How to consider opioid rotation for a patient on 27.5 Morphine Milligram Equivalents (MME) including as-needed (PRN) doses?

Opioid Rotation for a Patient on 27.5 MME

Opioid rotation should be considered for this patient on 27.5 MME (including PRN doses) if they are experiencing inadequate pain control or persistent side effects from their current therapy. 1

When to Consider Opioid Rotation

• Consider opioid rotation when the patient has inadequate pain control despite appropriate dose titration 1
• Consider rotation when the patient experiences persistent side effects that don't resolve with supportive care 1
• Rotation may be necessary when the patient requires dose escalation but is limited by combination medication components (e.g., acetaminophen in combination products) 1

Steps for Opioid Rotation

Step 1: Calculate Current Total Daily Dose

• Calculate the total 24-hour opioid dose (both scheduled and as-needed doses) 1
• For this patient, the total is already calculated at 27.5 MME/day 2
• Note that this dose is above the 20 MME/day threshold where increased risk of unintentional overdose begins (RR 2.81,95% CI 1.09-7.22) 2

Step 2: Select New Opioid and Calculate Equianalgesic Dose

• Determine the equianalgesic dose of the new opioid using conversion tables 1
• If pain was effectively controlled with the current opioid, reduce the calculated equianalgesic dose by 25-50% to account for incomplete cross-tolerance 1
• If pain was not effectively controlled, consider using 100% of the equianalgesic dose or increase by 25% 1

Step 3: Divide Total Daily Dose Based on Dosing Schedule

• For oral opioids, divide the total daily dose by the number of doses per day 1
• For extended-release formulations, divide appropriately (e.g., twice daily for 12-hour formulations) 1

Special Considerations for Specific Opioid Rotations

Converting to Transdermal Fentanyl

• For patients on low doses like 27.5 MME, the lowest available patch (25 mcg/h) would be appropriate if converting to transdermal fentanyl 1
• Prescribe breakthrough medication during transition, especially during the first 8-24 hours 1
• Avoid using transdermal fentanyl in patients with fever or exposure to external heat sources, as this increases absorption and risk of overdose 3

Converting Between Short-Acting and Long-Acting Formulations

• When possible, use the same opioid for both short-acting and extended-release forms 1
• For continuous pain, provide background analgesia with extended-release formulations 1
• Allow rescue doses of short-acting opioids at 10-20% of the 24-hour dose 1

Monitoring After Rotation

• Monitor patient closely during the first 24-48 hours after rotation 1
• Adjust dose as needed based on pain control and side effects 1
• If patient experiences unmanageable side effects, consider downward dose titration by approximately 25% 1
• For patients with persistent side effects, consider another rotation or adjuvant therapies 1

Important Cautions

• Avoid mixed agonist-antagonists in combination with opioid agonist drugs 1
• Be aware that converting from an agonist to an agonist-antagonist could precipitate withdrawal in opioid-dependent patients 1
• Avoid codeine or morphine in patients with renal failure due to risk of metabolite accumulation 1
• For safe discontinuation, taper gradually (e.g., no greater than 25% of total daily dose) to avoid withdrawal symptoms 3

Remember that even at this relatively low dose of 27.5 MME, the patient has an increased risk of unintentional overdose compared to doses below 20 MME/day 2, so careful monitoring is essential during any rotation process.