PO morphine tablets for SOA?

nutella, MSN, RN · Aug 31, 2016

I've worked as a hospice case manager for 1 year now and still have lots of questions. I have a COPD patient that can't tolerate Lorazepam but gets relief with Roxanol 0.5ml 4-5 x daily. Lately she is waking up SOA and having to take extra doses in the A.M. I'm curious if anyone has seen MS Contin used for SOA. Wondering if 1 at HS may help her get trough until morning?? I asked another more experienced nurse and her concern was the patient may not be able to swallow pills at end of life, but the Roxanol could still be PRN.

I just wanted to point out that morphine is the standard medication for symptom relief SOB in COPD and will provide better and more effective relief as opposed to lorazepam. In any way - it depends how far the patient is. If you think the patient has still some time left and is able to swallow switching from roxanol to long acting MS contin may provide overall better control of symptoms with some roxanol for breakthrough symptoms. Personally, I think the best way to go is to get the patient on roxanol first and once they need it every 4 hours or more often the total amount can be calculated and switched to long acting. You need to consider that the lowest amount is 15 mg of MS Contin. So if your patient takes the equivalent of around 30 mg of morphine / 24 hours it may work to switch to 15 mg MS contin BID with breakthrough dosing.

If a patient has been on roxanol for a while and equals at least 60 mg of morphine/24 hours some hospice MD will also consider a low dose fentanyl patch.

The advantage of long acting medication is that the patients may get overall a better control of symptoms and that can be beneficial if the patient has some more time left. Once the patient becomes unable to swallow pills whole it can be switched back to roxanol.

Also, when you write about doses it is better to write about mg as the ml amount does not tell much - roxanol comes in a variety of concentrations....

This book is my favorite and has served me well :

HPNA

Plus you should discuss your patient's need with the hospice MD and/or in IDT as switching from roxanol which is usually covered under standing orders to long acting formulas to long-acting medication requires a MD order.

sclpn · Sep 2, 2016

I agree with everything nutella said except be careful using fentanyl patches as they don't absorb well if there isn't enough subcutaneous fat...our MD will not use them on any patient that weighs 100 lbs or less and shows signs of muscle wasting.

elimayrn · Sep 2, 2016

Thanks for your reply! I've spoken with my patient and she is willing to try this, I will be calling her doctor today. Thanks for the link I have been looking at this and will be ordering it.

MSNMPHPhdNMD · Sep 3, 2016

I know there is liquid hydrocodone which may be helpful. I had a chf patient who had dysphagia and we gave her liquid which helped a great deal.

MSNMPHPhdNMD · Sep 3, 2016

Also I agree With everything nutellarn said

nutella, MSN, RN · Sep 3, 2016

I know there is liquid hydrocodone which may be helpful. I had a chf patient who had dysphagia and we gave her liquid which helped a great deal.

sorry for chiming in here - if your patient has dysphagia and needs narcotics for pain management or SOB you are better off with liquid morphine ("Roxanol" brand name) in a concentration 20 mg / ml as this mean usually very small amounts that can be given sublingual! Let's say your patient needs the standard starting dose of 5 mg it would only be 0.25 ml (you would use a 1 ml syringe to draw it out of hte bottle that has a special cap on it), which you can give sl - it does not need to be swallowed and gets absorbed easily - starts to work within 20 minutes (usually).

Liquid morphine is cheap and if not allergic a good narcotic.

Most facilities carry 20mg/ml - if you work in the community you need to call pharmacies because not all of them have it available and may need to order it - which is bad for patients who really need it but have to wait 3 days, which can result in re-admission. If the patient is on hospice , the hospice take care of it of course.

MSNMPHPhdNMD · Sep 3, 2016

I agree usually this comes in the comfort pak

elimayrn · Sep 3, 2016

She has no dysphagia, a&o x 3. She's currently taking Roxanol 10mg 3 to 4 times daily and 15mg at hs. I discussed the ms contin with her but daughter said they tried them before and she was loopy so they cut the dose in half and still loopy. That's what I don't understand I've had other patients I've tried to switch to extended relief morphine and they don't tolerate it but can tolerate roxanol all day. Also she doesn't tolerate Lorazepam for her severe SOA.

nutella, MSN, RN · Sep 4, 2016

She has no dysphagia, a&o x 3. She's currently taking Roxanol 10mg 3 to 4 times daily and 15mg at hs. I discussed the ms contin with her but daughter said they tried them before and she was loopy so they cut the dose in half and still loopy. That's what I don't understand I've had other patients I've tried to switch to extended relief morphine and they don't tolerate it but can tolerate roxanol all day. Also she doesn't tolerate Lorazepam for her severe SOA.

I would discuss that with the MD and the team in IDT. If the patient wants and needs a long acting narcotic other than MS contin there is also oxycontin - but that is much more expensive.

Most of my patients tolerated switching to MS contin without much problems. Initial side effects that can be bothersome are tiredness, sometimes nausea for some days and of course constipation. If a patient gets confused and/or is hallucinating it has been my experience that this does not get better and the pat needs to switch to a different medication.

pfeliks · Sep 5, 2016

I give up. What does SOA stand for?

elimayrn · Sep 5, 2016

Shortness of air. Many at least in my area have gotten away from SOB.