1.
Converting    Short   acting   Æ   Long   Acting   (IR Æ   SR)   when   pain   is   well ‐ controlled
*Use   for   :
¾ CHRONIC   pain
¾ Pts   on   scheduled   IR   opioids   –   pain   that   recurs   before   the   next   dose
PP:    ‐  Can   use   equianalgesic   dosing   when   using   same   drug
‐  Avoid   combination   agents   if   you’re   at   this   step
‐  Bowel   regimen,   bowel   regimen,   bowel   regimen
Instructions:
1.
Calculate   how   many   mg   of   opioid   pt   is   using   in   24   hrs Æ   convert   that   amt   to   long ‐ acting
Opioid   (SR)
2.
Add   a   rescue   doses   (IR)   of   same   opioid   if   possible  ‐  should   be~10 ‐ 20%   of   total   daily
opioid   dose
Case1:    Mr.
Smith   is   a   58 ‐ year   old   AAM   with   chronic   bone   pain   from   metastatic   prostate   CA.
He   was   prescribed
Percocet   (5/325)   in   the   ER   2   weeks   ago   and   is   now   in   your   clinic   for   f/u.
Pain   is   well ‐ controlled   on   current   meds,   but   tends   to   recur   ~   1   hr   before   the   next   dose.
He   is   taking   2   Percocet   every   4   hrs   around   the   clock,   even   at   night.
10mg   oxycodone   6   times/day   =   60mg   oxycodone   in   24   hrs
Equivalent   SR   Oxycodone   =   Oxycontin   30mg   q12h
Add   opioid   rescue   dose   –   10%   of   60mg   =   6mg       20%   of   60mg   =   12mg
ANSWER:    Oxycontin   30mg   q12h    with   Oxycodone   5 ‐ 10   mg   q4h   prn
2.
Converting   Short   acting   Æ   Long   acting   (IR Æ SR)   at   a   higher   dose
*Use   for:    Chronic   pain  ‐  unrelieved/   partially   relieved   by   IR   meds
Instructions:
1.
Calculate   how   many   mg   of   opioid   pt   is   using   in   24   hrs Æ   convert   to   long   acting   opioid
2.
Increase   long   acting   opioid   by   50%
3.
Round   up   or   down   based   on   what   pill   form   is   available
4.
Adjust   rescue   dose   –   [10 ‐ 20%   new   daily   dose]
1

Case   2:    Same   case   as   above   –   Mr.
Smith   –   Pain   partially   relieved   (9/10 Æ 6/10)   with   2   percocet   q4   hrs   round   the   clock
10mg   oxycodone   6   times/day   =   60mg   oxycodone   in   24   hrs
*Increase   oxycodone   by   50%   [(60   mg   +   (60mg   X50%)]   =   60mg   +   30   mg   =   90   mg   oxycodone/day
Oxycontin   45mg   q   12hr   –   Check   pill   availability   –   would   give   Oxycontin   40mg   q12h
Rescue   dose:      10%   80mg   =   8   mg        20%   80mg   =   16mg
ANSWER:    Oxycontin   40mg   q12h   with   Oxycodone   10 ‐ 15mg   q4h   prn
3.
Using   rescue   doses   to   increase   sustained ‐ release   opioid
PP:
‐ Can   safely   escalate   opioid   dose   in   pt   with   constant   pain   after   pt   has   been   taking   SR   preparation   for   24 ‐ 48   hrs
‐ Ask   pt   to   record   all   rescue   doses   he   takes
‐    If   the   total   amount   of   drug   taken   as   a   rescue   dose   is   more   than   25%   of   the   total   SR   dose,   increase   the   SR   dose   by   the   amount   in   the   rescue   doses
Case   3:    Mr.
Smith   returns   to   clinic   2   weeks   later.
He   is   taking   Oxycontin   40mg   q12h   and   Oxycodone   10mg   q4h   prn.
He   reports   that   he   is   consistently   taking   4   oxycodone/day   for   breakthrough   pain.
