What are the standard hospice morphine orders for pain management?

Standard Hospice Morphine Orders

For hospice pain management, start with oral morphine immediate-release (IR) 15-30 mg every 4 hours scheduled, with the same dose available every hour as needed for breakthrough pain, then titrate daily based on total rescue doses used. 1, 2

Initial Dosing Strategy

Opioid-Naive Patients

• Begin with morphine IR 15-30 mg orally every 4 hours around-the-clock 1, 2
• For patients over 70 years old, consider starting at 10 mg every 4 hours 3
• Provide the same dose (15-30 mg) for breakthrough pain, available as often as every hour 1, 4

Dose Titration Protocol

• Review total morphine consumption after 24 hours (scheduled doses + all breakthrough doses) 4
• Increase the regular scheduled dose based on breakthrough dose frequency: if patient required multiple rescue doses, add them to calculate new total daily dose and redistribute 1
• Continue this daily assessment until pain is controlled 1

Transition to Long-Acting Formulations

Converting to Extended-Release (ER) Morphine

• Once dose is stable on IR morphine, convert to ER morphine by dividing total daily dose by 2 for twice-daily dosing 4
• Breakthrough dose = one-third of the 12-hour ER dose (equivalent to the 4-hourly IR dose) 1, 4
• Example: For 120 mg total daily dose → morphine ER 60 mg every 12 hours + morphine IR 20 mg every hour as needed 4

Bedtime Dosing Adjustment

• For patients on IR morphine every 4 hours, give double dose at bedtime to prevent nighttime awakening from pain 1, 4
• This practice is widely adopted and effective without causing adverse effects 1

Alternative Routes When Oral Route Unavailable

Route Selection Priority

• First alternative: Rectal administration (same bioavailability as oral, 1:1 potency ratio) 1, 5
• Second alternative: Subcutaneous administration (either bolus every 4 hours or continuous infusion) 1
• Avoid intramuscular route - subcutaneous is simpler and less painful 1

Conversion Ratios for Route Changes

• Oral to subcutaneous: 1:2 ratio (divide oral dose by 2) 1
• Oral to intravenous: 1:3 ratio (divide oral dose by 3) 1, 2
• Oral to rectal: 1:1 ratio (same dose) 1, 5

Parenteral Dosing

• Subcutaneous morphine starting dose: 5-10 mg every 4 hours 1
• Intravenous morphine starting dose: 5-10 mg 1
• For severe pain requiring urgent relief, use parenteral route initially then convert to oral 1

Critical Safety Considerations

Formulation Warnings

• Never crush controlled-release/ER morphine tablets - this destroys the extended-release mechanism causing dose dumping, respiratory depression, and potential death 1, 5
• Do not use ER tablets rectally or vaginally 1, 5

Monitoring Requirements

• Monitor closely for respiratory depression, especially in first 24-72 hours after initiation or dose increases 2
• Assess for constipation and prescribe prophylactic laxatives routinely 4
• Initial drowsiness, dizziness, or mental clouding typically resolves within days 4

Common Pitfalls to Avoid

Dosing Errors

• Do not use smaller breakthrough doses than recommended - the full dose (equal to regular 4-hour dose) is more effective and dose-related adverse effects are insignificant 4
• Do not increase dosing frequency beyond every 4 hours for IR or every 12 hours for ER - this complicates the regimen without benefit 1, 4
• If pain returns before next scheduled dose, increase the dose amount, not the frequency 1

Special Circumstances

• Some patients may require ER morphine every 8 hours instead of every 12 hours if adequate analgesia duration is not achieved 1, 4
• For patients with poor peripheral circulation, generalized edema, coagulation disorders, or erythema at injection sites, subcutaneous route may not be practical 1
• Consider alternative opioids (diamorphine in UK, hydromorphone elsewhere) for parenteral use due to greater solubility 1

Dose Range Expectations

Typical Dosing

• Most patients achieve adequate pain control with oral morphine 30 mg or less every 4 hours 6
• Effective doses range from as little as 2.4 mg to over 100 mg every 4 hours 6
• At 4 weeks, mean dose typically remains around 45 mg daily for opioid-naive patients started on low doses 3

High-Dose Morphine

• High-dose morphine (≥300 mg/day) is required in approximately 9-12% of hospice patients 7, 8
• Younger patients, males, and those with bone metastases, GI/lung primaries, or spinal disease more commonly require higher doses 7, 8
• High-dose morphine does not adversely affect survival and should not be a barrier to adequate pain control 7, 8
• No upper dose limit exists - maximum dose depends on tolerance development 1