DOSIS OPIOID

Funded by the foundation for women’s cancer opioids are the first line treatment for cancer
related pain as the only oncologist that provide both medical and surgical oncologic care
gynecologic oncologists encounter an exceptionally broad range of indications exceptionally
broad range of indications for prescribing opioids from management of acute post operative pain
to chronic cancer related pain to palliative end-of-life care as GYN oncologists frequently utilize
opioids to manage pain our patients it is important to have a strong understanding of the
principles of opioid prescribing including basic opioid conversion and dose adjustments this
module will focus on the details of opioid conversion at the presentation learners will be able
identify a strategy for opioid conversion articulate the steps involved in opioid conversion and
describe the phenomenon of cross tolerance and indications for dose reductions during opioid
conversion there are several important steps to consider when planning to adjust the dosage or
convert to a different opioid medication always perform a clinical evaluation to investigate the
etiology of the new pain or the change in the patients pain symptoms it is important to rule out
another cause that could be contributing to the change in symptoms and determine if additional
test or imaging is needed prior to adjusting the pain medications next determine the amount of
opioid that the patient is currently taking on a daily basis and convert both long and short acting
opioids to oral morphine equivalents which we abbreviate as omae decide which opioid you will
use by asking these questions is the current formulation working well for the patient have they
developed intolerable side effects or is there a change in clinical status such as the patient not
tolerating oral.

Intake then calculate the dosages of each medication using jen rules and individualized those
calculated doses as needed finally try to anticipate the potential side effect and provide
prophylaxis if available we have delineated four basic rules for conversion the first rule is to
always convert to oral morphine equivalents second if you are switching from one opioid to
another dose reduce the ome total by about 25% to account for incomplete cross tolerance rule
three is to calculate the long-acting dose which is equivalent to about two thirds of the 24 hour
ome and rule four is to calculate the short-acting dose which is approximately 10 to 15% of the
24 hour long-acting opioids os there are many opioid calculators and dose conversion tables
online however it is important to have a basic knowledge of equi analgesic doses of opioids an
equi analgesic dose is defined as that dose at which two opioids at steady state provide
approxiamately the same pain relief here.

Is an example of a table of ACMA analgesic dosing in this kind of equi analgesic table all cells
in the table are equivalent for example 10 milligrams of IV morphine is equivalent to 30
milligrams of oral morphine an example of how to use this table to convert to ome e’s let’s take a
patient take a patient taking 40 milligrams of oxycodone since 20milligram of oxycodone is
equivalent to 30 milligram of oral morphine therefore you can multiply the oxycodone dose by
1,5 to obtain the equivalent ome ease in a patient taking 40 milligrams of oxycodone 40 times
1,5 is equivalent 60 ome here’s another example the table tells us that 7,5 milligrams of
hydromorphone is equivalent to 30 milligrams of oral morphine if patient is taking 20 milligrams
of oral hydromorphone daily convert that to ome by multiplying by 4 therefore 20 milligrams of
oral hydromorphoneis equivalent to 80 ome here are a couple easier rules ofthumb to remember
the firstis the 1 to 3 rule which is that 1 a gram of IV morphine equals two milligrams of oral
oxycodone equals three milligrams of oral morphine another rule is the 30 20 10 7,5 1,5 rule
which provides an easy to remember conversion between some of the more commonly utilized
opioids including oral and IV morphine and dilaudid as well as oral oxycodone to add a layer
complexity transdermal fentanyl

conversions are a bit more tricky because the patches are dosed in micrograms per hour and are
only available in certain doses to convert from a fentanyl patch to ome double the transdermal
fentanyl dose of micrograms this be equal to your oral morphine equivalent in milligram it is also
important to note that fentanyl dosed transdermally reaches a therapeutic level in 13 to 24
hours so when switching from a long-acting opioid to a fentanyl patch the patch should be
applied with the last dose of the long-acting oral opioid to avoid pain during the transition when
starting a patient on an oral opioid medication the first opioid chosen is generally short-acting
morphine or oxycodone to determine the required dosage as well as to ensure tolerance
short-acting opioids can be converted to long-acting formulations dosed once or twice daily to
both minimize breakthrough pain and decrease administration issues morphine is the most
commonly used long-acting opioid due to ease of administration and cost unless there is a
contraindication such as renal or past intolerance other considerations include the route of
administration for example women with intermittent follow obstructions who are unable to
tolerate oral intake may benefit from a transdermal fentanyl patch which would allow more
reliable absorption obey rotation occure when a patient is transitioned from one opioid to another
rotating opioids is indicated when the patient is unable to achieve adequate pain control due to
intolerable side effect that dose escalation another indication for opioid rotation is a change in
clinical status such as new onset renal insufficiency or an inability to tolerate oral intake

