What is the recommended approach for managing opioids in a hospital setting?

Management of Opioids in the Hospital

Immediate-release opioids administered via the oral route as soon as possible, using scheduled (not PRN) dosing at fixed intervals, represent the safest and most effective approach for managing acute pain in hospitalized patients. 1

Initial Assessment and Route Selection

• Transition to oral administration immediately when feasible, as this route minimizes complications and facilitates safer titration compared to intravenous administration 1
• Monitor sedation scores in addition to respiratory rate to detect patients at risk of opioid-induced ventilatory impairment 1
• Recognize that escalating pain intensity may indicate surgical complications (compartment syndrome, anastomotic leak) rather than inadequate analgesia 1

Opioid Selection and Dosing Strategy

For Opioid-Naïve Patients

Mild Pain (1-3/10):

• Start with non-opioid analgesics (NSAIDs, acetaminophen) before considering opioids 1
• If opioids needed, use slower titration of short-acting formulations 1

Moderate to Severe Pain (≥4/10):

• Liquid oral morphine 10 mg (5 mL) is the preferred first-line opioid due to regulatory advantages facilitating timely administration 1
• Dose should be age-related (not weight-based) and adjusted for renal function 1
• Immediate-release oxycodone is NOT recommended as first-line due to scheduling restrictions that delay administration 1
• In patients >70 years or with renal failure, alternative opioids may be preferred per local protocols 1

For Opioid-Tolerant Patients

Critical principle: Continue baseline opioid therapy and add short-acting opioids for breakthrough pain 2, 3, 4

Patients on Methadone:

• Continue usual daily methadone dose without interruption 2, 4
• Add short-acting opioids (morphine, hydromorphone, oxycodone) at higher doses and more frequent intervals than opioid-naïve patients due to cross-tolerance 2, 3, 4
• Use scheduled dosing at fixed intervals, not PRN 3, 4
• Rescue doses should equal 10-20% of total 24-hour opioid requirement, given every hour as needed 1, 4
• Consider splitting methadone into 6-8 hour intervals (adding 5-10% to afternoon/evening doses) to leverage its shorter analgesic effect 4

Patients on Buprenorphine:

• Continue buprenorphine maintenance therapy 2
• Add short-acting full opioid agonists 2
• Consult palliative care, pain, or addiction specialists for optimal approach 2

Scheduled vs. PRN Dosing

Use scheduled (around-the-clock) dosing rather than PRN administration for several critical reasons:

• Scheduled dosing provides superior pain control with no increase in adverse events 5
• Ensures 70.8% of ordered opioid is administered vs. only 38% with PRN dosing 5
• Prevents pain recurrence between doses, which causes unnecessary suffering and increases patient-provider tension 3
• Maintains more stable plasma opioid levels 5

Titration Protocol

For breakthrough pain in opioid-tolerant patients:

• Calculate previous 24-hour total opioid requirement 1
• Increase rescue dose by 10-20% of total 24-hour opioid dose 1, 4
• Reassess every 60 minutes for oral opioids, every 15 minutes for IV opioids 1
• If pain unchanged or increased: give 50-100% of previous rescue dose 1
• If pain decreased to 4-6/10: repeat same dose 1
• After 2-3 cycles without improvement: consider route change (oral to IV) or alternative strategies 1

Multimodal Analgesia Foundation

Continue non-opioid analgesics even after opioid initiation:

• Acetaminophen 650 mg every 4-6 hours (maximum 4-6 grams daily) 2
• NSAIDs if not contraindicated 2
• These agents provide additive analgesia and should continue throughout opioid therapy 2
• Avoid fixed-dose combination products in patients requiring high opioid doses due to hepatotoxicity risk 4

Critical Medications to AVOID

Never use the following in hospitalized patients:

• Mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) - can precipitate acute withdrawal syndrome 2, 3, 4
• Tramadol and codeine in opioid-tolerant patients - limitations in dose titration, neurotoxicity risk, significant drug interactions 2
• Modified-release or transdermal opioid preparations - associated with harm in acute postoperative setting 1
• Dopamine for renal protection - ineffective and may cause adverse effects 1

Safety Monitoring

Essential monitoring parameters:

• Sedation scores PLUS respiratory rate (not respiratory rate alone) 1
• Level of consciousness 2
• Have naloxone immediately available 2, 4
• For unstable patients receiving opioids: ventilation bag and opioid antagonist must be readily accessible 1

Special Populations

Renal Impairment:

• Start with lower doses and titrate slowly 6
• Morphine metabolites (M3G, M6G) accumulate significantly in renal failure 6
• Consider methadone (fecally excreted), fentanyl, oxycodone, or hydromorphone 2
• Avoid morphine, meperidine, codeine, and tramadol 2

Hepatic Impairment:

• Morphine clearance decreases with corresponding increase in half-life 6
• Start with lower doses and titrate slowly with careful monitoring 6

Unstable/Septic Patients:

• Use opioids cautiously - may cause respiratory depression, hypotension, bradycardia, altered mental state 1
• Administer only diluted concentrations intravenously 1
• Avoid intramuscular injections of large depot doses (unpredictable effects) 1
• Septic shock patients typically require lower opioid doses than hemodynamically stable patients 1

Weaning Strategy: The Reverse Analgesic Ladder

When analgesic requirements decrease, follow this specific sequence:

1. Wean opioids FIRST 1
2. Then stop NSAIDs 1
3. Finally stop acetaminophen 1

This approach prioritizes reducing opioid exposure while maintaining non-opioid analgesia as long as beneficial.

Discharge Planning

Opioid prescribing at discharge:

• Prescribe 5 days, maximum 7 days of opioids (including tramadol) 1
• Prescribe opioid and non-opioid analgesics separately to allow individual dose adjustments 1
• Discharge letter must explicitly state: recommended dose, amount supplied, planned duration 1
• Avoid modified-release preparations without specialist consultation 1
• Provide patient education on safe administration, weaning, storage, and disposal 1
• Warn about driving/machinery operation risks 1
• Ensure timely discharge letter to all providers including community pharmacists to prevent acute prescriptions becoming repeat prescriptions 1

Special Considerations for Substance Use Disorder

Reassure patients explicitly that:

• Addiction treatment will continue uninterrupted 2, 3
• Pain will be aggressively treated 2, 3
• This decreases anxiety and improves cooperation 2, 3

Involve inpatient pain service for opioid-tolerant patients - psychology input may be needed 1

Establish clear treatment agreements regarding number of pills, frequency, duration, and single provider/pharmacy when appropriate 2, 3

Common Pitfalls to Avoid

• Undertreating pain due to "opiophobia" - leads to decreased responsiveness to subsequent opioid analgesics 2, 3
• Using pain scores alone to guide opioid administration - elevated pain may indicate complications, not inadequate analgesia 1
• Allowing pain to reemerge before next dose - causes unnecessary suffering and patient-provider conflict 3
• Misinterpreting drug-seeking as addiction - may represent pseudoaddiction (uncontrolled pain) or therapeutic dependence 3
• Prescribing modified-release opioids in acute setting - associated with harm 1