These Opioid Use Guidelines have been prepared by the NHHPCO Palliative Care Clinicians Special Interest Group as part of their 'Best Practices Project'. This card has been updated to reflect prescribing "best practices" for 2010.

Pocket card ordering information and order form available here.

Updated Opioid Use Chart

Steps to Rotate or Change Opioids

  1. Calculate 24 hr dose of current drug.
  2. Translate that to equianalgesic 24 hr dose of oral morphine.
  3. Calculate 24 hr equianalgesic dose of new drug and reduce dose to 50-75% of calculated dose if pain is well controlled; use 100% otherwise.
  4. Divide to attain appropriate interval and dose for new drug.
  5. Always have breakthrough dosing available while making changes.

Breakthrough Dosing (immediate release (IR) / short acting meds only) 50-150% of IV basal dose q15 minutes OR 10-20% of 24 hr oral dose q1hr.

Changing Basal Rates (due to inadequate baseline pain control)
Increase rate by 50-100% of basal po dose q24-48 hr or IV rate q15-60 minutes. Give a breakthrough dose each time basal rate is increased.

Ceiling Effect = uncontrollable pain with appropriate increases in dose OR side effects such as neuroexcitation, myoclonus, or protracted central effects.

a) Rotate to another opioid as above.
b) Dose reduce opioid by 25-50% with addition of other treatment for pain.
c) Treat side effect +/- dose reduce.

Partial Reversal with Naloxone: ONLY for overdose in rare cases:
→ mix 0.4 mg amp with saline to make 10cc + administer 0.5 -1 ml (0.02-0.04 mg) IV/SC q2-5 minutes until response; naloxone effect shorter in duration than long acting opioids and close monitoring +/- repeat doses sometimes necessary.

Rotation to Methadone

Day 1: Calculate dose (above). Give @ 33% methadone dose + @ 66% of present drug. Day 2: Give @ 66% methadone dose + @ 33% present drug.
Day 3: Give 100% methadone dose.

Rotation from Methadone

CAUTION: Ratios above do not necessarily apply – consult an expert.

METHADONE: CAUTION: Use only with experience or training in pain mgt.
- Dosing interval is titrated for analgesic effect q4-12h; start with q8h.
- Delayed side effects @ Day 4 after initiation: highly lipid soluble with potential delayed and

prolonged side effects that outlast analgesic efficacy.
- Prolonged QT esp at high dose > 200 mg/day; interactions at CYP450
(esp 2D6, 3A4) - Some common drugs that increase methadone effect: SSRI’s (fluoxetine), TCA’s

(amitriptyline), macrolides, metronidazole, antifungals, grapefruit juice.
- Decrease methadone effect: many HIV drugs, carbamazepine, rifampin, phenytoin.

Rotating to and from Transdermal Fentanyl (TDF)

SHORTCUT: Transdermal Fentanyl (mcg/hr) X 2 = approx 24 hr dose of MS PO (mg). From TDF: Start new drug @ 50% dose for 6-24 hrs after removal of TDF.
To TDF: Continue old drug @ 50% dose for 6-24 hrs after starting TDF.

Bowel Regimen: All patients on opioids should be on a stepped BOWEL REGIMEN: 1. Senna + docusate (Senokot S) 1-2 tabs twice daily or

MOM 30-60 cc twice to three times daily or
Lactulose 30-60 cc twice to three times daily or PEG solution (Miralax) 1-4 T daily

2. Double dose or high dose stimulant + osmotic
3. Methylnatrexone (Relistor) for unresponsive opioid bowel while continuing conventional 
bowel management preparations (this is normally a short-term intervention).

a. Methylnatrexone is a Mu opioid antagonist that does NOT cross BBB
b. Dosing: 8 mg (81-135lb); 12 mg (> 135 lb) or 0.15 mg/kg sc every other day or as 
needed not to exceed q24hr

Always treat impaction with enemas/suppositories

NOTE: This card was produced as a guide ONLY. All doses and recommendations should be checked and verified by an experienced provider prior to use. The authors assume no responsibility for its use. References available upon request or at www.nhhpco.org/opioid.htm.
© NHHPCO
2006 (rev. 2010)


REGRESSION EQUATION

Repetitive research (see references below) shows that equianalgesic ratios between methadone and morphine are dose dependent and vary depending on dose. Studies show relationships that vary considerably with the most conservative ratio listed above in Table 2 (Ms : Me). Intuitively the variation in ratio occurs gradually, not at sudden intervals. A regression equation can be derived that estimates the relationship based on gradual change in ratio. Below is one regression equation derived from slightly more aggressive ratios than in Table 2.

Please use with caution.

Special thanks to Louis Gallerani for deriving the equation and plotting the graph.

REFERENCES

Main reference: Quigley C. Opioid Switching to improve pain relief and drug tolerability. Cochrane Review, 2004, Issue 3, pg 1-34 (everyone should have this comprehensive review and use it to access primary literature)

Additional references:

Pereira J et al. Equianalgesic Dose ratios for Opioids: a critical review and proposals for long term dosing. J of Pain and Symp Mgt, 22(2), August 2001, pg 672-687

Benitez-Rosario MA et al. Opioid switching from transdermal fentanyl to oral methadone in patients with cancer pain. Cancer, 2004, Dec 15; 101(12):2866-72

Kornick CA et al. A safe and effective method for converting cancer patients from IV to TD fentanyl. Cancer, 2001, Dec 15; 92(12):3056-61

ADJUVANT THERAPIES FOR PAIN

Bone Pain
NSAIDS, steroids, calcitonin, bisphosphonates

- ibuprofen 600 mg every 6 hours
(no NSAID has been proven any more effective than any other in large studies though individual responses vary)
- if one NSAID does not work, try another in a different class

Neuropathic Pain
gabapentin, TCAs, topical anesthetics
- gabapentin 100 mg po tid rapidly escalating to up to 4800 mg/d
- desipramine 10-25 mg po qhs up to 100 mg po qhs
- transdermal lidocaine 5% applied as needed
- compounded mixes (ie ketamine 5-10%; amitriptylline 2-5%; ketoprofen 10-20%; baclofen 2-10%)

Muscle Spasm
- baclofen 5-20 mg 2-4 times per day up to 60 mg/day
- tizanidine 2-8 mg tid up to 36 mg/day

Tramadol 50-100 mg tid

Also

  • Cognitive Behavioral Therapy
  • Physical treatments (heat, cold, splinting)
  • Sensual Therapy (art, music, touch, aromatherapy)
  • Spiritual assessment and treatment

Please Note: The foregoing information was produced as a guide ONLY. All doses and recommendations should be checked and verified by an experienced provider prior to use. The authors assume no responsibility for its use.