Spinal opioids in the home and hospice setting.

The outpatient management of spinal opioids presents multiple challenges to the home infusion pharmacist. These include compounding, Schedule II prescription control, dispensing for long-term infusion or injection, reimbursement, and the management of opioids in the home. Although spinal opioids such as meperidine, fentanyl, and methadone have been used to control intractable pain, preservative-free morphine is the preferred opioid for epidural and intrathecal injection. Commercial products, including Astromorph (Astra) and Duramorph (Elkins Sinn), are available but relatively expensive when compared with morphine prepared in the pharmacy or morphine with preservatives. Local anesthetics, including bupivacaine, have been combined with preservative-free morphine in the home setting. Spinal opioids can be administered intermittently, by continuous infusion, or patient-controlled analgesia pump. Extensive clinical experience indicates that the home administration of spinal opioids is safe and effective. There is a need for additional research on stability, storage and use of various opioids administered in the home environment.