OPIOID CONVERSIONS Small Groups Answer Sheet 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. 15mg IR morphine X 8 doses = 120 mg morphine/day Sustained release =60mg MS Contin q12h Rescue dose 10% of 120 mg = 12mg, 20% 120mg = 24mg ANSWER: 60mg MS Contin q12h + 15mg MS IR q3 hr prn 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? 20mg oxycodone X 5 doses = 100mg oxycodone/day 100mg + (50% 100mg) = 100 mg + 50mg = 150mg oxycodone/day Rounding up based on pill dose availability 80mg oxycontin q12h Rescue dose – 10% 160mg = 16 mg, 20% 160 mg = 32mg Answer: Oxycontin 80mg q12h with 15‐30mg Oxycodone q4h prn ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 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? Total Morphine/day = 60mg (SR) + 60mg (IR) = 120mg total morphine/day Convert all to long‐acting = MS Contin 60mg q12h Rescue dose – 10% 120 mg = 12 mg, 20% 120mg = 24mg Answer: MS Contin 60mg q12h + 15‐20mg MS IR q4h prn 1 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? 25mcg/hr patch = 75 mg po morphine/day 75 mcg/hr patch X [75 mg po morphine/day] = 225 mg po morphine/day [ 25mg/hr patch] Reduce for cross‐reactivity (2/3) 225 ~= 150mg morphine/day = MS Contin 75 mg q12h Breakthrough 10% 150mg = 12mg, 20% 150mg = 30 mg MS IR Answer: MS Contin 75mg q12h with 15‐30mg MS IR q4h prn ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 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? Oxycodone in 24 hrs = 40mg (SR) + 20mg (IR) = 60mg oxycodone/day = 60mg po morphine/day Oxycodone = Morphine Reduce for cross‐reactivity ½ (60mg morphine) = 30mg po morphine/day = MS Contin 15 mg q12h Breakthrough – 10% 30mg = 3mg 20% of 30mg = 6 mg Answer: MS Contin 15mg q12h + MS IR 5mg q4h prn pain 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. How much should you increase her methadone? Calculate morphine she takes in 24 hrs = 60mg X 6 doses = 360mg morphine/day 360mg morphine/day X [1mg po methadone/10mg po morphine] =36 po methadone/day Decrease for cross tolerance = 50% (36mg po methadone)= 18 mg po methadone Add 18mg po methadone/day + current dose 15 mg methadone/day = 33 mg po methadone/day New dose of methadone = 10mg methadone q8h 2 Miss D is a 25 yo AAF sickle cell patient who comes into the ED in crisis. She is dehydrated secondary to gastroenteritis. She is unable to keep any food (or pills) down. According to the pt (and the Red Book), she takes 90 mg IR morphine q1hr prn when she goes into crisis. IV dilaudid is available in the ER. How much do you want to give her? 90 mg po morphine = 30mg IV morphine = 6 mg IV dilaudid 2/3 (6mg ) = 4 mg IV dilaudid** **If pt writhing in 10/10 pain in ED, you could opt not to reduce for cross tolerance and give 6mg IV dilaudid Ex. 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 is required 60mg IV dilaudid in the last 24 hrs. You would like to put her on methadone. What starting dose do you choose? 60mg IV dilaudid/day = 300mg IV morphine/day = 900 mg po morphine/day 900mg po morphine/day = 90 mg po methadone/day Decrease by ½ for cross tolerance = 45 mg methadone/day Methadone 15 mg po q8h 3