what do you think of this pain med schedule?

[Ms.RN]

i work in ltc and we dont give pain meds every 2 hours like hospitals do. we usually see pain meds scheduled tid or qid and prn. yesterday i had a patient and this patient and he was scheduled with two different doses of morphine surfate plus dilaudid. his schedule is like ms 70mg tid, oramorph 80mg tid then dilaudid 7mg q4 hrs. all at different times. does this make sense to you or should i question this and clarify with doctor?

[shiccy]

I say Kudos to you questioning that order. A patient should NOT be on three different high dose narcotics like that, unless the patient is terminal and expected to die very soon.

For MSContin - Tablets 15 mg 30 mg 60 mg 100 mg* 200 mg* *100 mg and 200 mg are for use in opioid-tolerant patients only* MSContin is, obviously, sustained release morphine

Oramorph - (Morphine sulfate) 15 mg, 30 mg, 60 mg, or 100 mg in a tablet that provides for sustained release of the medication.

Dilaudid - Give 2 to 4 mg orally every 4 to 6 hours as needed. (More may be required w/ pain)

For the record, this patients doses of narcotics are ridiculously high, and while I'm not saying that they've NOT had these narcs in this fashion, good job on using your head.

FWIW I've never EVER seen more than MSContin >80mg BID or TID alone (and then PRN dilaudid for acute breakthrough from surgery), but NEVER EVER higher on a patient that wasn't actively dying. That being said, double checking is a great thing, after that everything should be gravy!

[morte, LPN, LVN]

I say Kudos to you questioning that order. A patient should NOT be on three different high dose narcotics like that, unless the patient is terminal and expected to die very soon.

For MSContin - Tablets 15 mg 30 mg 60 mg 100 mg* 200 mg* *100 mg and 200 mg are for use in opioid-tolerant patients only* MSContin is, obviously, sustained release morphine

Oramorph - (Morphine sulfate) 15 mg, 30 mg, 60 mg, or 100 mg in a tablet that provides for sustained release of the medication.

Dilaudid - Give 2 to 4 mg orally every 4 to 6 hours as needed. (More may be required w/ pain)

For the record, this patients doses of narcotics are ridiculously high, and while I'm not saying that they've NOT had these narcs in this fashion, good job on using your head.

FWIW I've never EVER seen more than MSContin >80mg BID or TID alone (and then PRN dilaudid for acute breakthrough from surgery), but NEVER EVER higher on a patient that wasn't actively dying. That being said, double checking is a great thing, after that everything should be gravy!

the MS mentioned in the OP is short acting, I think. I have seen Oxycontin 360 mg 6am and 10pm and 270 at 2pm.......patient had terminal Ca, but was not actively dying at the time, and was drowsy but rousable. the dose equivalency is 2:3 oxy to ms.

[shiccy]

the MS mentioned in the OP is short acting, I think. I have seen Oxycontin 360 mg 6am and 10pm and 270 at 2pm.......patient had terminal Ca, but was not actively dying at the time, and was drowsy but rousable. the dose equivalency is 2:3 oxy to ms.

That is saying what tablets they come in (dosages). Also the doses are for the sustained release as mentioned in my original message.

Regardless, however, doses that high should be double checked if it's a new admit unless they're A&Ox3 and tell you that's their dose (and are of the reliable type), or the prescriber is at hand. Most times I have to call for admit orders anyways, so I'll tell them, "These are the doses, I'm questioning the doses b/c the patient is confused"

[ZippyGBR, BSN, RN]

assuming that the patient is actually requiring this amount of analgesia - i.e. they are not over sedated etc etc ...

the patient could do with a proper pain management review and a rationalisation of their meds , if the immediate release morphine is a regular fixture, perhaps the m/r dose needs to be upped to include that and a new PRN breakthrough dose of immediate release calculated and prescribed ...

the multiple agents approach may have a good reason or equally may be something else that could be rationalised with a proper analgesia review ...

does the patient have optimal other meds pain management - i.e. 4g / day paracetamol and an NSAID if indicated ...

there is also the consideration to be made of alternative agents and routes e.g. transdermal fentanyl 'patch' and the revised breakthrough dose as either immediate release morphine or intra nasal fentanyl...

