Slow-release oral morphine: Difference between revisions

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(Created page with "== Dosing == === BC OUD Guidelines === * Increase doses q48h * When transitioning from methadone, the eventual dose will usually be 6- to 8-times higher, but generally sho...")
 
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== Dosing ==
 +
== Background ==
⚫
=== BC OUD Guidelines ===
  
⚫
* Increase doses q48h
  
⚫
* When transitioning from [[methadone]], the eventual dose will usually be 6- to 8-times higher, but generally should start with a 4-times higher dose to be safe
  
⚫
* For other opioids, start with dose of 30 to 60 mg
  
⚫
* Average stable doses are 60 to 1200 mg daily
  
   
  +
* Morphine sulphate sustained release capsules (Kadian)
⚫
==== Missed doses ====
  
  +
** Beads contain both immediate release and slow release morphine
  +
** IR released by stomach acid and SR released in bowels at higher pH
  +
** Capsules themselves may pass in the stool
  +
* Full opioid agonist
  +
* Approved for chronic pain, but used off-label for [[opioid use disorder]]
  +
* Appears likely to be equivalent to [[methadone]], but higher patient satisfaction
  +
* Peak plasma level 8.5 to 10 hours
  +
* Elimination half life 11 13 hours
  +
  +
==Dosing==
  +
  +
* For daily dispensed, often opened and sprinkled on apple sauce or yoghurt, or water
  +
* Capsule sizes include 10, 20, 50, and 100 mg
  +
* Specify on the prescription if it is being used for OUD or chronic pain
  +
  ⚫
===BC OUD Guidelines===
  +
  +
*Eligible in age >19 and switching from methadone or actively using opioids
  ⚫
*When transitioning from [[methadone]], the eventual dose will usually be 8 times higher, but generally should start with a 4-times higher dose to be safe
  ⚫
**Increase by 30 to 60 mg daily q48h
  ⚫
*For other opioids, start with dose of 30 to 60 mg
  +
**Increase doses q48h based on withdrawal symptoms
  ⚫
*Average stable doses are 60 to 1200 mg daily
  +
  ⚫
====Missed Doses====
 
{| class="wikitable"
  
{| class="wikitable"
−
! Number missed !! Action
 +
!Number missed!!Action
 
|-
  
|-
−
| 1 || no change
 +
|1||no change
 
|-
  
|-
−
| 2 || 40% reduction
 +
|2||40% reduction
 
|-
  
|-
−
| 3 || 60% reduction
 +
|3||60% reduction
 
|-
  
|-
  +
|4||80% reduction
−
| 4 || 40 mg or starting dose
  
 
|-
  
|-
−
| 5 || re-initiate
 +
|5||re-initiate
 
|}
  
|}
   
−
=== St. Michael's Protocol ===
 +
===St. Michael's Protocol===
 
{| class="wikitable"
  
{| class="wikitable"
−
! Day !! Slow-release morphine !! Instant-release morphine
 +
!Day!!Slow-release morphine!!Instant-release morphine
 
|-
  
|-
−
| 1 || 200-300 mg || 30-50 mg po q2h while awake + 30-50 mg po q3h prn
 +
|1||200-300 mg||30-50 mg po q2h while awake + 30-50 mg po q3h prn
 
|-
  
|-
−
| 2 || SR dose from Day 1 + 50% of IR dose from Day 3 || 30-50 mg po q2h while awake + 30-50 mg po q3h prn
 +
|2||SR dose from Day 1 + 50% of IR dose from Day 3||30-50 mg po q2h while awake + 30-50 mg po q3h prn
 
|-
  
|-
−
| 3 || SR dose from Day 2 || 30-50 mg po q3h prn
 +
|3||SR dose from Day 2||30-50 mg po q3h prn
 
|-
  
|-
−
| 4 || SR dose from Day 3 + 50% of IR dose from Day 3 || 30-50 mg po q3h prn
 +
|4||SR dose from Day 3 + 50% of IR dose from Day 3||30-50 mg po q3h prn
 
|-
  
|-
−
| 5 || SR dose from Day 4 || 30-50 mg po q3h prn
 +
|5||SR dose from Day 4||30-50 mg po q3h prn
 
|-
  
|-
−
| 6 || SR dose from Day 5 + 50% of IR dose from Day 5 || 30-50 mg po q3h prn
 +
|6||SR dose from Day 5 + 50% of IR dose from Day 5||30-50 mg po q3h prn
 
