Opioid Conversions/ Weaning Tips

Question 1

What do we do first when considering converting?

Answer 1

PQRSTU

• consider long-acting
• use non-opioid alternatives when possible
• wean opioid dose (if hyperalgesia)

Question 2

How are IR formulations prescribed?

What opioids are IR?

Answer 2

q4-6h

• see effect in 30 mins
• t1/2 = 2 hrs

oxycodone
morphine
hydromorphone

Question 3

How are ER formulations prescribed?

What opioids are ER?

Answer 3

q8-12h

• baseline coverage
• several hours before effect

methadone
fentanyl patches
oxycodone ER

Question 4

What do we give opioid NAIVE pts?

Answer 4

IR opioids initially
(ER have incr. risk of respiratory depression, or inadequate pn control)

low dose IR (scheduled) + extra for breakthru pn (prn)

–> cont. incr. doses until pt no longer needs breakthru & THEN convert to ER

Question 5

Six steps of opioid conversion?

Answer 5

1. pain assessment (PQRSTU)
2. calculate total daily dose
3. determine appropriate change
   (renal/hepatic func., cost, compliance, wt, nutrition, swallowing ability)
4. Adj. new dose to match pt needs
5. Check new dose
6. Close monitoring/ follow-up initially

Question 6

SA –> LA conversion

Answer 6

1. determine TDD

2. divide q8-12h to determine how many times/ what amt daily

Question 7

IV –> PO

Answer 7

1. determine TDD
2. use chart proportion
3. is it gonna be LA or SA (improving = SA)

Question 8

PO –> IV

Answer 8

1. TDD
2. chart proportion
3. evenly spread dose over 24 h

Question 9

Breakthru pn tips

Answer 9

• try non-pharm (RICE) THEN non-opioid first
  (maybe use nerve based agents if neuropathic indications)
• provide prior to activities that cause flair
• match your IR to ER if pt is on opioid

Question 10

What if pt is using breakthru med excessively?

Answer 10

they need an incr. in basal coverage

Question 11

Breakthru pn –>

Answer 11

1. use 10-15% of TDD (all opioids pt is taking)

2. q4-6h prn

Question 12

Incomplete Cross Tolerance –>

Answer 12

*changing opioid type FROM ONE TO ANOTHER

1. TDD
2. convert with chart
3. decr. new TDD by 25-50%
4. evenly distribute throughout the day per IR or ER

calculate breakthru prn

• if they were well controlled use the lower end of the range on new opioid
• it is easier to add than to take some off

Question 13

Fentanyl –>

Answer 13

1. TDD
2. convert to morphine prn
3. convert to fentanyl

apply patch @ next scheduled dose of LA opioid

follow up

Question 14

Methadone –>

Answer 14

10:1 morphine : methadone

(when converting back to morphine use 3:1 morphine : methadone) - multiply TDD x 3

• can cut methadone tabs in 1/2

Question 15

What kind of opioids should opioid naïve pts be taking?

Answer 15

SHORT ACTING

Question 16

What are the exceptions for incomplete cross tolerance?

Answer 16

fentanyl & methadone