Prescription & Rotation of Opioids

Prescription & Rotation of Opioids

Vanessa Cardy, MD, and Heidi James, MD

Background

• Opioids are important medications in palliative care
• All physicians should be comfortable with their use

Management

• Starting doses 
• Morphine 2.5-5mg po q4h prn 
• Hydromorphone 0.5-1mg po q4h prn
• If patient taking many prn doses during a 24 hour period, switch to long acting forms
• To change routes of administration or rotate opioids 
• Convert current total daily dose (TDD) to oral morphine equivalency
• Use opioid calculator (table below is Opioids app by Professor EBM group)
• Monitor for signs of opioid toxicity 
• Myoclonic jerks 
• Opioid-induced hyperalgesia
• Snoring and respiratory depression
• Nausea and vomiting
• Urticaria
• Urinary retention
• In opioid toxicity must change opioids (e.g. switch from morphine to hydromorphone)
• Calculate TDD of current opioid
• Convert TDD to equivalent po morphine dose
• Convert to new opioid by using ratios above or opioid calculator
• Adjust for incomplete cross-tolerance by ↓ TDD new opioid dose by 25%
• Ensure prns are available 
• Dose = 10% of regular dose