Opioid Rotation Handout - FreeCE

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Page 2Opioids and Opioid Rotation – What Pharmacists Need to Know© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.Reasons for Changing Opioids• Lack of therapeutic response• Development of adverse effects• Change in patient status• Other considerations– Opioid/formulation availability– Formulary issues– Patient/family health care beliefs• Opioid rotation, substitution, switching• Opioid Conversion Calculations!Equianalgesic Dosing Terminology• Opioid responsiveness– The degree of analgesia achieved as the dose istitrated to an endpoint defined either by intolerableside effects or the occurrence of acceptable analgesia• Potency– Intensity of the analgesic effect of a given dose– Dependent on access to the opioid receptor andbinding affinity• Equipotent doses = equianalgesic• Equianalgesic Opioid DosingConverting Among Routes: Same Opioid• Bioavailability– The rate and extent to which the activeingredient or active moiety is absorbed from adrug product and becomes available at the siteof action• Oral bioavailability– Morphine 30-40% (range 16-68%)– Hydromorphone 50% (29-95%)– Oxycodone 80%– Oxymorphone 10%Equianalgesic Opioid DosingEquianalgesic Doses (mg)Drug Parenteral OralMorphine 10 30Buprenorphine 0.3 0.4 (sl)Codeine 100 200Fentanyl 0.1 NAHydrocodone NA 30Hydromorphone 1.5 7.5Meperidine 100 300Oxycodone 10* 20Oxymorphone 1 10Tramadol 100* 120* - Not available in the USMcPherson ML. Demystifying Opioid Conversion Calculations: A Guide ForEffective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010.
Page 3Opioids and Opioid Rotation – What Pharmacists Need to Know© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.The Problem with “Those Charts”• Source of equianalgesic data• Patient-specific variables• Unidirectional vs. bidirectionalequivalencies5-Step OCC Process1. Globally assess pain complaint (PQRSTU)2. Determine TDD current opioid (LA and SA)3. Decide which opioid analgesic will be usedfor the new agent and consult establishedconversion tables to determine new dose4. Individualize dosage based on assessmentinformation gathered in Step 15. Patient follow-up and continualreassessment (7-14 days)Gammaitoni AR, et al. Clinical J Pain 2003;19:286-297Conversion Conversations Same opioid, from one oral dosageformulation to a different oral dosageformulation Same opioid, from one route of administrationto another route of administration From one opioid to a different opioid,regardless of dosage formulation Conversions to/from transdermal opioidsSame Opioid (PO → PO): Case 1• HW is an 84 year old man in a LTC facilitywith general debility on oxycodone 5mg/acetaminophen 325 mg tabs, six perday, pain well controlled.• He can no longer swallow the tablets andhis physician asks you convert him to anoral solution of oxycodone 5mg/acetaminophen 325 mg per 5 ml.
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Opioid Rotation Handout - FreeCE

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