Total   oxycodone   /day   =   80mg   (SR)+   40mg   (IR)   =   120   mg   oxycodone/day
New   Oxycontin   dose   60mg   q12h
Rescue   dose   10%   of   120mg   =   12mg         20%   of   120mg   =   24   mg
ANSWER:    Oxycontin   60mg   q12h   with   15 ‐ 20   mg   oxycodone   q4h   prn
2

SMALL   GROUPS
Ms.
X   is   a   60   –   yo   WF   with   chronic   RA   pain   has   failed   all   non ‐ opioid   pain   regimens.
You   started   her   on
Morphine   sulfate   15   mg   IR   q3h   prn,   which   is   controlling   her   pain   and   improving   her   function.
She   takes   the   MS   IR   8   times/day,   around   the   clock.
You   want   to   start   her   on   a   sustained   release   morphine   preparation   with   immediate ‐ release   morphine   for   breakthrough   pain.
Ms.
Y   is   a   35   yo   HF   with   a   newly   diagnosed   soft   tissue   sarcoma   that   was   resected   3   months   ago.
She   continues   to   have   8/10   pain   despite    taking   oxycodone   20mg    five   times/day   .
What   dose   of   oxycontin   and   oxycodone   IR   do   you   want   to   start?
Mr.
Z   is   a   45   yo   WM   with   a   h/o   multiple   back   surgeries,   herniated   discs,   and   spinal   stenosis   after   a   construction   accident   6   years   ago.
He   is   currently   taking   MS   Contin   30mg   q12h   with   MS   IR   15mg   q4h   prn   pain.
He   reports   pain   is   well   controlled,   with   improved   function   and   is   back   at   work   at   a   desk   job.
He   takes   4   MS   IR   tabs/day   for   breakthrough   pain.
How   would   you   adjust   his   MS   Contin   and   MS   IR?
CHANGING   OPIOID   AGENTS
Use   for:    Pt’s   having   intolerable   side   effects   on   one   opioid;   cost   or   delivery   method   may   necessitate   changing   opioids
PP:
‐  There   is   incomplete   cross ‐ tolerance   between   different   opioids,   but   the   exact   amount   will   differ,   thus,   equianalgesic   tables   are   only   approximations.
‐  Depending   on   age,   prior   side   effects,   etc,   most   experts   recommend   starting   a   new   opioid   at   ½ ‐ 2/3   of   the   calculated   equianalgesic   dose.
Instructions:
1.
Calculate   the   24   hr   current   opioid   dose
2.
Use   the   equianalgesic   ratio   to   calculate   new   opioid   dose
3.
Reduce   dose   by   ½ ‐ 2/3   for   cross   tolerance   –   take   individual   patient   into   account
3

Mrs.
T   is   a   40   yo   AAF   with   a   h/o   multiple   myeloma   whose   chronic   bone   pain   is   well   controlled   on   Oxycontin   80mg   q12h   with   only   an   occasional   Oxycodone   30mg   q4h   for   breakthrough.
Her   pharmacy   is   no   longer   carrying   oxycontin   because   of   recent   break ‐ ins.
You   want   to   convert   her   to   MS   Contin   with   MS   IR   for   breakthrough.
Current   24   hr   opioid   dose   =   160mg   oxycodone/day
Po   morphine   =   po   oxycodone
160mg   oxycodone   =   160mg   morphine
2/3   (160mg   morphine)   ~=   106   mg
New   morphine   dose   (taking   into   account   pill   availability)   =   45mg   q12h   MS   Contin
Breakthrough   dose   –   10%   90mg   =   9   mg,    20%   90mg   =   18mg
ANSWER:    45mg   MS   Contin   q12h   with   15   mg   MS   IR   q4h   for   breakthrough
Mr.
X   is    a   80yo   WM   with   a   h/o   chronic   abdominal   pain   after   multiple   abdominal   surgeries   for   colon   cancer.
His   pain   is   well   controlled   on   MS   contin   100mg   q12h   with   MS   IR   20mg   q2h   prn   (which   he   takes   5X/day).
He   is   admitted   to   the   hospital   with   a   new   L   MCA   CVA   with   mild   deficits.
He   is   having   difficulty   swallowing   his   pills   and   wants   to   try   a   Fentanyl   patch.
