What is the best approach to convert a hospice patient with significant pain, currently on hydromorphone (opioid analgesic) 0.4mg/hr, to a fentanyl (opioid analgesic) patch, with hydromorphone 1mg/ml liquid available for breakthrough pain?

Converting Hospice Patient from Hydromorphone Infusion to Fentanyl Patch

Convert the patient from hydromorphone 0.4 mg/hr IV to a fentanyl 12 mcg/hr patch, and provide hydromorphone 1 mg oral liquid every 2 hours as needed for breakthrough pain. 1

Step-by-Step Conversion Algorithm

Calculate Total Daily Hydromorphone Dose

• The patient is receiving 0.4 mg/hr × 24 hours = 9.6 mg/day IV hydromorphone 1

Convert to Fentanyl Patch Using Guideline Tables

• According to NCCN guidelines, 1.5 mg/day IV hydromorphone converts to a 25 mcg/hr fentanyl patch 1
• Since this patient is receiving 9.6 mg/day IV hydromorphone, this exceeds the threshold for a 25 mcg/hr patch but falls well below the 50 mcg/hr threshold (which requires 3.0 mg/day IV hydromorphone) 1
• Start with a 12 mcg/hr fentanyl patch (using the intermediate strength available) to account for the 25-50% dose reduction recommended when rotating opioids due to incomplete cross-tolerance 1

Breakthrough Pain Dosing with Hydromorphone Liquid

• Provide hydromorphone 1 mg oral liquid every 2 hours as needed for breakthrough pain 2
• This represents approximately 10-20% of the total 24-hour opioid requirement when converted to oral equivalents 2
• Using the IV to oral hydromorphone conversion ratio of 1:2.5, the 9.6 mg IV daily dose equals approximately 24 mg oral hydromorphone daily 3
• A 1 mg breakthrough dose represents approximately 4% of the daily oral equivalent, which is conservative and appropriate during the conversion period 2

Critical Implementation Steps

Timing of Conversion

• Apply the fentanyl patch and continue the hydromorphone infusion for 8-12 hours before discontinuing the IV, as fentanyl patches take 12-24 hours to reach therapeutic levels 1
• After 12 hours, discontinue the IV hydromorphone infusion 1
• Ensure breakthrough medication is readily available during the first 24 hours, as this is when patients most commonly need supplemental analgesia 1

Monitoring and Titration Protocol

• Assess pain and side effects every 4-6 hours for the first 24-48 hours after conversion 4
• Do not increase the fentanyl patch dose for at least 3 days after initial application, as it takes this long to reach steady state 5
• If the patient requires more than 3-4 breakthrough doses per day, increase the fentanyl patch by 12 mcg/hr (to 25 mcg/hr) rather than shortening intervals 2
• Wait at least 6 days between subsequent dose increases, as this is how long it takes for fentanyl levels to reach equilibrium on a new dose 5

Common Pitfalls to Avoid

Do Not Use Standard Conversion Tables Directly

• The conversion tables in guidelines are designed to be conservative and will underestimate the fentanyl dose needed 1, 5
• This is intentional to prevent overdosing, but recognize that upward titration will likely be needed 1

Do Not Convert Back Using the Same Tables

• Never use fentanyl-to-opioid conversion tables in reverse, as this will overestimate the dose of the new agent and can cause fatal overdose 5

Avoid Premature Dose Escalation

• Resist the urge to increase the patch before 72 hours (3 days), even if pain control seems inadequate 5
• Instead, use breakthrough medication liberally during this period and calculate the total breakthrough usage to guide the next patch dose increase 1

Special Considerations for Hospice Patients

• Fentanyl patches are only appropriate when pain is relatively stable; they are not recommended for rapidly changing pain requiring frequent dose adjustments 1
• Avoid applying heat (heating pads, electric blankets) over the patch site, as this accelerates fentanyl absorption and increases overdose risk 1
• In hospice patients with fever, monitor more closely for signs of excessive sedation or respiratory depression 1

Renal Impairment Considerations

• Hydromorphone accumulates in renal failure, so if this patient has renal impairment, the fentanyl patch may actually provide better pain control at lower equivalent doses 6
• Fentanyl is safer than hydromorphone in renal impairment, as it does not produce problematic metabolites that accumulate 6

Safety Measures

Naloxone Availability

• Ensure naloxone is immediately available in the home, with clear instructions for caregivers on when and how to administer it 2
• Discuss overdose risk factors with family members, particularly the danger of applying heat to the patch site 1

Bowel Regimen

• Continue or initiate a stimulant laxative regimen, as constipation is universal with sustained opioid therapy and does not improve with opioid rotation 2

Documentation for Caregivers

• Provide written instructions specifying when to give breakthrough doses, how to apply/change patches, and warning signs of oversedation 7
• Caregivers administering opioids at home often under-utilize breakthrough medication, particularly with flexible regimens, so clear guidance is essential 7