What are the typical doses of Kadian (morphine sulfate) used for opioid therapy in Canada?

From the Guidelines

Kadian (morphine sulfate extended-release) in Canada is typically initiated at 20-30 mg once daily for opioid-naive patients, with careful titration based on pain control and tolerability, as supported by the most recent and highest quality study available 1. The dosing of Kadian for opioid therapy in Canada should be approached with consideration of the patient's current opioid use status and their individual needs for pain management.

• For opioid-naive patients, the starting dose is usually 20-30 mg once daily, with adjustments made based on pain control and tolerability.
• For patients already on opioids, the starting dose of Kadian should be calculated based on their current 24-hour opioid requirement, taking into account the equivalency of different opioid formulations. Maintenance doses of Kadian can range from 20-100 mg once daily, though some patients may require higher doses up to 200 mg daily, which should be approached with caution and specialist consultation 1. It is crucial to follow proper administration guidelines for Kadian, including taking it at the same time each day, swallowing it whole or opening and sprinkling it on soft food, but never crushing or chewing it, to avoid destroying the extended-release mechanism and risking dangerous rapid absorption. Dose adjustments should be made no more frequently than every 1-2 days, with smaller increments (e.g., 20-30%) preferred for safety, especially in elderly patients, those with renal or hepatic impairment, and opioid-naive individuals who require lower starting doses and more gradual titration 1. Regular reassessment of pain control, side effects, and continued need for therapy is essential, as is monitoring for signs of opioid use disorder, to ensure the safe and effective use of Kadian for opioid therapy in Canada.

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 [see Warnings and Precautions (5)] 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 [see Warnings and Precautions (5. 1)] .

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 FDA drug label does not answer the question.

From the Research

Typical Doses of Kadian for Opioid Therapy in Canada

• The optimal dose of morphine, which Kadian is a form of, is one that improves function or decreases pain ratings by at least 30%, and for most patients, this dose will be well below a 200-mg morphine equivalent dose per day 2.
• A low initial dose and slow upward titration is recommended for opioid therapy, with patient education and close monitoring 2.
• In a study on the factors affecting dosing regimens of morphine sulfate extended-release (KADIAN) capsules, mean daily KADIAN doses were lower in patients who remained on a once-daily (q24h) regimen compared to those who switched to a twice-daily (q12h) regimen 3.
• The study also found that patients who switched to a q12h regimen had higher pain scores at baseline and week 2 compared to patients who remained on a q24h dosing regimen 3.
• In a case series on outpatient rapid titration of slow-release oral morphine for the treatment of opioid use disorder in a Canadian setting, patients received supervised short-acting morphine doses, which were consolidated into a 12-hour extended-release morphine dose (to a maximum of 500 mg) on the evening of the titration, and the total titration-day dose was summed into the post-titration-day slow-release oral morphine dose, to a maximum of 1000 mg 4.

Dosing Regimens for Kadian

• KADIAN capsules are indicated for once-daily (q24h) or twice-daily (q12h) dosing 3.
• A study compared the efficacy and safety of Kadian every 24 hours to Kadian every 12 hours and MS Contin tablets every 12 hours, and found that time to first remedication was longer for Kadian every 24 hours, but there were no statistically significant differences among the treatments for any morphine-related side effects when adjusted for baseline 5.
• Patient global assessment significantly favored Kadian every 24 hours over MS Contin every 12 hours 5.

Considerations for Opioid Therapy in Canada

• The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain recommends screening for addiction risk before prescribing opioids, and a low initial dose and slow upward titration with patient education and close monitoring 2, 6.
• The guideline also recommends that opioids play an important role in the management of chronic noncancer pain, but careful prescribing is needed to limit potential harms 2.
• A qualitative study found that pain physicians had generally positive attitudes toward the Canadian Opioids Guideline, but limited use, and recognized gaps in the guideline, especially recommendations for urine drug screening and pain severity-specific therapy 6.