What are the appropriate doses of morphine in hospice care?

From the Guidelines

Morphine Doses in Hospice Care

Morphine doses for hospice patients are typically individualized and titrated to achieve adequate pain relief, with a common starting dose of 2.5 to 5 milligrams of oral morphine every 4 hours as needed, adjusted based on patient response and tolerance 1.

• For patients with severe pain, doses may be increased to 10 to 20 milligrams every 4 hours, or more, under close medical supervision.
• Sustained-release morphine formulations may be used, with doses ranging from 15 to 60 milligrams every 8 to 12 hours.
• It is essential to monitor patients closely for signs of overdose, such as respiratory depression, and to adjust doses accordingly.
• Breakthrough pain may be managed with short-acting morphine formulations, such as immediate-release oral morphine, at doses of 2.5 to 10 milligrams every 2 hours as needed 1.
• The optimal route of administration of morphine is by mouth, with two types of formulation required: normal release (for dose titration) and modified release (for maintenance treatment) 1.
• The simplest method of dose titration is with a dose of normal release morphine given every 4 hours and the same dose for breakthrough pain, with the total daily dose of morphine reviewed daily and adjusted accordingly 1.

Key Considerations

• Dose titration should be done carefully, with increases in dose made every 24-48 hours as needed, to avoid adverse effects 1.
• Breakthrough pain should be managed with a rescue dose of morphine, which can be given as often as required (up to hourly) 1.
• Subcutaneous administration may be used as an alternative to oral administration, with a relative potency ratio of oral morphine to subcutaneous morphine of 1:2 to 1:3 1.
• Rectal administration may also be used, with a relative potency ratio of oral morphine to rectally administered morphine of 1:1 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse
2. 2 Initial Dosage Use of Morphine Sulfate Tablets as the First Opioid Analgesic (Opioid-naïve or Opioid-non-tolerant patients): Initiate treatment with morphine sulfate tablets in a dosing range of 15 mg to 30 mg every 4 hours as needed for pain

The appropriate doses of morphine in hospice care are not explicitly stated in the provided drug label. However, the label does provide general guidance on dosage and administration.

• Initial dosage: 15 mg to 30 mg every 4 hours as needed for pain for opioid-naïve or opioid-non-tolerant patients.
• The dosage should be individually titrated to a dose that provides adequate analgesia and minimizes adverse reactions.
• It is recommended to use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.
• The label advises to initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse 2.

From the Research

Appropriate Doses of Morphine in Hospice Care

The appropriate doses of morphine in hospice care vary depending on the individual patient's needs and the severity of their pain.

• The effective analgesic dose of morphine can range from as little as 2.4 mg to more than 100 mg by mouth every 4 hours, though most patients do not need more than 30 mg 3.
• In some cases, patients may require higher doses of morphine, with 39 patients (9%) receiving more than 299 mg per day, and 7 patients (1.6%) receiving very high doses of more than 600 mg per day 4.
• Sustained-release morphine preparations can also be used, with daily dosages ranging from 60 mg to 420 mg morphine administered at intervals from 6 to 14 hours 5.

Factors Influencing Morphine Dosage

Several factors can influence the dosage of morphine required by a patient, including:

• Age, with morphine dosage found to be inversely correlated with age 4.
• Sex, with male patients requiring slightly higher dosages than female patients 4.
• Type of cancer, with primary gastrointestinal, lung, and metastatic bone disease associated with higher morphine dosages 4.
• Use of coanalgesics and adjuvant treatments, which can allow for lower opioid doses and fewer side effects 6.

Safety and Efficacy of High-Dose Morphine

The use of high-dose morphine in hospice care has been found to be safe and effective, with:

• Adverse effects similar to those experienced by patients receiving regular doses of morphine 4.
• No significant impact on patients' life expectancy, with median survival times of 27 days for patients treated with high doses of morphine and 37 days for those treated with very high doses 4.