|}
  
|}
  +
  +
=== Off-Guideline ===
  +
  +
* For induction from methadone or non-methadone opioids with high opioid tolerance
  +
* Start at 200 to 300 mg, then increase by 100 to 150 q48h
  +
* Missed days
  +
** 1: full
  +
** 2: 50% reduction
  +
** 3: 75% reduction or resume at initiation dose
  +
** 4: resume at initiation dose
  +
  +
=== Carries ===
  +
  +
* Per guidelines, doses should be indefinitely witness ingestion
  +
* However, may be reasonable to do same for [[methadone]]
  +
** No carrier x 8 weeks, then one carry per week every month with weekly urine drug screens
  +
  +
=== Switch to Methadone ===
  +
  +
* Must stop SROM and start [[methadone]] titration from 30 mg
  +
  +
=== Switch to M-Eslon ===
  +
  +
* Split SROM dose for BID M-Eslon
  +
* Dosages include 10, 15, 30, 60, 100, and 200 mg
  +
  +
== Safety ==
  +
  +
* Adverse effects include GI cramping, abdominal pain, headache, hyperhidrosis, constipation, frequent urination, nausea/vomiting, and insomnia
  +
* Risk of respiratory depression and other forms of [[opioid toxicity]]
  +
* Safe in pregnancy
  +
** Small RCT suggests no difference from [[methadone]] in neonatal outcomes but possibly lower unprescribed drug use in SROM
  +
  +
=== Contraindications ===
  +
  +
* Hypersensitivity to morphine
  +
* Respiratory
  +
** Significant respiratory depression
  +
** Acute or severe bronchial asthma
  +
** Severe respiratory compromise or obstructive disease
  +
* Gastrointestinal
  +
** Known or suspected paralytic ileus
  +
** Short gut syndrome of transit time abnormalities
  +
* Alcohol use
  +
* MAOI use within 14 days
   
 
[[Category:Medications]]
  
[[Category:Medications]]

Revision as of 21:07, 10 February 2021

Background

  • Morphine sulphate sustained release capsules (Kadian)
    • Beads contain both immediate release and slow release morphine
    • IR released by stomach acid and SR released in bowels at higher pH
    • Capsules themselves may pass in the stool
  • Full opioid agonist
  • Approved for chronic pain, but used off-label for opioid use disorder
  • Appears likely to be equivalent to methadone, but higher patient satisfaction
  • Peak plasma level 8.5 to 10 hours
  • Elimination half life 11 13 hours

Dosing

  • For daily dispensed, often opened and sprinkled on apple sauce or yoghurt, or water
  • Capsule sizes include 10, 20, 50, and 100 mg
  • Specify on the prescription if it is being used for OUD or chronic pain

BC OUD Guidelines

  • Eligible in age >19 and switching from methadone or actively using opioids
  • When transitioning from methadone, the eventual dose will usually be 8 times higher, but generally should start with a 4-times higher dose to be safe
    • Increase by 30 to 60 mg daily q48h
  • For other opioids, start with dose of 30 to 60 mg
    • Increase doses q48h based on withdrawal symptoms
  • Average stable doses are 60 to 1200 mg daily

Missed Doses

Number missed Action
1 no change
2 40% reduction
3 60% reduction
4 80% reduction
5 re-initiate

St. Michael's Protocol

Day Slow-release morphine Instant-release morphine
1 200-300 mg 30-50 mg po q2h while awake + 30-50 mg po q3h prn
2 SR dose from Day 1 + 50% of IR dose from Day 3 30-50 mg po q2h while awake + 30-50 mg po q3h prn
3 SR dose from Day 2 30-50 mg po q3h prn
4 SR dose from Day 3 + 50% of IR dose from Day 3 30-50 mg po q3h prn
5 SR dose from Day 4 30-50 mg po q3h prn
6 SR dose from Day 5 + 50% of IR dose from Day 5 30-50 mg po q3h prn

Off-Guideline

  • For induction from methadone or non-methadone opioids with high opioid tolerance
  • Start at 200 to 300 mg, then increase by 100 to 150 q48h
  • Missed days
    • 1: full
    • 2: 50% reduction
    • 3: 75% reduction or resume at initiation dose
    • 4: resume at initiation dose

Carries

  • Per guidelines, doses should be indefinitely witness ingestion
  • However, may be reasonable to do same for methadone
    • No carrier x 8 weeks, then one carry per week every month with weekly urine drug screens

Switch to Methadone

  • Must stop SROM and start methadone titration from 30 mg

Switch to M-Eslon

  • Split SROM dose for BID M-Eslon
  • Dosages include 10, 15, 30, 60, 100, and 200 mg

Safety

  • Adverse effects include GI cramping, abdominal pain, headache, hyperhidrosis, constipation, frequent urination, nausea/vomiting, and insomnia
  • Risk of respiratory depression and other forms of opioid toxicity
  • Safe in pregnancy
    • Small RCT suggests no difference from methadone in neonatal outcomes but possibly lower unprescribed drug use in SROM

Contraindications

  • Hypersensitivity to morphine
  • Respiratory
    • Significant respiratory depression
    • Acute or severe bronchial asthma
    • Severe respiratory compromise or obstructive disease
  • Gastrointestinal
    • Known or suspected paralytic ileus
    • Short gut syndrome of transit time abnormalities
  • Alcohol use
  • MAOI use within 14 days
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