In hospice care, how much should the baseline opioid dose be increased when pain is inadequately controlled, and what alternatives should be considered if switching to a different medication is necessary?

Opioid Dose Escalation and Rotation in Hospice Care

When pain is inadequately controlled in hospice patients on baseline opioid therapy, increase the total 24-hour opioid dose (both scheduled and breakthrough doses combined) by 10-20%, and when switching to a different opioid, calculate the equianalgesic dose then reduce by 25-50% to account for incomplete cross-tolerance. 1

Dose Escalation for Inadequate Pain Control

For Opioid-Tolerant Patients with Breakthrough Pain

• Calculate the total opioid consumption over the previous 24 hours, including both around-the-clock scheduled doses and all rescue/breakthrough doses actually taken 1

• Increase the baseline dose by 10-20% of the total 24-hour requirement when pain remains at intensity ≥4 or when patients persistently require rescue doses 1

• Provide rescue doses of 10-20% of the new 24-hour total dose as short-acting opioid for breakthrough pain, available every 1-2 hours as needed 1

• Reassess efficacy every 60 minutes for oral opioids and every 15 minutes for IV opioids to determine if additional dose adjustment is needed 1

Rapid Titration Protocol

• If pain score remains unchanged or increases after 2-3 cycles of rescue dosing, administer 50-100% of the previous rescue dose and consider changing the route from oral to IV 1

• The rapidity of dose escalation should match the severity of symptoms—more aggressive titration is appropriate for severe uncontrolled pain 1

Opioid Rotation When Switching Medications

Three-Step Conversion Process

Step 1: Calculate 24-hour current opioid requirement 1

• Determine the total amount of current opioid taken in 24 hours, including both scheduled and breakthrough doses

Step 2: Convert to equianalgesic dose of new opioid 1

• Use standard equianalgesic conversion tables (e.g., 10 mg IV morphine = 2 mg IV hydromorphone; oral morphine to oral oxycodone ratio approximately 1.5:1 to 2:1) 1

Step 3: Apply dose reduction for incomplete cross-tolerance 1, 2

• If pain was well-controlled but side effects were intolerable: reduce by 50% 1, 2
• If pain was poorly controlled: reduce by only 25% 1, 2
• If pain was poorly controlled and requires aggressive management: may use 100% of equianalgesic dose or even increase by 25% 1

Preferred Alternative Opioids

• Hydromorphone or oxycodone are the preferred alternatives to morphine, both available in immediate-release and extended-release formulations 2

• Hydromorphone is 5-10 times more potent than morphine with no major differences in efficacy when dosed equianalgesically 2

• Oxycodone has 60-90% bioavailability with equianalgesic dose between half and two-thirds that of oral morphine 2

• Methadone is effective but should only be initiated by experienced physicians due to marked interindividual variability in half-life and complex conversion ratios (4:1,8:1, or 12:1 depending on baseline morphine dose) 2

Special Considerations for Transdermal Fentanyl

• Convert to fentanyl patch only after pain is relatively well-controlled on short-acting opioids 1

• Use conversion tables directly: 60 mg oral morphine/day = 25 mcg/hour fentanyl patch; 120 mg oral morphine/day = 50 mcg/hour patch 1

• Continue short-acting opioid rescue doses for the first 8-24 hours until steady state is reached after 2-3 days 1

• Increase patch dose based on average daily rescue opioid requirements after steady state is achieved 1

Critical Safety Measures

• Monitor for respiratory depression at every dose increase, especially in elderly, cachectic, or debilitated patients 3

• Reduce doses by approximately 25% if unmanageable side effects occur with pain score <4, then closely monitor to ensure pain does not escalate 1

• Consider opioid rotation if pain remains inadequately controlled despite dose escalation or if persistent intolerable side effects occur 1

• Avoid abrupt discontinuation in physically-dependent patients as this can cause serious withdrawal symptoms, uncontrolled pain, and increased suicide risk 3

Common Pitfalls

• Conversion ratios are approximate guides—clinical judgment and close monitoring remain essential 1, 2

• Up to 40% of cancer pain patients may require opioid rotation during their disease course, so be prepared to switch medications when needed 2

• Do not use mixed agonist-antagonist opioids in combination with pure agonists, as this can precipitate withdrawal in opioid-dependent patients 1

• If more than 4 rescue doses are needed in 24 hours, the baseline scheduled dose is inadequate and should be increased 4