Opioid ceiling in cancer pain

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kstarm

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Palliative consults us on a patient with terminal cancer wondering about other options. Currently getting ~150mg IV dilaudid every 8 hours.

I started wondering how this dose could possibly be helping her. How is ~150mg that much better than say 70mg or 40mg? I searched the SDN forum and didn't see the issue of opioid ceiling in cancer pain specifically addressed. There were some threads that touched on it. I searched pubmed for more clarification and didn't come across anything to help me figure this out. I am sure I just missed it, or didn't have the right search terms.
With an internet search I found a number of articles stating that "pure opioids have no ceiling and dose is only limited by side effects" yet there was never a citation about this.

Is there evidence that ultra high doses of opioids are more efficacious than "standard" dosing plus/versus adjuvants, multi-disciplinary care, interventions, etc.?

Thanks for any help/citations.

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:whoa:

I don't even know where to start...
 
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Palliative consults us on a patient with terminal cancer wondering about other options. Currently getting ~150mg IV dilaudid every 8 hours.

I started wondering how this dose could possibly be helping her. How is ~150mg that much better than say 70mg or 40mg? I searched the SDN forum and didn't see the issue of opioid ceiling in cancer pain specifically addressed. There were some threads that touched on it. I searched pubmed for more clarification and didn't come across anything to help me figure this out. I am sure I just missed it, or didn't have the right search terms.
With an internet search I found a number of articles stating that "pure opioids have no ceiling and dose is only limited by side effects" yet there was never a citation about this.

Is there evidence that ultra high doses of opioids are more efficacious than "standard" dosing plus/versus adjuvants, multi-disciplinary care, interventions, etc.?

Thanks for any help/citations.

I don't have an answer to your question, but as an R3 would like to take a stab at this consult... if I remember correctly, IV dilaudid has a half-life of 2 hours. maybe the pt is getting a lot of peaks and valleys (Q8 H dosing) and thus got titrated up so high on such a short acting medication when they round on the pt in the morning and c/o "pain"

my thought regarding dosages of opioids were that they are all titrated to effect and side effect profile (the patient is stll breathing on 150mg, so can handle it). also, unique metabolic profiles of patients may cause increased/decreased metabolism (cue millenium labs)

I wonder what type of dx she has, and if a intervention may be more appropriate. (GI CA ---> celiac plexus chemolysis) Also, what type of pain is she suffering from? nociceptive, neuropathic, inflammatory, etc which may respond to different mechanism than opioids.

I think multimodal analgesia including transition to longer acting opioids +/- intervention might serve him/her better.

What did you do?
 
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