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Pharmacology of Opioids
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
Most opioids have a similar spectrum of adverse effects (see Table 4.3). Clinical trials in acute pain management have shown that opioids administered in equianalgesic doses to large population groups have a similar incidence and degree of side effects. However, there may be individual differences in patient responses and some patients may experience more side effects with one particular drug. In these instances, opioid rotation, that is, a change to another opioid, is appropriate if attempts to manage the side effects have been ineffective.
Palliative Care Pain Management
Published in Gary W. Jay, Practical Guide to Chronic Pain Syndromes, 2016
Opioid rotation, trials of different opioid drugs, can be used to attain the most favorable balance between analgesia and side effects. According to a systematic review of data, clinical improvement is seen in more than 50% of patients after opioid rotation. Reasons to consider opioid rotation are adequate pain control, but adverse side effect profile; inadequate pain control with inability to escalate dose secondary to side effects; and rapid dose escalation without pain relief (70). Prediction of response to the new opioid is variable due to effects of cross-tolerance and the incomplete understanding of exact equianalgesic doses. A commonly used practice to rotate opioids is to calculate the sum of opioids given during the previous 24-hour period in units of oral morphine equivalents. From this calculation, the new agent can be dosed up to 50% to 80% of the new agent’s equianalgesic dose except in the case of methadone.
Development of palliative medicine in the United Kingdom and Ireland
Published in Eduardo Bruera, Irene Higginson, Charles F von Gunten, Tatsuya Morita, Textbook of Palliative Medicine and Supportive Care, 2015
Dose reduction or discontinuation of opioids may usually not be an option for management of OIN due to the presence of uncontrolled pain or dyspnea. Opioid rotation, the term used for substituting one opioid for another, is usually preferred and allows for the reduction of neurotoxicity symptoms while simultaneously retaining or improving analgesia 1,58,60,91,92 However, opioid rotation has not been systematically studied in randomized controlled trials, and this evidence is mainly from observational or uncontrolled trials. Â 93
An update on the safety of prescribing opioids in pediatrics
Published in Expert Opinion on Drug Safety, 2019
Jagroop M. Parikh, Patricia Amolenda, Joseph Rutledge, Alexandra Szabova, Vidya Chidambaran
Extended use of one opioid results in low efficacy for the medication. In these cases, switching to another opioid in an equianalgesic dose may be considered. Table 1 depicts pediatric dosing guidelines for opioids. Opioid rotation is a strategy also used when there is a need for a different potency, a lowered opioid dose, use of a smaller quantity, and decreased intolerable side effects, when allow for use of a different formulation (for example, subcutaneous instead of intravenous), or because of practical considerations such as cost. Due to incomplete opioid cross-tolerance, the dose of the new opioid should be decreased by approximately 25–50% to minimize adverse effects and then the dose may be titrated to adequate pain control or supplemented with breakthrough medication doses for rescue analgesia. If the starting opioid has been escalated recently after a prolonged period of stability, then a dose closer to the previous stable level may be a more appropriate place to start [24,25]. In our clinical experience, many appropriate candidates for opioid rotation have chronic use of opioids, and while there are tables to calculate opioid analgesic equivalency, these tables are often based on opioid-naive patients and reflect variable patient populations.
Reduction of opioid use and improvement in chronic pain in opioid-experienced patients after topical analgesic treatment: an exploratory analysis
Published in Postgraduate Medicine, 2018
Jeffrey A Gudin, Michael J Brennan, E. Dennis Harris, Peter L Hurwitz, Derek T Dietze, James D Strader
There is lack of consensus among health-care providers about defining opioid-treated patients as naïve, experienced, or tolerant [46]. The FDA has defined opioid tolerance as patients who have been on an opioid for at least 1 week who have been prescribed a certain threshold dose of opioids, which is routinely a higher dose than is prescribed for acute pain. This ‘FDA-endorsed’ definition of opioid tolerance is also found in many of the new REMS documents and FDA-approved Medication Guides for new opioids [47]. We defined patients as opioid-experienced instead of opioid-tolerant as we did not request the duration of time the patient was on opioid therapy prior to enrolling in the study. That said, some researchers and entities have indicated that patients are opioid-naïve despite having been prescribed and treated with opioid therapy [46,48]. There is a need for consensus among health-care providers in order to limit the misunderstanding of the multiple definitions of those treated with opioid therapy. Evaluating the impact of opioid rotation in patients when determining consensus is also encouraged. Outcomes from this subset of OEPs from the observational OPERA study suggest that topical analgesics provide an effective and safe treatment alternative to opioids and may assist in shortening the length of time patients who are prescribed opioids for chronic pain are treated with prescribed opioids.
Substance use disorders: diagnosis and management for hospitalists
Published in Journal of Community Hospital Internal Medicine Perspectives, 2020
Ahmed K. Pasha, Arnab Chowdhury, Sanah Sadiq, Jeremiah Fairbanks, Shirshendu Sinha
Opioid rotation plays a vital role in inpatient care. Scenarios in which this becomes necessary include a new organ failure/dysfunction, side effects from a particular opioid, inability to tolerate previous route of administration, or incomplete pain relief from previous regimen. Unavailability of a specific opioid may necessitate opioid rotation as well such as with the recent shortages of injectable opioids. In the absence of the above indications, it is best to avoid changing a patient’s outpatient regimen. If the need arises to change to a different opioid, keeping incomplete cross-tolerance in mind, dose should be reduced by 25-50%. Follow up to evaluate analgesia and side effects should be 5–10 min after an intravenous test dose and 30–40 min after oral test dose [26].