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OPIOID CONVERSIONS

OPIOID CONVERSIONS

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OPIOID CONVERSIONS

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  1. OPIOID CONVERSIONS Sarah Beth Harrington, MD October 2, 2007 Resident Skills Session

  2. Objectives • Review basic principles for prescribing for long and short acting po opioids. • Demonstrate competence in calculating opioid dose conversions using standard published conversion ratios. • Calculate starting dose of methadone using common clinical scenerios • Compare costs of different opioids when making prescription decisions

  3. Equianalgesic ratios serve as rough clinical guides • Always take into account: • Age • Renal/Hepatic/Pulmonary function • Opioid tolerance/ naivety

  4. PRESCRIBING LONG-ACTING OPIOIDS • Short Long acting when pain well-controlled PP: Use equianalgesic dosing Avoid combo agents Bowel regimen! Instructions: • Calculate mg opioid in 24 hrs  convert to SR • Calculate rescue dose (IR); ~ 10-20% total daily dose

  5. Mr. Smith (Case 1) Case 1: 10mg oxycodone 6 times/day = 60mg oxycodone in 24 hrs Equivalent SR oxycodone= Oxycontin 30mg q12h Rescue dose – 10% (60mg) = 6 mg 20% (60mg) = 12mg ANSWER: Oxycontin 30mg q12h with Oxycodone 5-10mg q4h prn

  6. PRESCRIBING LONG-ACTING OPIOIDS • Short  Long-acting at higher dose - Use for: unrelieved/partially relieved chronic pain Instructions: 1. Calculate mg opioid used in 24 hrs and convert to long-acting opioid 2. Increase long-acting opioid by 50% 3. Check pill dose availability 4. Adjust rescue dose [10-20% new daily dose]

  7. Mr. Smith (Case 2) 10mg oxycodone 6 times/day = 60mg oxycodone in 24 hrs *Increase by 50% [ 60mg +(60mg X 50%)] =60+30= 90mg oxycodone in 24h Equivalent SR oxycodone = 45mg q12h Check pill availability = Oxycontin 40mg q12h Adjust rescue dose 10% 80mg = 8 mg 20% 80mg = 16mg Oxycontin 40mg q12h with 10-15mg Oxycodone q4h prn

  8. PRESCRIBING LONG-ACTING OPIOIDS • Using rescue doses to increase SR-opioid PP: Can safely escalate opioid dose in pt with constant pain after 24-48 hrs If total drug taken as rescue dose in 24hr is > 25% total SR dose, increase the SR dose by that amount

  9. Mr. Smith (Case 3) Total Oxycodone/day = 80mg (SR) + 40mg (IR) = 120mg oxycodone/day New Oxycontin dose = 60mg q12h Rescue dose 10% 120mg = 12 mg 20% 120mg = 24 mg Oxycontin 60mg q12h with 15-20mg oxycodone q4h prn

  10. Ms. X 15mg Morphine IR X 8 doses = 120mg morphine/day SR = MS Contin 60mg q12h Rescue doses 10% 120mg = 12mg 20% 120mg = 24mg MS Contin 60mg q12h + MS IR 15-20mg q3h prn

  11. Ms. Y 20 mg oxycodone X 5 doses = 100mg oxycodone/day Increase by 50% = 100mg + (50% (100mg)) = 100 +50 = 150mg oxycodone/day Check pill availability - 80mg Oxycontin q12h Rescue dose – 10% 160mg = 16mg 20% 160mg = 32 mg Answer: Oxycontin 80mg q12h + 15-30mg oxycodone q4h prn

  12. Mr. Z 60mg (SR) +60mg (IR) = 120mg total MS/day Convert to long-acting = MS Contin 60mg q12h Rescue dose – 10% (120mg) = 12 mg 20% (120mg) = 24 mg Answer: MS Contin 60mg q12h + 15-20mg MS IR q4h prn

  13. CHANGING OPIOID AGENTS PP: Remember - Incomplete cross-tolerance between different opioids Start new opioid at ½-⅔ of the calculated equianalgesicdose. Instructions: • If working with SR opioid, calculate 24 hr current opioid dose • Use equianalgesic ratio to calculate new opioid dose • Reduce dose by ½-⅔ for cross tolerance

  14. Mrs. T 80mg oxycontin q12h=160mg total oxycodone/day ⅔ (160mg) ≈ 100 mg morphine/day (Check pill availability) – MS Contin 45mg q12h Rescue dose 10% 90mg = 9 mg 20% 90mg = 18mg MS Contin 45mg q12h + MS IR 15mg q4h prn

