Upping the Dose vs Combination Therapy
Physicians in my hospital often seem to add a second opioid for treating pain rather than increasing the dose of the initial opioid. Do you have any suggestions for changing this practice that makes nursing care confusing and does not seem to promote patient comfort?
Dr. Chou: This seems to be the kind of thing that could be fairly easily flagged through electronic prescription records and brought to the attention of the physicians, so that they stick with one opioid rather than more. In some cases, there may be a reason to use two opioids (eg, one long-acting and one short-acting for titration or breakthrough pain), but there aren't too many reasons to prescribe more than one short-acting or more than one long-acting opioid.
Dr. Argoff: This is not a simple question to answer. The first step is to understand why the prescriber is adding another opioid. Whereas some patients sufficiently benefit from a single opioid, others experience optimal benefit when one particular opioid is used as a long-acting agent (eg, a fentanyl patch) and a different opioid compound is used for pain that breaks through this regimen (eg, short-acting oxycodone or oxymorphone).
There has been recent interest in the formal clinical development of a new medication that combines morphine and oxycodone in one preparation, because studies have shown that such a combination may enhance outcome; however, this preparation is not currently approved by the US Food and Drug Administration.