New Hampshire Hospice and Palliative Care Organization
125 Airport Rd, Concord, NH 03301    603-415-4298    info@nhhpco.org

... improving access to quality care for New Hampshire residents with life-threatening conditions

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Opioid Use Guidelines

ORDERING Information and ORDER FORM available HERE
 

  Ordering Information
Regression Equation
References
Adjuvants

 

The following Opioid Use Guidelines have been prepared by the NHHPCO Palliative Care Clinicians Special Interest Group as part of their 'Best Practices Project'. 

Please Note: This 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.

Table 1:   Equianalgesic Dosing 

                        

 

Drug

Initial (IR)  Dose PO

Peds dose: (IR) initial / kg

PO:IV

PO MS : Drug PO

Drug PO :
PO MS

Morphine (MS)

2.5 to 15 mg

0.1 - 0.3 mg/kg

 3 : 1

 1 : 1

1 : 1

Hydromorphone (HM)

1, 2 or 4mg

0.04 - 0.06 mg/kg

 4 : 1

 1 : 0.25

1 : 4

Oxycodone (Oxy)

2.5, 5 or 10mg

0.2 mg/kg

 n/a

 1 : 0.66

1 : 1.5

Oxymorphone**

2.5, 5 or 10 mg

n/a

10 : 1

 1 : 0.33

 1 : 3

Methadone (Me)

2.5 or 5mg

0.1 mg/kg

 2 : 1

See over

See over

Transdermal Fentanyl (TDF) @ = SC/IV. Equianalgesic dosing:  see over OR 1:300 to PO MS.        TDF for chronic stable pain; absorption has slow onset + is erratic with cachexia or fever.        Buccal/SL fentanyl for B/T pain NOT proportionate. Start low. Opioid tolerant patients only. 

* Patients on codeine and hydrocodone can be treated as opioid naïve.

** Oxymorphone levels increase @ 50% when taken with food and erratically with alcohol use.

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 IV basal rate q15 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.

 

Table 2:  MS : Me    

One Way Rotation from PO Morphine ( MS) to PO Methadone (Me)

 4 : 1   for up to 100mg MS

15 : 1  for  501 - 1000 mg MS

 8 : 1   for 101 - 300 mg MS

20 : 1  for  > 1000 mg MS

 12 : 1  for 301 - 500 mg MS

 

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, pg1-34  (
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


Equianalgesic cards and tables:

UpToDate www.uptodate.com
The Prescriber’s Letter www.fhea.com/prescribers_newsletter_request.htm
Life’s End Institute www.lifes-end.org
Partners Against Pain www.partnersagainstpain.com
GlobalRPH.com www.GlobalRPH.com
PainCare.ca www.PainCare.ca
Northwestern Memorial Hospital Pain Mgt Card www.nmh.org
Bedside Pain Manager, Judi Hunt RN www.bedsidepainmanager.com

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, TCA’s, 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


Pocket Cards Available

This information is available on plastic laminated Pocket Cards directly from the New Hampshire Hospice and Palliative Care Organization.
ORDERING Information and ORDER FORM available HERE.


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.

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