Administration advice :
-This drug should be prescribed only by healthcare professionals knowledgeable in the use of potent opioids for the management of chronic pain.
-Patients should not consume alcoholic beverages while on morphine.
-When this drug is administered intravenously, an opiate antagonist and facilities for administration of oxygen and control of respiration should be available.
-This drug has been reported to be physically or chemically incompatible with various drug products. Specialized references should be consulted for specific compatibility information.
-Dose should be titrated based upon individual response to the initial dose.
-Extended-release capsules should be taken whole, not crushed, chewed, or dissolved; for patients who have difficulty swallowing, Kadian(R) and Avinza(R) may be opened and the contents of the capsule sprinkled on applesauce, immediately swallow without chewing.
-Patients considered opioid tolerant are those taking, for 1 week or longer, at least 60 mg of morphine daily, at least 30 mg of oral oxycodone daily, at least 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid.
-The extended-release formulations should not be used for breakthrough pain or on an as needed basis.
-Use only the preservative free injectable formulations for preparations given via the epidural and intrathecal routes, and in neonates.
-Immediate-release tablets: The 10 and 20 mg tablets are not recommended for children under 3 years. The 50 mg tablets are not recommended for children.
Patient advice :
-Side effects associated with opioids, apart from constipation, generally reduce with time. Anticipation and management of these effects may improve tolerability. Patients taking this drug may require an antiemetic during early therapy.
In fact, more recent data demonstrates that these conversion ratios may be too simplistic and can vary based on many factors such as chronicity of opioid use, total daily dose, ethnicity, age, and can even differ depending on the direction of conversion (. conversion from morphine to hydromorphone ¹ hydromorphone to morphine). Increasing research in the area of pharmacogenetics examines how genetic polymorphisms of liver metabolic enzymes can explain some of these highly variable effects seen from patient to patient. An expert panel (Fine et al.) suggested the need to revise these tables with different conversion values that take into account this complexity. In addition updated approaches on opioid switching have been discussed in several resources. Of particular note are substantial changes to calculations when converting to PO methadone, which is more potent than originally thought. Due to potential for serious adverse patient outcomes equianalgesic dose calculations are now adjusted based on the total daily dose of morphine equivalents with higher daily doses requiring increasingly less methadone.
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