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. Fentanyl patches provide continuous pain relief for 72 hours and are ideal for patients who cannot take oral medications. Start with a low dose such as 12 mcg/hour for opioid-naive patients or convert from their current opioid dose using appropriate conversion tables 1. For breakthrough pain, consider fentanyl buccal tablets, sublingual fentanyl, or injectable hydromorphone as needed. Alternatively, hydromorphone via subcutaneous infusion is an excellent option, especially if the patient already has a subcutaneous pump in place. Methadone in liquid form placed under the tongue can also be effective. These medications are appropriate choices because they don't rely on the oral route, have different allergenic profiles than morphine, and provide reliable pain control for end-of-life care.
Key Considerations
- Fentanyl transdermal patches are a good option for patients who are unable to swallow or have poor tolerance to morphine 1.
- Hydromorphone and methadone are effective alternatives to oral morphine, but require careful dose conversion and monitoring 1.
- Regular assessment of pain control and side effects is essential, with dose adjustments as needed to ensure comfort.
- The choice of opioid should be individualized based on the patient's medical history, current medications, and personal preferences.
Benefits of Fentanyl Transdermal Patches
- Provide continuous pain relief for 72 hours
- Ideal for patients who cannot take oral medications
- Have a different allergenic profile than morphine
- Can be used in combination with other opioids for breakthrough pain
Important Safety Considerations
- Fentanyl transdermal patches should be used with caution in opioid-naive patients, and the dose should be carefully titrated to avoid overdose 1.
- Patients should be monitored closely for signs of opioid toxicity, such as respiratory depression, and the dose should be adjusted as needed.
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, or methadone 2, 3.
- 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 in hospice patients 3.
Considerations for Patients Unable to Eat
- For patients who are unable to eat, opioid medications that can be administered via alternative routes, such as transdermal or subcutaneous, may be considered 4, 5.
- Transdermal fentanyl is a viable option, but opioid rotation from transdermal fentanyl to an alternate opioid requires careful consideration and dose adjustment to avoid opioid toxicity 4.
- Subcutaneous hydromorphone infusion is another option, but the initial dose should be reduced by 30-50% of the calculated equianalgesic dose to avoid opioid toxicity 4.
Selection of Opioid Medication
- The selection of an opioid medication should be based on individual patient factors, including the type and severity of pain, renal function, and potential for drug interactions 5.
- Buprenorphine is a top-line choice for opioid treatment in elderly patients with impaired hepatic and renal function, due to its favorable pharmacological profile and minimal immunosuppressive effects 5.