Liquid Concentrated Opioid CRT

Morphine & Oxycodone

The following guidelines have been established for nurses to use in determining appropriateness in recommending liquid concentrated opioids for patient use. Follow these guidelines to provide safe and effective care.

Complete a thorough pain assessment. Documentation should reflect the indications for use in that particular patient prior to initiation of opioid therapy.

Criteria For Use

Be sure your patient meets all of the following criteria before recommending an opioid. If a primary physician has ordered liquid concentrated opioids and the patient does not meet the criteria listed, a thorough assessment should be conducted to ensure patient safety. Any concerns should then be discussed with staff pain resource people prior to contacting the prescribing physician.

  • Documented opioid responsive pain or dyspnea
  • Unable to swallow tablets or
  • Number of tablets required to control pain exceeds patient preference

Opioid Selection

Morphine 20 mg/ml

  1. Patients under 75 years of age requiring opioid therapy.
  2. Patients with adequate hepatic and renal function.

Oxycodone 20mg/ml

  1. Patients over 75 years of age requiring opioid therapy
  2. Patients with impaired hepatic and/or renal function
  3. Patients who demonstrate toxicity or adverse reactions to morphine.
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General Considerations

  1. When ordering these products, dosages are noted in units of mg rather than ml.
  2. Short acting opioids are not dosed more frequently than every 3 hours for breakthrough pain, and every 4 hours if used around the clock. Some patients may require every 6-8 hour dosing based on their organ function.
  3. If a patient requires > 3 doses of prn opioids/day, assess pain and evaluate if patient is on appropriate adjuvant agents such as anti-inflammatory agents. If pain is improved but not optimally controlled, titrate upward. Dose titration should occur no more frequently than every 24 hours. (Refer to titration guidelines).
  4. One drop of food coloring per bottle of liquid opioid is acceptable if needed for ease in measuring.
  5. Mixing liquid opioid with juice or other beverage is acceptable in an attempt to disguise offending taste. Cranberry juice has been found to be the preferred flavor for mixing.
  6. Liquid opioids may be placed sublingually or buccally if a patient has difficulty swallowing. Be sure to administer slowly to patient who is unable to swallow to avoid gurgling. Consider change to SQ/IV opioid if concentrated dose exceeds 40 mg/2 cc.
  7. Educate patient/caregiver on the use of liquid concentrated opioids.
  8. Reassess pain and side effects within 24 hours.
  9. Continually monitor patient for signs of opioid accumulation and/or renal or hepatic dysfunction. If signs of accumulation occur, immediately reduce dose and/or extend dosing interval and closely monitor.
  10.  If patient is unresponsive with signs and symptoms of respiratory depression secondary to opioid over-medication, contact your PFCC/senior staff nurse to determine need for initiation of naloxone (Narcan®) therapy.
  11. Assessment of pain and documentation of assessment should occur with each patient visit and within 24 hours of any medication dosage adjustment.

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