which precludes the administration of the current medication it is important tonote that opioid
rotation is not indicated in situations of inadequate pain control wear side effects are not
prohibiting theup titration of the current opioid. Opioid tolerance is defined as a decrease in
pharmacologic response following repeated of prolonged administration cross tolerance refers
the development of tolerance to the effects of another structurally similar drugs in the same
pharmacologic class after long-term exposure whatever tolerance a patient has developed to their
current opioid may not translate to a different opioid which is known as incomplete cross
tolerance therefore when we switch a patient from one opioid to to another we reduce the total
dose to account for the possibility of incomplete cross tolerance it is recommended to dose
reduce by approximately 25% to avoid overdosing the new opioid this reduction should be
apllied to the calculated 24 hour ome. Now that we’ve reviewed the principle of opioid
conversion let’s apply this informations to few cases for refence remember these four basic rules
as we work through each case rule number one convert all opioids to 24 hour oral morphine
equivalents rule number 2 decreased 24 hour need by 25% to account for incomplete cross
tolerance when rotating opioids rule number three two-thirds of your total 24 hour OMA it
should be long-acting and rule four ten to 15% of your long-acting dose will be your short acting
dose given every three hours on an as-needed basis our first case involves converting a PCA to
oral opioid medications we’ll start with a 60 year old patient with recurrent cervical cancer who
presents to clinic with uncontrolled pain she tearful and rating

her pain at ten out often after several bolus is of IV morphine the patient has appropriate pain
control you decide to admit the patient hospital to optimize her pain control for homegoing
medications you perform a full evaluation of causes of pain and approach and appropriate pain
assessment then after 48 hours her pain is well controlled she has used a total of 100 milligrams
of IV morphine in 24 hours now we will covert this IV usage homegoing oral medication
regimen starting with rule number one we will convert the IV morphine to ome 10 milligrams of
IV morphine equals 30 milligrams of oral mark therefore 100 milligrams of IV morphine is equal
to 300 milligrams of oralmorphine for rule number 2 theadjusments for cross tolerance when
switching opioids will be admitted in this circumstance as morphine will remain our opioid of
choice we then move to rule number 3 to calculate the dose of long-acting opioid which will be
2/3 of the 24 hour ome calculated above in this example 2/3 300 ome is equivalent to 200
milligrams of oral morphinr as there are no contraindications we would use divided doses of
long-acting morphine which is 100 milligramsof MS Contin administered twice daily

finally rule number 4 states that the short acting dosage should equal 10 to 15 percent of the total
24 hour long-acting dose therefore 10 to 15% of milligrams is 20 to 30 milligrams of oral
morphine as immediate release morphine is available in 15 and 30 milligram tablets our short
acting dose will be 15 to 30 milligrams of oral morphine every three hours as needed for
breakthrough pain case 2 will work through an example of starting long-acting opioids on a
patient currently taking short-acting opioids medications this patient is a 55 year old with stage
3b cervical cancer she recently had a year read oral stent placed do two hydronephrosis and is
currently undergoing treatment with chemo radiation she presents to your clinic with pelvic and
back pain. She is currently taking an average of 80 milligrams of oxycodone per day which is
providng moderate control of her pain she’s tired of taking the medication so free and is waking
uo at night to take pain medication you decide to transition her to a long-acting opioid so going
through our rules first we will calculate the 24 hours ome we start with 20 milligrams of
oxycodone which is equivalent to to 30 milligrams of oral morphine so for this patient she’s
taking 80 milligrams of oxycodone in 24 hours which is equal to 120 ome for rule 2 we’ll then
adjust for complete incomplete past tolerance as we plan to convert from oxycodone to morphine
we will reduce the total ome by 25% so 25% of 120 ome is equal to 90 ome for the 24 hours for
rule number 3 will calculate the long-acting opioids which is two thirds of the 24 hour ome in
this example two thirds of 90 oh ma is 60 therefore we would prescribe long-acting morphine in
the form of MS contin 30 milligram tabs twice daily

