Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Appropriate Morphine Dosing for Opioid Tolerant Patients

What do we do, when treating a patient already taking opioids? When the patient is already taking a large dose of an opioid and has a valid prescription for the doses of opioid being taken?

Remember that there is no maximum dose for morphine. There is no maximum dose for any opioid – as long as there are no adverse effects, such as depressed respirations, altered mental status, hypotension, or bradycardia.

What do we do when this patient has something like a femur fracture that produces severe pain?

This patient is opioid tolerant, so the standard doses of opioid are unlikely to produce a satisfactory effect. By standard doses, I mean doses that would be appropriate for a patient who is not currently taking opioids. That would be a starting dose of 0.05 mg/kg morphine to 0.1 mg/kg morphine – repeated as necessary until the pain is managed to the patient’s satisfaction or until side effects interfere with treatment.

The patient will probably receive more relief by releasing some flatulence than he will from 2 mg morphine. The flatulence may even provide more benefit than 10 mg morphine for an opioid tolerant patient.

Standard doses are not going to work, so do we just ignore this patient’s pain?

Do we tell this patient that our medical director does not trust us to give larger doses of morphine/fentanyl/hydromorphone than standard, because the medical director either has not really considered this possibility or doesn’t think that patients, who are legally prescribed high doses of opioids, deserve to have their severe pain treated effectively. Or maybe the medical director is just so irrationally afraid of opioid medications that he is not interested in understanding opioid tolerance.

It isn’t necessarily the medical director who is the obstacle to treatment. I know of plenty of medics who would not even start treatment of this patient’s pain. Maybe out of fear of causing respiratory depression. Maybe out of fear of causing addiction, in which case they really need to work on their response time, because it is a bit late to be considering addiction or tolerance.

What do you think are the chances of causing dangerous respiratory depression for this patient:

With 10 mg morphine?

Low Medium High

With 20 mg morphine?

Low Medium High

With 30 mg morphine?

Low Medium High

With 40 mg morphine?

Low Medium High

With 50 mg morphine?

Low Medium High

With 60 mg morphine?

Low Medium High

With 70 mg morphine?

Low Medium High

With 80 mg morphine?

Low Medium High

With 90 mg morphine?

Low Medium High

With 100 mg morphine?

Low Medium High

Why?

What would be considered dangerous respiratory depression for this patient?

Why?

.

Comments

  1. We only carry 40mg, with 10 mg being the max we can give a single person without requesting more. Opioid tolerant? I’d see what they are normally prescribed and start higher than that. We can manage respiratory depression.

    • Russell,

      We only carry 40mg,

      That doesn’t mean that you can’t call for other medics to meet you on scene. For example, a supervisor may be able to carry more and may be better known to medical command physicians (making it easier to get orders for doses that make medical command physicians, who do not seem to have much experience treating pain, uncomfortable.

      There is no good reason for a maximum dose other than running out of the opioid.

      with 10 mg being the max we can give a single person without requesting more.

      That is unfortunate, but common. I like to ask for orders to continue giving whatever I am giving as long as level of consciousness, blood pressure, heart rate, and respirations remain adequate. Once the medical command physicians understands that I understand the side effects, and I mention them before the doctor can, they seem to be much more comfortable with aggressive dosing. There are several physicians who will tell me to do whatever I feel is appropriate and just call them back with the result. Unfortunately, there are nowhere near enough of these.

      Opioid tolerant? I’d see what they are normally prescribed and start higher than that. We can manage respiratory depression.

      What if the patient is taking 120 mg of morphine PO (Per Os – Latin for by mouth)?

      How are you going to start higher than that? ;-)

      I am not considering a patient who has been cut off from her daily medication, but someone who is having severe acute pain. While I might end up with a total dose of more than her daily dose, IV morphine is different from PO morphine.

      The conversion from PO morphine to IV morphine is to cut it by at least a third. A 3:1 PO:IV ratio is what I tend to see, but I am not familiar with doing these conversions. This is meant just as a rule of thumb.

      I am less interested in what the patient takes on a regular basis, than I am in their response to each dose of whatever I give. By switching to a different opioid, I may avoid some of the tolerance. For example, if the patient is taking morphine, switch to fentanyl or Dilaudid (hydromorphone); if on Duragesic (fentanyl) switch to morphine or Dilaudid. I don’t know how much difference this may make, but in dealing with limited supplies of opioids, we might as well stretch what we have as much as possible.

      If the PO morphine is about the same as what you carry for IV administration, you can easily end up needing more, but I wouldn’t start at the daily dose. The best guide to dosage is what the patient tells us is enough.

  2. I agree, we should give what is enough to control the pain. I like the idea of rotation of drugs when faced with a different one. Still being limited by quantity, it may ease it a little. Anecdotally, my first sickle cell case was extreme and when she said the morphine didn’t do anything for her, 10 mg worked well at least to the point of reducing her perceived anxiety.

    • Russell,

      Anecdotally, my first sickle cell case was extreme and when she said the morphine didn’t do anything for her, 10 mg worked well at least to the point of reducing her perceived anxiety.

