Palliative Care Analgesia and Dyspnea Protocol

The information provided on the Web site is for Health Care Practitioners and is for informational purposes only. It is not professional medical advice, diagnosis, treatment or care, nor is it intended to be a substitute therefor.

If you are a Health Care Professional this information is shared with you on the express condition that you will use your own expertise and professional judgment in applying any information to a specific case. This is general information only the validity of which may be affected by individual patient factors that are unknown to the author(s).

It is the responsibility of those using this information to ensure appropriate interpretation and application is undertaken with regards to any specific clinical situation.

The following protocol for the use of opioids in pain control and dyspnea has been in use in Winnipeg since 1997, and is a modification of an analgesic protocol used for many years previously at the St. Boniface General Hospital. It is the responsibility of those using the information provided here to ensure that appropriate interpretation and application of the material is undertaken with regards to the specific clinical situation at hand.

If questions please contact:

Mike Harlos MD, CCFP, FCFP
Professor, Faculty of Medicine, University of Manitoba
Medical Director, Palliative Care Sub Program, Winnipeg Regional Health Authority
Medical Director, St. Boniface Hospital Palliative Care
Rm.A8024, 409 Taché Ave,
Winnipeg, Manitoba, Canada R2H 2A6
Ph:1-204-235-3929; Fax:1-204-237-9162; Pager:1-204-932-6231
Email:mike@harlos.net

OPIOID	ROUTE	DOSAGE STEPS (# mg every 4 hours)
Morphine	po/pr/SL	5	10	15	20	30	40	60	80	100	130	160	200	240	280
SQ	2.5	5	7.5	10	15	20	30	40	50	65	80	100	120	140
Hydromorphone	po/pr/SL	1	2	3	4	6	8	12	16	20	26	32	40	48	56
SQ	0.5	1	1.5	2	3	4	6	8	10	13	16	20	24	28

DETAILS:

A registered nurse who has approval to use the protocol may, without contacting a physician:

administer a breakthrough medication dose consisting of 50-100% of the q4h dose, up to q1h prn. If more than 3 doses of aggressive breakthrough medications are needed (eg. q1h dosing), the physician should be contacted to review options.
Comment: This dose not mean that breakthroughs must be given prior to moving to the next step of the Protocol (see next point below). It is to emphasize that if a circumstance has developed requiring aggressive breakthrough administration, that the patient should be reviewed.
progress to the next level of the protocol up to once per 24 hours, even without having given prior breakthrough doses.
Comment: In general, it takes 3-5 half-lives to reach a steady state of a drug given on a regular dosing interval. (Most commonly, the dose interval is equal to the half-life). It would not make pharmacologic sense to keep increasing the regular q4h dose before the previous dose adjustment has reached steady state.
The Protocol allows for generous administration of breakthrough opioids to address discomfort while awaiting the effect of a recent increase of the regular opioid dosing.
change the route of administration as per the protocol table above.

Consider decreasing the opioid dose by one increment using the Opioid Dosage Chart if the pain control is adequate and:

The patient is drowsy and/or
The respiratory rate persists between 8-10 per minute. If the respirations are below 8 per minute, the opioid is held and the physician called.

A physician must be contacted when any of the following present:

Patient's respirations are less that 8 per minute;
Patient's respirations persist between 8-10 per minute in spite of decreasing the opioid dose on the Analgesia and Dyspnea Protocol;
There are persisting jerking movements, raising the possibility of opioid-induced myoclonus and neurotoxicity;
The patient is both drowsy and in discomfort;
The patient requires 3 or more of aggressive breakthrough medication, i.e. every 1 hour dosing;
The patient develops mental disturbances;
Dosage has reached the maximum dose on the Opioid Dosage Chart;
In order to change opioid;
Any time there is concern about administration of the protocol opioid.