and finally for rule number four the short acting dose is equal to 10 to 15 percent of the total 24
hour long-acting dose in this example 10 to 15 percent of 60 milligrams is equal to 6 to 9
milligrams as immediate-release morphine is available in 15 milligram tablets we would
prescribe one half tablet of morphine or a 7 point 5 milligrams per dose every three hours as
needed case three will work through the concept of rotating opioids for this example we’ll use a
patient who is a 55 year old woman with recurrent sarcoma who returns to your clinic ten days
after previous escalation in her opioid medications she notes that she has been quite somolent
and nauseated however her pain is now well controlled she is currently taking long-acting
opioids in the form of MS contin 100 milligrams three times per day and forty five milligrams of
immediate –release morphine an average of five times per day although her pain is well
controlled her side-effect profile is negatively affecting her quality of life for tha reason we will
rotate her opioid medication from morphine to oxycodone we will again start with rule number
one

and convert her total opioid use into ome as 100 milligrams of MS contin td equals 300 ome and
five daily doses of 45 milligrams of immediate-release morphine equals 225 ome she’s using a
total of 525 ome and a 24 hours period using rule number 2 will then adjust for incomplete cross
tolerance by decreasing the ome total by 25% in this example 525 ome reduced by 25% is equal
to 394 ome will plan to use oxycodone and its long acting equivalent oxycontin for for this
conversion we’ll use 30 milligrams of morphine which is equivalen to 20 milligrams of
oxycodone and therefore 394 ome equals two hundred and sixty-theree miligrams of oxycodone
rule number three states tha the long-acting doses is equivalent to two thirds of the 24 hour ome
total for this patient two thirds of two hundred and sixty-three milligrams is equal to 175
milligrams for convenient dosing we will use 160 milligrams of oxycodone in divided doses
which will be 80 milligrams of oxycontine twice per day finally rule nuber four states that ten to
fifteen percent of this long-acting dose will be used for short-acting intermittent dosing 10 to 15
percent of 175 milligrams equals seventeen point five to twenty six milligrams of oxycodone
ease of dosing with the available oxycodone tablets we will plan to use 20 milligrams of
oxycodone every three hours as needed for breakthrough pain for case number four let’s consider
the same patient as above she is now placed on hospice and is unable to take oral medications her
pain currently well controlled with oxycontin 80 milligrams twice daily with an average of three
doses of oxycodone 20 milligrams used per day as she unable to tolerate oral medications we
will rotate her opioids to transdermal fentanyl and an oxycodone suspension for short acting
medication for real one the total ome used in 24 hours is calculated she is currently usng
oxycontin 80 milligrams twice per day which equals 160 milligrams of oxycontin total and 20
milligrams of oxycodone and 3 times per day to equal 60 milligrams of oxycodone for a total of
220 milligrams of oxycodone in a 24 hours period oxycodone in a 24 hours period using
transition of 20 milligrams of oxycodone equaling 30 milligrams of oral morphine the 220
milligrams of oxycodone is equivalent 330 ome for rule number 2 will decrease the 24 hour ome
2025 percent to count for incomplete tolerance ae we rotating opioids for this case 25 a 25%
reduction of 330 ome leaves us a 248 ome for rule number three our long-acting opioids will be
equal to two thirds of the 24 hours total ome two thirds of 248 ome equals one hundred and
sixty-five ome for the transdermal fentanyl patch remember that the dose of the fentanyl patch in
micrograms per hours is equal to one-hal of the total ome therefore one half of one hundred and
sixty-five ome is 82,5 due to the formulation of the transdermal fentanyl patches we would use
an 80 micrograms per hour fentanyl patch finally rule number four states that ten 15% of the
long-acting dose should be available for short-acting breakthrough dosing so 10 to 15% of 165 is
sixteen point five to twenty four point seven five omfor the example we would choose a highly
concentrated oral oxycodone solution again 30 milligrams of oral orphine is equivalent to 20
milligrams of oxycodone therefore the 16,5 to 24 24 miligrams range of morphine would be
equal to 11 to 16 point 5 milligrams of oxycodone the oxycodone suspension is available 20
milligrams per milliliter so we would prescribe one half to one milliliter every three hours which
would equal 10 to 50 milligrams of oxycodone every three hours in conclusion opioid titration
and conversion our our important skills for the gynecologic oncologist remember these four
rule number one convert all opioids to 24 hour oral morphine equivalent rule number 2 decreased
24 hour need by 25% to account for incomplete cross tolerance whe rotating opioids rule number
3 two-thirds of your total 24 hour oma should be long-acting opioids and rule number 4 10 to 15
percent of long-acting dose will be a short-acting dose given every three hours on an as-needed
basis by applying these rule in combination with your clinical judgment you will be to titrate
convert