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