Increasing the dose of regular opioid therapy in palliative care

Eisenberg, 2015Latremoliere, 2009Mercadante, 2007

Increase the dose of regular opioid therapy in patients with palliative care needs when the following criteria are met:

  • the pain appears to be responsive to opioids
  • 3 or more breakthrough doses have been used in 24 hours
  • overall pain management has been reviewed and optimised as much as possible (see Key questions to assess poor response to pain management in palliative care for key questions to assess poor response to pain management in palliative care)
  • the minimum time between dose increases has been observed (ie avoid dosage adjustments before steady state has been reached).

Determine the increase to the daily dose of regular opioid therapy by calculating the total amount of opioids taken in the previous 24 hours (both breakthrough and regular therapy). Do not include doses of opioid taken for incident pain in the calculation. In general, do not increase the dose of regular opioid by more than 50% at one time. If the regular opioid dose needs to be increased to more than oral morphine 100 mg (or equivalent) in 24 hours, seek advice from a palliative care specialist.

Note: In general, do not increase the dose of regular opioid by more than 50% at one time.

When increasing the dose of regular opioid therapy, review the breakthrough dose; the breakthrough dose usually also needs to be increased. Example of calculating a dose increase of opioid therapy in palliative care gives an example of how to calculate dose increases for regular opioid therapy and breakthrough doses.

For a small minority of patients, twice-daily oral modified-release opioids may provide pain relief for less than 12 hours—seek specialist advice.

The practical use of buprenorphine, codeine, tramadol and tapentadol is limited by maximum daily doses. For patients who take codeine, tapentadol or tramadol regularly and do not experience adequate analgesia, switch to an approximate equianalgesic dose of morphine or oxycodone (or transdermal fentanyl if a patch is required), rather than increasing the dose. See Approximate equianalgesic doses of opioids in palliative care for approximate equianalgesic doses and Regular oral opioids for background pain in palliative care for dosage advice.

If pain is not controlled with opioid dose adjustment, see Refractory pain in palliative care.

Table 1. Example of calculating a dose increase of opioid therapy in palliative care

Original dose

A patient taking morphine modified-release 30 mg orally, twice daily has taken 4 as-required doses of morphine immediate-release 10 mg orally in 24 hours. One as-required dose was taken 30 minutes before showering for incident pain; the other 3 were breakthrough doses. All doses were effective in relieving pain and a decision has been made to increase the regular morphine dose.

Calculation [NB1]

morphine modified-release 30 mg twice daily is morphine 60 mg in 24 hours

3 breakthrough doses of morphine immediate-release 10 mg is morphine 30 mg in 24 hours [NB2]

regular dose plus breakthrough doses gives a total of morphine 90 mg in 24 hours

For the regular modified-release morphine dose

use half of the total 24-hour morphine dose twice daily: modified-release morphine 45 mg twice daily [NB3]

For the breakthrough immediate-release morphine dose

use one-twelfth to one-sixth of the total 24-hour morphine dose: immediate-release morphine 7.5 mg to 15 mg as required

New dosage regimens

Increase the patient’s regular opioid dose to morphine modified-release 45 mg orally, twice daily.

Either keep the as-required dose of immediate-release morphine at 10 mg or increase it to 15 mg, 1-hourly as required for breakthrough and incident pain.

Note:

NB1: Confirm manual calculations using a digital opioid conversion calculator (eg eviQ calculator or the Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine opioid calculator and application), or check them with a palliative care specialist, pharmacist or colleague.

NB2: Do not include as-required immediate-release morphine doses taken for incident pain in the calculation.

NB3: In general, do not increase the dose of regular opioid by more than 50% at one time.