That extra pain medicine didn’t help!
What to do when your patient is getting opioids, but is still in pain
Teaching Guide – Case Study
Discussion leader: make copies of the cases below. Separate your group into teams of two. Give them 5-10 minutes to
review each case, and then bring the group together to discuss possible approaches to the case.
Case 1
You make a follow-up visit for a colleague’s patient who has cancer pain that is “difficult to control.” The primary nurse
has documented that the patient describes her pain as aching and throbbing in her left shoulder. She last rated it at 8/10,
at which point she had been taking 90mg sustained release morphine bid with 10-20mg short acting morphine q4h prn
for breakthrough pain. The patient had been taking four 20mg breakthrough doses per day, which would decrease her
pain score to a 6 or 7 for an hour or so.
On the previous visit, your colleague had obtained an order to increase the sustained release morphine dose to 120mg q
12h. The patients now rates her usual pain at 7/10, and she still gets “a little relief, maybe a point or two” from her
breakthrough pain dose, which she continues to take 4 times per day. The patient says “I know this morphine is
supposed to be strong, but it just doesn’t seem to work for me.”
1. Why was the previous increase in dose ineffective for this patient?
2. What are your recommendations for this patient’s care? How would you present them to her physician?
Case 2
Your patient had a knee replacement last week, and is taking
2 hydrocodone 5mg/acetaminophen 500mg tablets every 6 hours for pain control. The patient tells you that he
sometimes takes a 5th dose during the course of the day, “because it hurts so bad.” He has aching, deep pain which at
worst is 7/10, but decreases to 5/10 for approximately 3 to 4 hours after each dose of his pain medicine.
1. What concerns do you have about his acetaminophen intake?
2. Identify two possible approaches to improving his pain control.
Discussion guide
Case 1 discussion points
Use this case to review the principles of titration and calculating doses for breakthrough pain.
1. The patient was taking a total of 260mg of morphine in 24 hr:
Sustained release morphine 90mg bid
=
180 mg morphine/24h
20mg short acting morphine 4x/24h
=
80 mg morphine/24h
Total
260mg morphine/24h
A patient with moderate (5-6/10) to severe (7-10/10) pain should have a dose increase of 50-100%. Since the 24-hr
intake was 260mg, the new 24-hr dose should have been between 390 and 520 mg. Sustained release morphine can be
given q12h, so divide the 24h dose into two equal doses (i.e. 195-260mg q12h).
Also, each dose of the short acting opioid for breakthrough pain should be 10-20% of the 24-hour dose, given q2h prn. If
the dose of sustained release morphine is 200mg q12h, the breakthrough pain dose should be 10-20% of 400mg, or 4080 mg morphine q2h prn.
2. Follow the principles above. This patient is now taking 320mg morphine per day (240 from her scheduled and 80
from her breakthrough doses). Since the patient’s least pain is of moderate intensity, increase the opioid dose by at least
50%, which would yield a new 24h dose of 480mg. Give this as 240mg sustained release morphine q12h, with 50100mg short acting morphine q2h prn for breakthrough pain. Adjust the dose of sustained release morphine slightly if
needed to fit the dosage form available at the patient’s pharmacy.
Consult with the patient’s pharmacist about dosage availability before contacting the physician. Present a complete
assessment and specific recommendations to the physician. Keep written guidelines on hand that justify your
recommendations – it may be helpful to share these with the physician and/or pharmacist.
Case 2 discussion points
1.
2.
This patient is already taking the maximum recommended acetaminophen dose of 4000mg per day. Any additional
doses expose him unnecessarily to liver toxicity.
A patient with pain of moderate intensity at best needs an opioid dose increase of at least 50%. He is taking 10mg
hydrocodone q6h, so he needs an increase to 15mg q4h. Hydrocodone only lasts 4 hours, so a 6-hour dosing
regimen is not appropriate. Some hydrocodone preparations contain 7.5 or 10 mg per tablet with as little as 325 mg
of acetaminophen. Call the patient’s pharmacist to see what the pharmacy stocks.
Alternatively, switch the patient to another opioid that does not contain acetaminophen. Milligram per milligram,
oxycodone and morphine provide approximately as much analgesia as hydrocodone. This patient’s pain could be
managed with 15mg of either drug q4h. When using oxycodone in this situation, be sure it is NOT in combination
with acetaminophen or aspirin.
Dahl J, Stevenson K, Gordon D,  UW Board of Regents, 2000