      I give 20 mg morphine/200 mcg fentanyl, or more, a couple of times a year. It is not easy to predict who will require a lot. Dislocations, amputations, long bone fractures, burns are some of the painful ones, but they are not the only ones.

  3. Several thoughts here…
    We only have 20mg of Morphine, but 400mcg of Fentanyl. I would administer the Fentanyl to the extent that their pain was controlled, requesting orders if needed, and asking for more from the Supervisor.
    As mentioned above – we can address respiratory depression.
    I would also strongly consider (as in ‘do it’) a co-administration of Versed. That should increase the effect of the fentanyl, but also create some sedation which can only add to the overall ease of the patient (and the medic).
    Oh, monitor EtCO2 as well…

    • RevMedic,

      Several thoughts here…
      We only have 20mg of Morphine, but 400mcg of Fentanyl. I would administer the Fentanyl to the extent that their pain was controlled, requesting orders if needed, and asking for more from the Supervisor.

      Excellent way to approach things. I prefer using fentanyl, since it will be wearing off at about when we drop the patient off, so there is less of the I’m no longer bouncing along in a truck, on a hard board, on potholed streets, with lots of turns - now I’m in a much more comfortable bed (by comparison), with much less painful stimulus and much less observationI think respiratory depression is a good idea r i g h t . . . a b o u t . . . n o w . . .

      No insult to nurses, but the medic is sitting right next to the patient for the whole ride, anybody who can’t recognize respiratory depression in that situation should not be a medic. The nurse has several patients in different parts of the ED.

      As mentioned above – we can address respiratory depression.

      I think that – except for procedural sedation – the use of naloxone for therapeutic doses of opioids should be considered a sentinel event. Generally, the person giving the naloxone does not know what he is doing. All that should be needed is to talk with the patient. In the ED, with the limited resources, giving some tiny dose of naloxone to perk the patient up, can be acceptable. 20 to 40 MICROgrams is often plenty.

      I would also strongly consider (as in ‘do it’) a co-administration of Versed. That should increase the effect of the fentanyl, but also create some sedation which can only add to the overall ease of the patient (and the medic).

      Versed (midazolam) is a great drug. It wears off even more quickly than fentanyl, so residual respiratory depression in the ED should not be a problem.

      Oh, monitor EtCO2 as well…

      Absolutely. For the cost of an ALS transport the roughly $7 cannula/EtCO2 device is cheap insurance and maybe the best aid to learning for any new medic.

  4. So, here’s my concern. Those of us out there that care and are trying for patients will always do our best to find a way to lessen the patient’s pain to the best of our ability. That being said, what about when the doctor says no. What about if you carry 20mg of morphine and 200mcg of fentanyl and the only way to give both is to call medical control. I see no problem with calling medical control for that, but, and there’s always a but, what if about oh 90% or greater of your docs either won’t let you mix the two for some reason that we can’t hope to understand(as we’re just stupid medics) or just think that medics shouldn’t ever have to give both because the pain can’t be that bad. But then as soon as they get to the ER, they start pounding the dilaudid until the pain is gone. Why not educate the medics, I mean we have the tools, if we’re not educated enough we shouldn’t have them until we’re educated enough, can I get an amen?

  5. I have to agree with the cocktail of Versed and Morphine; primarily because they are the only narcotics we have on the rig but in large part because our medical director gives us a large degree of latitude for administration.

    Our standing order for a 100K patient is 15mg Morphine for pain and 10mg Versed for associated anxiety/sedation. Typically I will alternate 5mg Morphine then 2mg Versed and often, because of short urban transports and time requirements between doses, I end up with a total dose of 10/4 respectively.

    My administration method, for what it’s worth, seems to mitigate the nausea effects. I change the drip set to 60 and set it to approximately 1 drop every 2 seconds. Injecting in the higher hub I get a one half ml infusion rate of one minute. I had some fun playing around with food coloring in the tube on a slow day. So basically I set up a slow drip that alternates Morphine/Versed during transport. Titrate to effect or significant change in BP or RR; keeping one eye on the capnography wave form and the other on the BP.

    The one thing that would be beneficial to patient care would be an initial weight based loading dose chart for the Morphine as opposed to the 2-5mg increments. For patients taking significant opiates I would make base contact. Fortunately they did away with the largely ineffective MICN process and all of our base contacts go through the attending MD at the county hospital which is trauma/teaching. I’ve had positive experiences with base contacts though rarely have I had to call for pain management issues as our standing orders are fairly liberal.

  6. So…what do you do when the service you work for only carrys 10mg of Morphine AND NOTHING ELSE AS A BACK UP!!!

    • Unfortunately, there are a lot of medical directors who do not understand pain management. Ridicule is one way of influencing them, but you might be better off going to another service and helping to recruit the good medics away from the dangerous medical director.

      Too many doctors think that because they are doctors, they know everything. This is a lie.

      Some medical directors are willing to learn, but others are only interested in what they hear from other doctors. Another way of educating a medical director can be to point out to other doctors that your medical director does not understand pain management and ask for advice on the ways to influence that medical director to permit appropriate care to patients.

      It may be that the agency is the problem and the medical director would authorize more morphine. Talking with the person handling quality control might help to determine why you carry so little.

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