  15. Quick TIP • OXYCODONE  MORPHINE Easy! Take current dose and reduce by ½-⅔

  16. Mr. X 200mg morphine (SR) + 100mg (IR) = 300mg total morphine/day Reduce for cross tolerance: ½ (100mcg/hr patch) = 50mcg/hr Fentanyl patch

  17. Mr. Z Convert MS IR  Dilaudid 4-5 mg po morphine = 1mg podilaudid ⅔ (6mg) = 4 mg podilaudid 4mg po dilaudid q4h prn

  18. Ms. B ⅔ (225 mg) ≈ 150 mg morphine/day 75 mg MS Contin q12h Breakthrough - 10% 150 = 15 mg 20% 150 = 30 mg MS Contin 75 mg q12h with 15-30mg MS IR prn

  19. Mr. C Oxycodone in 24 hrs = 40mg (SR) + 20mg (IR) = 60mg oxycodone/day 60mg oxycodone/day = 60mg morphine/day ½ (60mg ) =30mg po morphine/day =15mg MS Contin q12h Breakthrough – 10% 30mg = 3 mg 20% 30mg = 6 mg Answer: MS Contin 15 mg q12h + MS IR 5 mg prn

  20. METHADONE PP: Cheap, effective, neuropathic pain Long-acting, would wait 3 days before titrating dose Pay attention to ratios Decrease by 50% for cross tolerance

  21. Mr. D 400mg (SR)+200mg (IR) = 600mg morphine/day 10mg po morphine = 1mg po methadone 50% (60mg methadone/day) = 30mg methadone/day 10mg po methadone q8h

  22. Mr. X 900mg MS Contin q12h = 1800mg morphine/day 50% (90 mg methadone) = 45mg po methadone/day Methadone 15mg q8h

  23. Ms. Y 24 hr morphine = 60mg X 6 doses = 360mg po morphine/day 50% (36 mg) = 18 mg po methadone/day 18mg + 15 mg = 33mg po methadone/day New dose of methadone = 10mg q8h

  24. Multiple opioid conversions PP: Convert everything to morphine Decrease for cross tolerance at the end

  25. Mr. Y MS Contin 100mg q8h = 300mg morphine/day Oxycodone 30mg/day = 30mg po morphine/day Dilaudid po16mg/day = 80mg po morphine/day Fentanyl patch 50mcg/hr = 150mg morphine/day ------------------------------------------------------------------- Total morphine equivalent/day = 560mg/day

  26. 50% (56 mg methadone/day) = 28 mg methadone/day Answer: 10mg po methadone q8h +4-8mg po dilaudid prn

  27. CHANGING OPIOID ROUTE: SAME DRUG PP: Do NOT stop long-acting opioid Start equivalent parenteral basal dose

  28. Ms. T 60mg MS Contin q12h = 120mg po morphine/day 40mg IV morphine/24 hr = 1.6mg IV morphine/hr

  29. Mr. M EASY!! 20mg po methadone q8h 10mg IV methadone q8h

  30. CHANGING OPIOID ROUTE: DIFFERENT DRUG PP: Easiest to convert to morphine 1st Remember to reduce ½-⅔ for X-tolerance

  31. Mr. A Oxycontin 120mg q12h = 240mg oxycodone/day 240mg 240 mg 80mg IV morphine/ oxycodone/day po morphine/day day 16 mg IV dilaudid/24h = 0.67 mg IV dilaudid/hr ⅔ (0.67mg/hr) = 0.4 mg IV dilaudid/hr

  32. Miss D 90 mg po 30mg IV 6 mg IV morphine morphine dilaudid ⅔ (6mg) = 4 mg IV dilaudid **

  33. Ms. P 60mg IV 300mg IV 900 mg po dilaudid/day morphine/day morphine/day 50% (90 mg) = 45mg po methadone/day Answer:15 mg po methadone q8h

  34. Ms. P Other answers: 300mg MS Contin q12h + 60mg MS IR prn Fentanyl patch 200 mcg/hr WHY is Methadone the better choice??

  35. Cost Comparison

  36. Cost Comparison

  37. Conclusion • Avoid combo agents • Bowel regimen • Rescue dose -10-20% total daily dose • Incomplete X-tolerance between opioids • When changing agents, reduce by ½-⅔ • Methadone = good • Do not ever stop a pt’s long-acting opioid • Remember $$

  38. Resources Palliative Care Consult Team • Call N4N (6-1295) • Page–Dr. Swetz, Dr. Patel, Pat Coyne • Place consult in Cerner – Pain CNS