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Background: A common question from trainees is how fast, and by how much, can opioids be safely dose escalated? I like to use the analogy of furosemide (Lasix) when discussing this topic. I have never seen a resident order an increase in Lasix from 10 mg to 11 mg, yet that is precisely what often happens with opioids, especially parenteral infusions. Like furosemide, dose escalation of opioids should be done on the basis of a percentage increase. In fact, this is reflexively done when opioid-non-opioid fixed combination products are prescribed; going from one to two tablets of codeine/acetaminophen represents a 100% dose increase. The problem arises when oral single agents (e.g. oral morphine) or parenteral infusions are prescribed. Increasing a morphine infusion from 1 to 2 mg/hr is a 100% does increase; while going from 5 to 6 mg/hr is only a 20% increase, and yet many orders are written, “increase drip by 1 mg/hr, titrate to comfort.” Some hospitals and nursing units even have this as a standing pre-printed order or nursing policy.
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