What   dose   do   you   choose?
Total   morphine/day   =   200mg   morphine   (SR)   +   100mg   morphine   (IR)   =   300mg   po   morphine/day
25mcg/hr   fentanyl   patch   =   1mg/hr   IV   morphine
25mcg/hr   fentanyl   patch   =   75   mg   po   morphine/day
300mg   po   morphine/day   X   [25mcg/hr   fentanyl   patch]    =      100mcg/hr   fentanyl   patch
[   75   mg   po   morphine/day]
Reduce   for   cross   tolerance   ½   (   100mcg/hr   fentanyl   patch)   =   50mcg/hr   fentanyl   patch
Answer:    50   mcg/hr   Fentanyl   patch
Breakthrough   with   MS   IR   –   can   use   same   breakthrough   dose   as   before   (change   form   to   liquid   so   pt   can   swallow)
Mr.
Z   is   a   55   yo   AAM   with   intermittent   pain   in   knees   from   OA.
He   currently   takes   MS   IR   30mg   q4h   prn   which   helps   his   pain.
However,   he   complains   of   “cloudy   thinking”   at   this   dose.
You   try   to   decrease   the   dose,   which   improves   the   side   effect,   but   does   nothing   for   the   pain.
You   are   considering   opioid   rotation   with   Dilaudid.
What   is   his   new   prescription?
4 ‐ 5   mg   po   morphine   =   1mg   po   dilaudid
30mg   po   morphine   X    [1mg   po   dilaudid]=   6   mg   po   dilaudid
[5mg   po   morphine]
Reduce   for   cross ‐ tolerance   2/3   =   4mg   po   dilaudid
Answer:    4mg   po   dilaudid   q4h   prn
4

SMALL   GROUPS:
Ms.
B   is   a   50   yo   breast   CA   survivor   with   chronic   neuropathic   pain   from   her   mastectomy.
She   currently   is   well ‐ controlled   on   a   75mcg/hr   fentanyl   patch.
She   lost   her   job   and   can   no   longer   afford   the   patch.
You   want   to   switch   her   to   MS   Contin   with   MS   IR   for   breakthrough.
What   dose?
Mr.
C   is   a   65   yo   WM   with   severe   emphysema   with   chronic   back   pain   from   OA   and   is   taking   Oxycontin
20mg   q12h   with   oxycodone   5mg   q4h   prn   (takes   4/day   consistently),   and   is   experiencing   constipation   despite   a   very   good   bowel   regimen.
You   want   to   rotate   opioids.
What   is   the   new   prescription   for   MS
Contin   with   MS   IR   for   breakthrough?
Methadone   –   don’t   be   afraid
PP:   ‐        Methadone   is   a   good   drug ‐  cheap,   effective,   great   for   neuropathic   pain
‐ Long   acting,   would   wait   3   days   before   changing   dose
‐ Pay   attention   to   ratios
‐ When   changing   opioids,   reduce   by   50%   for   cross   tolerance/   NMDA   activity
Mr.
D   is   a   45   yo   WM   with   a   h/o   prostate   ca   with   bony   mets.
He   currently   takes   MS   Contin   200mg   q12h   with   MS   IR
40mg   q4h   prn   pain   (which   he   takes   5   X   /day).
His   pain   is   well   controlled   on   this   medication,   but   he   is   starting   to   have   periodic   hallucinations.
You   want   to   switch   him   to   Methadone,   what   dose   to   you   start   with?
Total   Morphine/day   =   400mg   (SR)   +   200mg   (IR)   =   600mg   morphine/day
10mg   po   morphine   =   1mg   po   methadone
600mg   po   morphine/day   X   (1   mg   po   methadone)    =   60mg   po   methadone/day
(   10mg   po   morphine)
Decrease   by   50%   for   cross   tolerance   =   30mg   po   methadone/day   =   10mg   q8h
Answer:    Methadone   10mg   q8h
5

Mr   X   is   a   80   yo   AAM   with   metastatic   lung   CA   with   multiple   bony   lesions.
He   is   taking   MS   contin   900mg   q12h   with
MS   IR   for   breakthrough.
