Maximum medication dosages

 

Although opiates are very safe medications from a toxicity standpoint and there is no absolute ceiling on the maximum dose, there are common-sense limits PTCOA recommends.  Patients treated for chronic pain are always at risk for episodes of medication non-compliance and diversion episodes.  Limiting the amount of medication in their possession is sensible from both a patient management and a community public health standpoint.


Patients who continually feel that they need higher doses than the protocol maximum should always be given the option of an implantable medication infusion pump where there are essentially no limits to the doses.  Implanted infusion devices also allow for PCA dosing which can eliminate the need for addition break-thru-pain medication.  Managing implanted infusion devices also allows the patient extended lengths of time between office visits.


From a public health standpoint, having medication locked up in a “tin-can” implanted within the patient’s body essentially eliminates the potential for diversion within a community.


Limits table:

                       

morphine sulfate:    300 mg daily

                                MS Contin      = 100 mg q8 hours

                                Kadian            = 150 mg q12 hours

                                Avinza             = 300 mg QD


fentanyl patches:    200 mcg hourly

                                100 mcg patch x 2 either q72 or q48 hours


Oxycontin:               240 mg daily              

(oxycodone)            80 mg q8 hours


methadone:             90 mg daily

                                10 mg x 3 (30 mg) q8 hours


Opana ER                120 mg daily

(oxymorphone)         30 mg x 2 q12 hours


Exalgo                      64 mg daily

(hydromorphone)     16 mg x 4 QD



There are also common-sense limits on the amount of break-through pain (BTP) medication.  As a general rule, it is simplest to use the same medication in an immediate release for BTP.  However, this is not possible with methadone and with fentanyl, the lozenges and suckers are expensive and typically only covered by insurance in cancer-pain.


The limit for BTP medication is maximum one tablet q6 hours or four tablets per day.


The dosage should start low and titrate upward along with the extended-release medication.


A good example is oxycodone (supplied in 5mg, 7.5mg, 10mg, 15mg, and 30mg tablets).