What oral opioid regimen is appropriate for an elderly patient with dementia and multiple comorbidities, currently on 30 mg of intravenous (IV) morphine per day for pain control, to be discharged home?

Recommended Opioid Regimen for Discharge

Morphine, 15 mg orally every four hours as needed (Option A) is the appropriate choice for this patient.

Conversion Calculation and Rationale

The patient received 30 mg IV morphine over 24 hours with adequate pain control. Using the standard conversion ratio:

• The oral to IV morphine conversion ratio is 2:1 to 3:1 1
• 30 mg IV morphine × 3 = 90 mg oral morphine equivalent per 24 hours 1
• Divided by 6 doses (every 4 hours) = 15 mg per dose 1

This calculation directly supports Option A as the correct answer.

Why Other Options Are Inappropriate

Option B (Hydromorphone 2 mg PO q4h PRN) - Incorrect

• Hydromorphone is approximately 5-7 times more potent than morphine 2
• 2 mg oral hydromorphone every 4 hours = 12 mg/day oral hydromorphone
• Using the conversion ratio of 1 mg IV hydromorphone = 11.46 mg oral morphine equivalent 3, this patient's 30 mg IV morphine would convert to approximately 2.6 mg IV hydromorphone
• Converting 2.6 mg IV hydromorphone to oral using the 2.5:1 ratio 3 = approximately 6.5 mg oral hydromorphone per day
• Option B provides nearly double the required dose (12 mg vs 6.5 mg daily), creating significant overdose risk 2

Option C (Fentanyl patch 25 mcg q72h) - Contraindicated

• Fentanyl patches are NOT recommended for unstable pain requiring frequent dose changes 1
• Pain should be relatively well controlled on short-acting opioid before initiating the fentanyl patch 1
• This patient just achieved pain control and requires PRN dosing flexibility during the transition home 1
• Using the conversion table, 60 mg oral morphine daily converts to 25 mcg/hour fentanyl patch 1, but this patient requires 90 mg oral morphine equivalent, making 25 mcg inadequate 1
• Fentanyl patches should only be used in opioid-tolerant patients, and while this patient has received opioids, the acute nature and need for titration makes patches inappropriate 4

Option D (Acetaminophen and ibuprofen only) - Inadequate

• This patient has metastatic cancer with spinal compression fractures requiring opioid analgesia 1
• Non-opioid analgesics alone are insufficient for moderate-to-severe cancer pain 1
• Abrupt opioid discontinuation after 30 mg IV morphine daily creates risk of withdrawal and uncontrolled pain 1

Critical Safety Considerations for This Patient

High-Risk Features Requiring Caution

• Elderly with BMI 17 (cachexia), dementia, and low albumin (2.9 g/dL) increase vulnerability to opioid adverse effects 5
• Dementia patients receive opioids more frequently but have higher safety concerns 5, 6
• Coronary artery disease on beta-blocker may mask tachycardia from respiratory depression 1

Essential Discharge Instructions

• Prescribe prophylactic stimulant laxatives (senna/docusate) immediately - constipation is universal with opioid therapy and does not improve over time 1
• Provide rescue doses for breakthrough pain at 10-20% of total daily dose (approximately 15 mg additional as needed) 1
• Schedule follow-up within 24-48 hours to assess pain control and side effects 1
• Educate the family member on signs of oversedation and respiratory depression given dementia and inability to self-report 5

Dosing Schedule

Morphine 15 mg orally every 4 hours as needed provides:

• Appropriate conversion from IV to oral route 1
• Flexibility for PRN dosing during transition home 1
• Ability to titrate based on pain response 1
• If patient requires more than 3-4 breakthrough doses daily, increase scheduled baseline dose by 25-50% 1

Common Pitfall to Avoid

Do not use fentanyl patches in this acute transition period - despite their convenience, patches lack the flexibility needed for dose adjustment and are contraindicated for unstable pain 1. The 72-hour duration prevents rapid titration if pain worsens or side effects develop 1.