What is the best substitute for hydrocodone (hydrocodone) in a patient with metastatic melanoma and fever, currently taking 30 mg daily, given a national drug shortage?

Opioid Substitution for Hydrocodone in Hospitalized Cancer Patient

Prescribe immediate-release oxycodone 20 mg total daily in divided doses (Option A, but with corrected dosing), as oxycodone is 1.5-2 times more potent than hydrocodone and is the appropriate equianalgesic substitute for a patient on chronic opioid therapy. 1

Critical Dosing Correction

Option A as written (10 mg total daily) significantly underdoses this patient and should not be selected. The correct equianalgesic conversion requires:

• Current hydrocodone dose: 30 mg/day oral [@question context@]
• Oxycodone is approximately 1.5-2x more potent than hydrocodone 2
• Correct equianalgesic oxycodone dose: 15-20 mg/day oral (using conservative 1.5x ratio) 1, 2
• Recommended starting dose after conversion: 10-15 mg/day (reducing by 25-50% for incomplete cross-tolerance) 1

Why Oxycodone Over NSAIDs

Option B (ibuprofen) is inappropriate for multiple reasons:

• This patient requires opioid-level analgesia - he is already opioid-tolerant on 30 mg hydrocodone daily, indicating moderate pain requiring WHO Level II-III analgesics 1
• Abrupt opioid discontinuation risks withdrawal in an opioid-dependent patient 1
• NSAIDs alone cannot substitute for chronic opioid therapy - they are WHO Level I analgesics intended for mild pain or as adjuncts 1
• Fever contraindicates transdermal fentanyl - the patient's temperature of 38.4°C (101.2°F) accelerates fentanyl absorption and is an absolute contraindication to patches 1

Guideline-Based Opioid Selection

Pure agonist short-acting opioids are preferred for cancer pain management:

• Morphine, oxycodone, hydromorphone, and fentanyl are the most commonly used medications for cancer pain 1
• Short half-life opioid agonists (morphine, hydromorphone, oxycodone) are preferred because they can be more easily titrated than long half-life analgesics like methadone 1
• Oral administration is the preferred route when feasible 1, 2
• Oxycodone is available in immediate-release formulations suitable for this clinical scenario 1

Practical Conversion Protocol

Using the equianalgesic table from NCCN guidelines:

1. Calculate total daily hydrocodone: 30 mg/day [@question context@]
2. Convert to oxycodone equivalent: Hydrocodone 30 mg ≈ Oxycodone 15-20 mg (using 1.5-2x potency ratio) 1, 2
3. Reduce for incomplete cross-tolerance: Decrease calculated dose by 25-50% 1
4. Final recommended dose: Oxycodone 10-15 mg/day divided into q4-6h dosing 1
5. Provide breakthrough doses: 10-20% of total daily dose (2-3 mg) for incident pain 1, 2

Critical Safety Considerations in This Patient

Infection and fever require special attention:

• Monitor for opioid-related side effects - infection and fever can alter opioid metabolism 1
• Institute prophylactic bowel regimen immediately with stimulant laxatives (senna/docusate) 1, 2
• Assess pain and side effects regularly - adjust doses based on response 1
• Avoid transdermal fentanyl due to fever accelerating absorption 1

Common Pitfall to Avoid

Do not underdose during opioid conversion - the 10 mg total daily dose in Option A represents a 67% dose reduction from the equianalgesic dose, which will result in inadequate analgesia and potential withdrawal symptoms in this opioid-tolerant patient 1, 2. The correct approach is to calculate the full equianalgesic dose (15-20 mg oxycodone), then reduce by 25-50% for safety (yielding 10-15 mg), not to arbitrarily select a lower dose 1.