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OPIOID CONVERSIONS

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

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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

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