Opioid Rotations

Information for Family Physicians

The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain recommends a new cross-titration method for opioid rotations as follows: 

  1. Decrease the total daily dose of the current oral opioid 10-30% while starting the new oral opioid at the lowest total daily dose for the formulation.
  2. Decrease the total daily dose of the current opioid 10-25% per week while titrating up the total daily dose of the new opioid weekly by 10-20% with a goal of switching over 3-4 weeks.

This cross-titration method is not reliant on equianalgesic dosing tables, which are known to have significant limitations. This method enhances safety by starting new opioids at their lowest available doses, and implementing weekly follow-ups for close monitoring. While achieving rotation completion by 3-4 weeks may be a reasonable goal in some cases, many patients will require a rotation taking place over a longer period of time. Please refer to the Appendix for an example of using this method.

 

The traditional method for opioid rotations was as follows:

  1. Record the total amount of each opioid (short and long acting) currently being taken in a 24-hour period.
  2. Convert each opioid to oral morphine equivalents and add them up for a total morphine equivalent daily dose (MEDD).
  3. Reduce this amount by 25-50% to determine the target MEDD.
  4. Use an equianalgesic table to determine the dose of the new opioid.

This method has been criticized due to reliance on equianalgesic tables, which have many limitations including single dose or limited range of doses, poor study designs, opioid-naïve patients, lack of consideration for ethnicity, advanced age, concomitant medications, comorbidities, organ dysfunction, direction of switching, and opioid-receptor polymorphism.

Opioid (doses in mg/day, except where noted)

To calculate oral morphine equivalent daily dose (MEDD), multiply by:

Buprenorphine transdermal (in mcg/hour)a

3

Codeine

0.15

Fentanyl transdermal (in mcg/hour)b

2.4

Hydromorphone

5

Methadonec

 

          1-20 mg/day

4

          21-40 mg/day

8

          41-60 mg/day

10

          ≥61-80 mg/day

12

Morphine

1

Oxycodoned

1.5

Tapentadol

0.4

Tramadol

0.15

a For example, buprenorphine transdermal patch 5 mcg/hour q7days: Multiply by 3, for an oral morphine equivalent daily dose (MEDD) of 15 mg per day.
b For example, fentanyl transdermal patch 25 mcg/hour q72h: Multiply by 2.4, for an oral morphine equivalent daily dose (MEDD) of 60 mg per day. Caution is re     quired with fentanyl as its absorption is affected by heat and other factors.
c Consult a pain specialist for all methadone rotations. Conversion of methadone to morphine must take into account the last known MEDD.
d Many pain specialists at the Chronic Pain Centre use a factor of 2 instead of 1.5.

  • The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain found low quality evidence regarding the impact of opioid rotation on pain and functioning:
    • With respect to pain, based on data from 524 patients in 5 studies, mean change score of -3.3 points on an 11-point numerical rating scale, considered a large reduction in pain and a clinically important difference.
    • With respect to physical function, based on data from 206 patients in 2 studies, opioid rotation resulted in a mean change score of +16.7 points on the SF-36 physical function scale, considered a large improvement in physical function and a clinically important difference. 
  • For patients who are currently using opioids and have persistent problematic pain and/or problematic adverse effects, an opioid rotation is recommended, rather than keeping the opioid the same.
  • An opioid rotation in such patients may also help facilitate a dose reduction.
  • Inadequate analgesia
  • Pharmacological tolerance
  •  Adverse events (e.g. sedation, constipation, falls in elderly, etc.)
  • Problematic drug-drug interactions
  • Long-term opioid complications including hyperalgesia, sleep apnea, and hypogonadism
  • Nonadherence to the treatment plan
  • Change in clinical status (e.g. risk for drug abuse, new-onset renal impairment)
  • Different route of administration is desirable (e.g. PO to transdermal)
  • Practical issues (e.g. cost, availability of opioids)
  • Patient request (e.g. due to negative social stigma, financial issues, etc.)
  • Treatment goals are not met; pain AND function have not improved by at least 30%

One strategy behind opioid rotation is the ability to reduce the dose of the new opioid by a significant amount, perhaps 25-50% of the original opioid’s morphine equivalent daily dose, due to incomplete cross-tolerance.

Key safety issues for consideration

  1. The cross tolerance to opioids is not complete.
  2. All health care providers should advise the patient of the risk of overdose and the signs and symptoms of intoxication from opioids.
  3. Physicians should indicate NEW or SWITCH on the prescription to alert the pharmacist that the opioid is being switched.
  4. Consider switching an opportunity to re-evaluate benefits and risks of opioids for pain.
  5. Pharmacists should check the conversion based on previous doses of opioids prescribed (when available) and how the medication was being taken before the switch.
  6. Morphine equivalent dose is recommended based on best possible medical history (BPMH). Speak to patients but communication between prescribers is crucial.
  7. Check for medication interactions that can cause inhibition of metabolic pathways. Medication interactions can lead to toxicity. Medications may increase or decrease elimination of the new opioid via either the hepatic or renal route.
  8. Carefully monitor the use of other substances that may potentiate the sedative/respiratory depressant effects of opioids (e.g. alcohol, benzodiazepines, barbiturates).
  9. As a rule, under-replace and titrate up after three to five half-lives to prevent overdose.
  10. Special consideration should be given when converting to fentanyl.

Underestimating the dose may seem safe, but may in fact lead to self-medication if the patient is trying to find adequate pain relief or to treat withdrawal symptoms. Open and honest conversations about these risks are important.

  • All patients are recommended to have a naloxone kit during an opioid rotation. Take home naloxone kits are available free of charge to all Albertans. Many pharmacies routinely carry naloxone kits, and other pharmacies can order inventory. Training is provided by the pharmacy and recommended for both the patient and family members. Get Naloxone
  • The first dose of a new opioid is recommended in the morning, to allow monitoring throughout the day.
  • Previous opioids should be taken back to the pharmacy for safe disposal.
  • Patients should be advised: do not drink alcohol, do not mix with other drugs that can cause sedation (e.g. benzodiazepines), do not take more than instructed, and do not drive until dose is stable.
  • Monitor for sedation, slurred speech, and slowed breathing.

Recommend naloxone. Patients may have difficulty understanding the concept of variation in opioid potencies and take more than their prescribed dose. Consider a tolerance/safety check in 3-4 days following rotation to reassess pain control, adverse effects, and withdrawal symptoms.

  • Teleconsult Service
    • Book a 15-minute telephone conversation to discuss your patient’s chronic pain management. Use the Path to Care Referral Form and refer to Chronic Pain Centre, select Requested Action “Telephone consultation”, and Fax to (403) 209-2954.
  • Specialist Link Advice
    • Call a chronic pain nurse practitioner at 403-910-2551 (toll-free 1-844-962-5465). Your call will be returned within one hour; available Mondays - Fridays 8:00am – 4:00pm.
  • eReferral Advice
    • Available via your Alberta Netcare login. Add eReferral to your Alberta Netcare homepage, search for your patient, and click on the Create Referral icon in the menu bar. You will receive advice within five calendar days.

Conversion Tables from the Canadian Opioid Guidelines and CDC Guidelines

Cross-Titration Method Example
Decrease total daily dose of current opioid by 10-25% per week while starting the new opioid at the lowest daily dose. Increase the new opioid 10-20% per week while decreasing previous opioid 10-25% per week. Suggest weekly follow-ups and weekly dispensing using dosette/blister pack.