What are the guidelines for opiate (opioid) titration?

Opioid Titration Guidelines

Opioid titration should be individualized with no specified dose limit, using bolus doses followed by continuous infusions when needed, and regular assessment of symptoms to guide adjustments. 1

Initial Titration Principles

• For opioid-naïve patients with moderate to severe pain, oral morphine is the first-choice opioid 1
• For opioid-naïve adults with severe pain requiring rapid control, administer 1.5 mg IV morphine boluses every 10 minutes until pain relief is achieved (or adverse effects occur) 1, 2
• IV titration achieves satisfactory pain relief in 84% of patients within 1 hour compared to only 25% with oral immediate-release morphine 2
• For opioid-naïve patients starting oral morphine, the initial bolus dose should be 2 mg IV (or equianalgesic dose of another opioid), adjusted based on size, age, and organ dysfunction 1
• If a patient is already comfortable on a stable dose of opioid and/or sedative, these should be continued at those doses during titration 1

Dosing Schedule and Adjustments

• Analgesics for chronic pain should be prescribed on a regular basis and not on an "as required" schedule 1
• All patients should receive round-the-clock dosing with provision of "breakthrough doses" to manage transient exacerbations of pain 1, 2
• Breakthrough doses should be approximately 10-15% of the total daily dose 1, 2
• If a patient is receiving an infusion of morphine or hydromorphone and develops pain or respiratory distress, it is reasonable to give a bolus dose of two times the hourly infusion dose 1
• If a patient receives two bolus doses in an hour, it is reasonable to double the infusion rate 1
• If more than four breakthrough doses per day are necessary, the baseline continuous infusion rate should be adjusted 1, 2

Route of Administration

• The oral route of administration of analgesic drugs should be advocated as the first choice 1
• Pain or respiratory distress should be treated with an IV bolus dose of an opioid followed by a continuous opioid infusion 1
• IV morphine bolus doses should be ordered every 15 min as required, and IV fentanyl bolus doses should be ordered every 5 min as required 1

Opioid Selection and Conversion

• When converting between opioids, if pain was effectively controlled, reduce the calculated equianalgesic dose by 25-50% to account for incomplete cross-tolerance 2
• For conversion to transdermal fentanyl, use established conversion tables based on 24-hour oral morphine equivalents 3
• In the presence of renal impairment, all opioids should be used with caution and at reduced doses and frequency 1
• Fentanyl and buprenorphine via transdermal route or intravenously are the safest opioids of choice in patients with chronic kidney disease stages 4 or 5 1

Titration for Special Populations

• For elderly patients, consider starting with lower doses (e.g., 0.5 mg IV hydromorphone) and titrating carefully 4
• For patients with hepatic impairment, start with one-half of the usual dosage of opioids and monitor closely 3
• For patients with renal impairment, start with one-half of the usual dosage of opioids and monitor closely 3

Management of Side Effects

• Sedatives should only be used once pain and dyspnea are effectively treated with opioids 1
• Laxatives must be routinely prescribed for both the prophylaxis and the management of opioid-induced constipation 1
• Metoclopramide and antidopaminergic drugs should be recommended for treatment of opioid-related nausea/vomiting 1
• If side effects become problematic, consider reducing the opioid dose if possible, adding adjuvant medications, or switching to another opioid 2

Documentation Requirements

• Whenever a patient is given any medication to treat or prevent symptoms during opioid titration, the rationale should be documented using specific criteria 1
• When appropriate, patients should be assessed for delirium during opioid titration using a standardized assessment tool validated in critically ill patients 1

Common Pitfalls to Avoid

• Avoid using morphine in patients with severe renal failure due to the risk of accumulation of renally cleared metabolites 2
• Avoid rapid discontinuation of opioids in physically dependent patients, as this can lead to withdrawal symptoms, uncontrolled pain, and potentially suicidal behavior 5
• Avoid transdermal fentanyl patches for unstable pain requiring frequent dose changes 1
• Avoid application of heat (e.g., fever or topical heat from heat lamps, electric blankets) when using transdermal fentanyl as this may accelerate absorption 1

By following these guidelines for opioid titration, clinicians can effectively manage pain while minimizing adverse effects and optimizing patient outcomes.