Opioid Titration
	• When starting an opioid, use immediate release (IR) until dose is stabilized. Alternatively, some clinicians may choose to start with an oral controlled-release (CR) formulation, with an IR form available for breakthrough pain.
	• In opioid naïve patients start with 2.5 to 5 mg of morphine or 0.5 to 1 mg of hydromorphone q4h with breakthrough medication ordered at 1.25 to 2.5 mg of morphine or 0.25 to 0.5 mg hydromorphone q1h prn.
	• Analgesic effectiveness can be reassessed after 24 hours as it takes five half lives to reach a steady state (5 x 4 hrs = 20 hrs).
	• Total all the regular and breakthrough opioid used in the last 24 hours to get the total daily dose (TDD).
	• Divide this amount by the number of doses for the next 24 hours (normally 6=q4h) and give this dose regularly q4h with 10% of the TDD given q1h p.r.n. as a breakthrough/rescue dose (BTD) for breakthrough/rescue pain.
	• Dose adjustments should not be made more frequently than every 24 hours. Also assess for end of dose pain, and the presence of incident pain, which may require further titration.
	• Use IR opioid formulations for breakthrough doses (BTD) and remember to increase the breakthrough dose proportionately when the regular dose is increased.
	• When full pain relief is achieved, yet adverse effect have developed, employ a dose reduction to try and maintain adequate pain control with diminished adverse effects.
	• Doubling the nightime dose will avoid wakening the patient in the early morning for a scheduled q4h dose, however, night loading doses should be considered only for patients with good pain control. The use of sustained release opioids appears to be a better dosing strategy, as shown in a study with SR morphine.
	• When good pain control is achieved with a stable dose with an immediate release formulation, consider use of a long acting product to improve compliance.
	• When the patient is on sustained release opioids or fentanyl patches it is usual to titrate the dose every 48 and 72 hours respectively. If fentanyl is used, total the amount of breakthrough opioid analgesic given in the last 24 hours and convert that amount to an additional equivalent size fentanyl patch. If titration is done frequently switch to a short acting preparation.
	• If pain is rapidly escalating or pain is requiring frequent titration use short acting opioids q4h until pain is controlled and opioid needs are stabilized. Consider development of tolerance (which may require opioid rotation) or reassessment for a new or progressive medical problem.
	• When patients are elderly or frail, titrate over a number of days rather than rapidly over 1 to 2 days.
	• For severe pain the rate of titration may need to be more aggressive.
https://web.archive.org/web/20200824041303/http://nperesource.casn.ca/wp-content/uploads/2017/03/16FHSymptomGuidelinesOpioid.pdf