From the Guidelines
For patients on buprenorphine patches requiring oral morphine (Oramorph) titration in palliative care, start with 5-10mg of Oramorph every 4 hours as needed, then increase by 30-50% every 24 hours based on pain control and side effects, as recommended by the European Association for Palliative Care 1. The presence of buprenorphine complicates dosing because it's a partial opioid agonist with high receptor affinity, potentially blocking morphine's effects, as noted in a study on acute pain management for patients receiving maintenance buprenorphine therapy 1. Higher initial morphine doses may be needed compared to opioid-naïve patients. Monitor patients closely for respiratory depression, sedation, and other opioid side effects, especially during the first 24-48 hours of combined therapy. Constipation prevention with laxatives should be initiated concurrently, as morphine's main continuing adverse effect is constipation 1. If pain remains poorly controlled despite increasing Oramorph doses, consider consulting with a specialist palliative care team about alternative approaches, including possibly discontinuing the buprenorphine patch and transitioning to a full opioid agonist regimen. Some key considerations in morphine administration include:
- The optimal route of administration of morphine is by mouth, with two types of formulation required: normal release (for dose titration) and modified release (for maintenance treatment) 1.
- The simplest method of dose titration is with a dose of normal release morphine given every 4 hours and the same dose for breakthrough pain, with the total daily dose of morphine reviewed daily 1.
- If pain returns consistently before the next regular dose is due, the regular dose should be increased, with normal release morphine not needing to be given more often than every 4 hours and modified release morphine more often than 12 or 24 hours 1. A typical progression might be 5mg to 7.5mg to 10mg to 15mg per dose, with the goal of achieving adequate pain control while minimizing side effects, as guided by the principles of palliative care and opioid titration 1.
From the Research
Buprenorphine and Oramorph in Palliative Care
- Buprenorphine is a partial mu-opioid receptor agonist that can be used for pain management and opioid use disorder in palliative care patients 2, 3, 4.
- When managing pain in patients taking buprenorphine, it is essential to consider the unique pharmacology of buprenorphine and its potential interactions with other opioids 4, 5.
Titration of Oramorph
- There is limited information available on the specific increments to up-titrate oramorph in palliative care patients taking buprenorphine patches.
- However, it is known that buprenorphine can pose challenges to the management of pain that necessitates full opioid agonists, such as oramorph 3.
- Microdosing strategies, which involve gradually titrating buprenorphine while continuing full agonist opioids, may be a viable alternative to traditional inductions 5.
Considerations for Palliative Care Clinicians
- Palliative care clinicians should be aware of the available routes of opioid administration and their respective advantages and disadvantages when managing pain in patients with advanced disease 6.
- The choice of opioid and route of administration should be individualized based on patient-specific factors and local guidelines 5.
- Further studies are needed to compare the safety and efficacy of different protocols for managing pain in patients taking buprenorphine 5.