one may switch to an equivalent dose of another agent. If two different opioid agents provide inadequate relief or limiting side effects then one may consider a trial of methadone |