From the Guidelines
For a hospice patient who is allergic to morphine and unable to eat, I would recommend fentanyl transdermal patches as the first-line opioid medication, as supported by the most recent and highest quality study 1. This recommendation is based on the fact that transdermal fentanyl is a highly lipid-soluble mu-opioid receptor agonist that can be administered by the parenteral, spinal, transdermal, transmucosal, buccal, and intranasal routes, making it suitable for patients who cannot eat. Some key points to consider when prescribing fentanyl transdermal patches include:
- Starting with a low dose such as 12.5 mcg/hour or 25 mcg/hour, depending on the patient's prior opioid exposure, and titrating as needed for pain control 1
- The patches are typically changed every 72 hours
- Alternatively, hydromorphone (Dilaudid) administered subcutaneously via continuous infusion or as needed injections would be appropriate
- For breakthrough pain, consider fentanyl sublingual tablets or spray which dissolve in the mouth without needing to be swallowed These recommendations are based on the medications' routes of administration that bypass the gastrointestinal tract, making them suitable for patients who cannot eat. Additionally, fentanyl and hydromorphone are good alternatives for patients with morphine allergies as they belong to different opioid classes and have less cross-reactivity, as noted in 1 and 1. Regular assessment of pain control and side effects is essential, with dose adjustments made accordingly to ensure patient comfort during end-of-life care. It's also important to note that transdermal fentanyl is not indicated for rapid opioid titration and should be recommended only after pain is adequately managed by other opioids in opioid-tolerant patients, as stated in 1. However, the latest evidence from 1 supports the efficacy of transdermal fentanyl for relieving moderate to severe cancer pain and suggests a reduction in opioid-related constipation compared with oral morphine regimens. Overall, the use of fentanyl transdermal patches in hospice patients who are allergic to morphine and unable to eat is supported by the most recent and highest quality evidence, and should be considered as a first-line treatment option.
From the Research
Opioid Medication Options for Hospice Patients with Morphine Allergy
- For a hospice patient with an allergy to morphine, alternative opioid medications can be considered, such as fentanyl, hydromorphone, methadone, or oxycodone 2, 3, 4, 5.
- Fentanyl is a preferred analgesic agent for critically ill patients with hemodynamic instability or for patients manifesting symptoms of histamine release with morphine or morphine allergy 2.
- Hydromorphone is an acceptable alternative to morphine for patients with significant adverse effects from morphine or severe renal dysfunction 2.
- Methadone has been found to be as effective as morphine, transdermal fentanyl, and common combinations of other opioids in controlling cancer pain, and has a low cost 3.
- Oxycodone has been shown to produce less delirium than morphine in palliative care patients, and can provide effective analgesia without significant side effects in patients with morphine-induced delirium 5.
Considerations for Patients Unable to Eat
- For patients who are unable to eat, alternative routes of administration, such as subcutaneous or transdermal, may be considered 6, 4, 5.
- The choice of opioid medication and route of administration should be individualized based on the patient's specific needs and medical condition 2, 3, 4.
- Close monitoring and dose titration are necessary to ensure effective pain control and minimize adverse effects 2, 6, 4.