He   is   extremely   constipated   on   this   dose   despite   an   aggressive   bowel   regimen.
What   dose   of   methadone   would   you   prescribe?
900mg   q12h   =   1800mg   po   morphine/day
1800mg   po   morphine/day   X   (1   mg   po   methadone/day   /20mg   po   morphine/day)   =   90mg   po   methadone/day
Reduce    by   50%   for   cross   tolerance   =45mg    po   methadone/day
Answer:   15mg   po   methadone   q8h
Small   Groups:
Ms.
Y   is   a   35   yo   AAF   with   h/o   breast   CA.
She   currently   takes   methadone   5mg   q8h   with   morphine   30mg   tabs   q3h   prn   pain.
She   comes   to   your   clinic   having   run   out   of   morphine   for   breakthrough   pain.
Upon   further   questioning,   she   reports   that   her   pain   is   manageable   but   only   if   she   takes   2   morphine   tabs
(60mg)   every   4   hrs   around   the   clock.
What   should   her   new   methadone   dose   be?
(Hint:    convert   her   breakthrough   morphine   to   methadone,   then   add   that   to   her   current   dose)
Complicated   /multiple   opioid   conversions
PP:    Convert   everything   to   morphine   and   go   from   there
Decrease   for   cross   tolerance   at   the   end
Ex.
Mr.
Y   is   a   60   yo   WM   who   is   admitted   to   your   medicine   team   with   cellulitis.
He   has   chronic   pain   from   multiple   back   surgeries   and   is   on   a   crazy   pain   regimen,   that   you   would   like   to   simplify.
He   takes   MS   Contin   100mg   q8h,
Percocet   (5/325)   6   X/day,   Dilaudid   4   mg   (which   he   takes   4X/day),   and   is   wearing   a   fentanyl   patch   50mcg/hr.
What   new   pain   regimen   do   you   recommend?
Convert   everything   to   morphine   –
MS   Contin   100mg   q8h    =    300mg   morphine/day
Oxycodone   5mg   X   6   doses=   30mg   oxycodone/day    =    30mg   po   morphine/day
Dilaudid   4mg   X   4   =   16mg   dilaudid/day    =    80mg   morphine/day
Fentanyl   patch   50mcg/hr    =    150mg   morphine/day
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
TOTAL   morphine   equivalent/day   =   560mg/day
Covert   to   methadone   –   560mg   morphine/day   X   (1mg   po   methadone/10mg   po   morphine)   =   56mg   methadone/day
Decrease   for   cross   tolerance   –   50%    56mg   =   28mg   po   methadone/day
Answer:    Methadone   10mg   q8h   +   Dilaudid   8   mg   po   q4h   prn   pain
6

4.
CHANGING   OPIOID   ROUTE:    same   drug
Use   for:    po Æ   IV   :    Pt   who   needs   to   be   NPO;    clinical   situation   that   requires   rapid   titration
IV   Æ   po:    calculating   home   dose   of   opioids/discharge   planning
PP:    If   pt   is   on   a   long ‐ acting   opioid   –   DO   NOT   just   stop   it   if   pt   unable   to   take   po,
start   parenteral   basal   rate
Ex.
Ms.
T   is   a   60   yo   WF   with   MM   who   is   taking   MS   Contin   60mg   q12h   with   an   occasional   MS   IR   for   breakthrough.
She   is   admitted   after   a   pathologic   fracture   of   her   humerus   and   is   NPO   for   surgery.
What   IV   dose   of   morphine   do   you   want   to   start   her   on   ?
Calculate   morphine   in   24   hrs   =   60mg   q12h   =   120mg   po   morphine/24   hrs
3mg   po   morphine   =   1mg   IV   morphine
120mg   po   morphine   X   (1mg   IV   morphine/3mg   po   morphine)   =   40mg   IVmorphine   in   24   hrs   =   1.6mg/hr   IV   morphine
Mr.
M   is   a   55   yo   WM   on   20mg   po   methadone   q8h   for   his   chronic   abdominal   pain   from   a   soft   tissue   sarcoma.