[Up2nogood RN, RN]

It's good to clarify and even look back to his hospital mar to see what schedule they were giving these meds. There's a good chance he was on the same meds. I would make sure the drugs are equally spread out over the 24 hr period the ms contin 08, 1600, 0000 , the oramorph 1200, 2000, 0400, and dilaudid in between for breakthrough. These doses aren't ridiculously high for a pt that has chronic pain and i've seen it frequently managed and followed by a pain management MD or NP. Chances are these doses won't keep the pain under control for too long and something will need to be increased.

[Altra, BSN, RN]

Without knowing anything about the patient ... I see nothing inherently wrong with this regimen. There is an array of meds out there and many ways to schedule them to achieve continuous pain control.

From your second post, it appears that you did speak with the prescriber for clarification -- was the rationale explained to you? Did you get the answers you were seeking?

[CoffeeRTC, BSN, RN]

You can always call the pharmacist too to ask questions.

As far as running out...it is the nurses job to look at the meds and look at how much the pt it taking and pull the re order tag and get it to pharmacy. We've had residents that use the meds up like crazy and were amost ordering every day or every other day. Anticipate the resident's needs.

[TDCHIM]

From a patient perspective, I would hope this individual could be switched onto something a little less oral-med-intensive. As others have mentioned, a pain management review might not be a bad idea; perhaps he could be switched onto a fentanyl patch to replace some of the current meds.

However, those patches definitely aren't for everyone. The adhesive can be very difficult on the skin for some people, even if you switch sites as indicated by the manufacturer. For others, excessive sweating due to a health condition or as a side effect of other medications can end up loosening the patch from the skin in far less than the normal three days. It may well be that the patient has tried other, more obvious regimens and this is the one that works.

[morte, LPN, LVN]

You can always call the pharmacist too to ask questions.

As far as running out...it is the nurses job to look at the meds and look at how much the pt it taking and pull the re order tag and get it to pharmacy. We've had residents that use the meds up like crazy and were amost ordering every day or every other day. Anticipate the resident's needs.

True, and now that you need to have the doc provide a hard script you have to plan in advance.....

[Ms.RN]

i didnt post exactly the same dosage patient is taking because i was afraid my boss is going to read this. but patient does have a cancer and he is taking total of 150mg of morphine everyday, in which is really not a high dosage. what i didnt understand was why patient is taking two different sustained release in same day. i asked pharmacist and she said both morphine sulfate 60mg and oramorph are the sustained release. i've seen patient taking like oxycontin bid and oxycodone which is a short acting in between but not oxycontin around the clock. this all happened when patient did not have any morphine in the narcotic box and i called pharmacy to reorder thinking ms is a short acting and oramorph is a long acting but found out both are long acting. so i called doctor and he in a voice of accusations why he ran out of medicine and the fact that i called him at 8pm on saturday ha ha... so doc reduced his dosage, i left not to don why he ran out medicine and now i'm worried my boss is going to be ****** off that i messed up his pain medicine.

[CoffeeRTC, BSN, RN]

Now I'm confused...are you talking about MS Contin? That is long acting and so is the oramorph. Morphine isn't that long acting? Reguardless...you can call the pharmacist and ask what is the dose conversion for alot of drugs when you want to get a longer acting med and reduce the amout of PRNs.

[tewdles, RN]

I say Kudos to you questioning that order. A patient should NOT be on three different high dose narcotics like that, unless the patient is terminal and expected to die very soon.

For MSContin - Tablets 15 mg 30 mg 60 mg 100 mg* 200 mg* *100 mg and 200 mg are for use in opioid-tolerant patients only* MSContin is, obviously, sustained release morphine

Oramorph - (Morphine sulfate) 15 mg, 30 mg, 60 mg, or 100 mg in a tablet that provides for sustained release of the medication.

Dilaudid - Give 2 to 4 mg orally every 4 to 6 hours as needed. (More may be required w/ pain)

For the record, this patients doses of narcotics are ridiculously high, and while I'm not saying that they've NOT had these narcs in this fashion, good job on using your head.

FWIW I've never EVER seen more than MSContin >80mg BID or TID alone (and then PRN dilaudid for acute breakthrough from surgery), but NEVER EVER higher on a patient that wasn't actively dying. That being said, double checking is a great thing, after that everything should be gravy!

Just for baseline...these are not ridiculously high doses of opiates...and people who have significant chronic pain can tolerate higher doses of MSContin than 80mg TID (with break through and adjuvant agents in place) while remaining "walkie-talkies". I find that actively living people have great need for adequate pain control ...