Multiple morphine orders for pain

I am enjoying my first week of orientation this week at hospice. I have noticed that patients have 4-5 different prn morphine orders. Morphine long acting, short-acting and oramorph I think it's called. morphine 10 mg, 30 mg, 100 mg etc. Which morphine order have you found to be the most effective for pain? Thanks :)

I work on a floor where we often get hospice patients or have patients that are being referred to hospice. We many times have people on multiple pain meds because that's what they require to have any quality of life at all.

Usually they have some base long-acting pain med...it varies from patient to patient because each patient is different. The most common we are seeing are Duragesic patches and Oxycontin.

The shorter acting are supposed to be for more acute pain that may occur. Such as prior to PT, wound care, etc. Some patients require pain meds prior to eating--especially pancreatic cancer pts.

Anyway, I probably haven't been much help at all...it just seems that each patient has to have their own regimen because they are all so different. We recently had a patient on 13mg Dilaudid/hour via PCA because that was what he required to just be able to sit up in the bed/sleep/etc--he was not in the least sedated by that level of medication.

Are you on an inpatient unit? Having that many prn orders sounds confusing. My experience is that morphine is morphine. I can't speak to oramorph because I have never seen that brand here. A long acting should never be prn. There should be a long acting dose that is scheduled and a short acting form prn for breakthrough pain. The short acting order might be a range so there is a little room for titration. If there is consistent need for the breakthough doses (more than 2-3 a day) then its probably time to titrate up the long acting based on how much breakthrough dose is being given in a 24 hour period.

If the patient is taking a tablet or capsule form of breakthough narcotic, there might be a second prn order for a concentrated liquid form on hand just in case they lost their ability to swallow. If you are in an inpatient unit, perhaps what you are seeing are standing orders for morphine in different forms so you can easily switch from one route to another without having to call for all new orders.

Yes I work in an inpatient unit. Thanks for the information. I had gotten mixed up about the long and short acting. The long acting is ordered every 12 hours on a routine basis not prn. :)

this pdf might help

http://www.urmc.rochester.edu/smd/education/gme/pdf/ACGME%20Pain%20Mgt%20Readings%209-17-04.pdf

this pdf might help

http://www.urmc.rochester.edu/smd/education/gme/pdf/ACGME%20Pain%20Mgt%20Readings%209-17-04.pdf

Thanks so much chicago student nurse. That's a fantastic link with lots of great and very useful information.