He   is   admitted   with   intractable   N/V.
What   do   you   do   with   his   methadone?
2mg   po   methadone   =   1mg   IV   methadone
Just   change   route   –   Answer:    10mg   IV   Methadone    q8h
5.
CHANGING   OPIOID   ROUTE:    different   drug
PP:    Same   rules   apply   –   use   morphine   to   calculate   equianalgesic   dose;   decrease   new   dose   by   ½ ‐ 2/3   for   cross   tolerance
Ex.
Mr.
A   is   a   66   yo   AAM   with   chronic   back   pain   from   multiple   surgeries.
He   is   on   Oxycontin   120mg   q12h   with   an   occasional   oxycodone   for   breakthrough.
He   is   admitted   for   a   laminectomy.
You   are   the   medicine   consult   for   pre ‐ op   and   the   surgical   team   wants   to   start   a   dilaudid   PCA.
What   basal   would   you   recommend   for   when   pt   is   NPO?
Oxycontin   120mg   q12h   =   240mg   oxycodone/24   hrs   =   240mg   po   morphine/24   hrs   =   80mg   IV   morphine/24   hrs
80mg   IV   morphine/24   hrs   X   (1   mg   IV   dilaudid/   5mg   IV   morphine)   =   16mg   IV   dilaudid/24   hrs   =    0.67
mg   IV   dilaudid/hr
Reduce   for   cross   tolerance   (2/3   X   0.67)   =   0.4mg
IV   dilaudid/hr
7

Small   Groups:
Miss   D   is   a   25   yo   AAF   with   sickle   cell   anemia   who   comes   to   the   ER   in   crisis.
She   is   dehydrated,   complains   of   N/V   X   2   days,   and   is   unable   to   keep   any   food   (or   medication)   down.
According   to   the   pt   and   the   Red
Book,   she   usually   takes   90   MS   IR   q1hr   prn   for   a   typical   crisis.
You   would   like   to   give   her   IV   dilaudid   prn.
What   dose   to   you   choose?
Ms.
P   is   a   54   yo   WF   with   breast   ca   with   progressive   bony   mets.
She   is   admitted   to   N4N   for   pain   control   and   is   placed   on   a   dilaudid   PCA   to   see   how   much   opioid   she   requires.
After   looking   at   the   pump   history,   she   has   required   60mg   IV   dilaudid   in   the   last   24   hrs.
You   would   like   to   start   methadone,   what   dose   do   you   choose?
8

Morphine   Sulfate   IR
Morphine   Sulfate   ER
(MS   Contin)
Oxycodone   IR
Oxycondone   SR
(Oxycontin)
Dilaudid
(hydromorphone)
Fentanyl   patch
Methadone
15   mg,
15mg,
5
10mg,
2
12
5   mg mg
,
30
30mg,
20mg,
4mg, mcg/hr, mg,   mg
10mg,
8
25
60mg,
40mg,
tabs; mg
10mg/ml,
100mg,
80mg, mcg/hr,
40mg,
20mg/ml
200mg
160mg
50mcg/hr,
10mg/5ml
75 tabs
solution
mcg/hr, solution,
RATIOS   morphine   PO   =   oxycodone   PO
1mg   IV   morphine    =   3   mg   PO   morphine
1mg/hr   IV   morphine   (=   72mg   po   morphine/day)   =   25   mcg/hr   Fentanyl   patch
1mg   IV   morphine   =   10   mcg   IV   fentanyl
100mcg   fentanyl   lollipop   =   1mg   IV   morphine
5   mg   po   morphine   =   1mg   po   dilaudid
5mg   IV   morphine   =   1mg   IV   dilaudid
1   mg   IV   dilaudid   =   4 ‐ 5   mg   po   dilaudid
10mg   PO   morphine   =   1mg   PO   methadone   (average)
20   mg   po   morphine   =   1   mg   po   methadone   (when   >1000mg   MS   in   24   hrs)
IV   =   SQ   (morphine   and   dilaudid)
100mg   IV   morphine   =   10mg   epidural   morphine   =   1mg   intrathecal   morphine
100mcg/hr
5mg/5ml
solution
9