OPIOID ROTATION :
A WAY TO BETTER ANALGESIA
A.M.TAKDIR MUSBA
DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN MANAGEMENT
FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
MAKASSAR INDONESIA
OBJECTIVES
• THE ROLE OF OPIOID IN CANCER PAIN
• OPIOID AND ANALGESIA RESPONSE
• THE IMPORTANT OF OPIOID ROTATION
• OPIOID ROTATION IN CLINICAL SETTING
THE ROLE OF OPIOID IN CANCER PAIN
• Opioid : the mainstay of cancer pain management
• Opioid : a preferred choice in treating cancer pain of moderate to severe intensity
• Unfortunately : Cancer pain is undertreated, due to fear of using opioid therapy
www.esmo.org
WORLD OPIOID CONSUMPTION, 2013
(mg/capita)
Sources: International Narcotics Control Board; United Nations population data
Opioid Consumption, ASEAN, 2013
Sources: International Narcotics Control Board; United Nations population data
INA: 0.100698
PHIL: 0.140324
MAL: 1.335027
SING: 1.167591
THAI: 1.076287
(mg/capita)
MYTHS OF USE OPIOID !!!!!!!
ADDICTION & DEPENDENCE
TOLERANCE
DOSE INCREMENT ISCONSERVATIVE
NARCOTIC IN OLDER BE AVOIDED
ADEQUATE PAIN CONTROL
PARENTERAL MORE EFFECTIVE
AS NEEDED BASIS
HEAVY SEDATION
OPIOID EFFECTIVE FOR ALL
PAIN CANNOT BE RELIEVED
M Y T H S
Opioid in Indonesia
Morphine considered to be the standard opioid analgesic, oral sustained release and IV prep. available
Fentanyl fast onset, more potent than morphine, less side effect, transdermal sustained and IV prep. available
Meperidine is not considered a first-line opioid analgesic medication, just IV preparation
Hydromorphone, semi-synthetic opioid agonist, more potent than morphine, just oral sustained release prep.
Codein, a weak opioid, is pro-drug of morphine, just oral
Tramadol, a weak opioid that acts on mu-receptors, is another reasonable alternative, oral and IV preparations
WHO Stepladder
FOR CANCER PAIN MANAGEMENT
• By the mouth
• By the ladder
• By the clock
• Individualized
for the patient
• Attention to detail
Work hard to relief pain
Analgesia Response
Type and temporal pattern of
pain
Development of tolerance
Pharmacokinetic profile
Pharmacodynamicfactor
Disease progression Side effect
Individual thinking
OPIOID RECEPTOR
More than 30-50 percent ranges of individual human differences μ-opioid receptor densities
Ravert HT, Bencherif B, Madar I, et al: PET imaging of opioid receptors in pain: Progress and new directions. Curr Pharm Des. 2004
Desensitisation and internalisation
Opioid Tolerance
INDIVIDUAL OPIOID RESPONSIVENESS ???
After you give the OPIOID,
some possibilities …
Pain is controlled but intolerable adverse effects
Pain is not adequately controlled, but it is impossible to increase the dose due to adverse effects
Pain is not adequately controlled by rapid increasing the dose of opioids, although the drug does not produce adverse effects
Pain is controlled and no or tolerable adverse effects
OPIOID ROTATION
A CHANGE IN OPIOID DRUG OR ROUTE OF ADMINISTRATION WITH THE GOAL OF IMPROVING OUTCOMES
Retrospective studies: opioid rotation rates 20-44%
Bruera EB.et al. Cancer. 1996
Fallon M. Palliat Med. 1997Muller-Busch HC. Et al. Eur J Pain. 2005
OPIOID ROTATION
• Lack of efficacy
• Side effect
• Tolerance
• Opioid-induced
hyperalgesia
Switching OPIOID
• Practical
consideration
• Patient’s condition
• Drug availability
Altering administration
route of OPIOID
Improving analgesic response and/or
reducing adverse effects
THE MAJOR INDICATION
• Lack of efficacy▫ Worsening of existing pain or underlying disease ▫ Development of opioid analgesic tolerance▫ Inability to tolerate side effects
• Development of intolerable side effects▫ Gastrointestinal (constipation, nausea, vomiting)▫ CNS (sedation, somnolence, dysphoria,
hallucinations, myoclonus)▫ Cardiovascular (orthostatic hypotension due to
histamine release)
OTHER INDICATION
• Change in patient's status▫ Inability to swallow▫ Poor peripheral vascular status▫ Poor absorption of transdermal medications▫ Requirements of high-dose opioids not practically
administered by oral, rectal, transdermal routes
• Practical considerations▫ Availability in local pharmacies▫ Cost▫ Amount of opioid needed▫ Route of administration▫ Opioiphobia
HOW TO DO THE ROTATION ???
• Opioid dose conversion
• Some consideration
▫ Pk/Pd drugs
▫ Available preparation
Equianalgesic Opioid Dosing
• Provides evidence-based values for the relative potencies among different opioid drugs & routes
• Only a broad guide for dose selection
• Reduce the risk of relative over or underdosing
• Larger interpatient variability
• Incomplete cross tolerance
Equianalgesic Opioids Dosing
Oral dose ( mg )
Opioid Parenteraliv/sc/im ( mg )
400 Meperidine 100
120 Tramadol 100
200 Codeine 130
30 Morphine 10
7.5 Hydromorphone 1.5
- Fentanyl 0.15 – 0.20
- Sufentanyl 0.02
Oral morphine (mg/day) by approximately dividing the oral morphine dose by 2. e.q. Morphine 50 mg PO in 24 hrs = Fentanyl patch 25 mcg/hr
McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For Effective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010Vadalouca A. et al. Opioid rotation in patients with cancerournal of OpioidManagement 4:4 2008
Switching from Morphine to Fentanyl,
vice versa
Morphine to TDS Fentanyl
• Calculate total daily dose of the current opioid
• Calculate the equianalgesic24-hour morphine dose
• Determine the equivalent transdermal fentanyl dose
• Continue the previous opioid for 8-12 hours
• Order adequate breakthrough dosing
TDS Fentanyl to Morphine
• Calculate the equivalent dose of the new opioid
• Calculate the scheduled interval and breakthrough dose of the new opioid
• Remove the patch and start the new opioid 12 hrs later
• Order adequate breakthrough dosing
Morphine Sustained Release to Transdermal Fentanyl
Waktu
Ko
ns
en
tra
si o
pio
id
-
-
Analgesic window
Kondisi stabil (dalam 12 jam)
IV
ER: sustained release opioidIV : intravena opioidTD : transdermal opioid
ER
TD
Equianalgesic Opioids Dosing
Oral dose ( mg )
Opioid Parenteraliv/sc/im ( mg )
400 Meperidine 100
120 Tramadol 100
200 Codeine 130
30 Morphine 10
7.5 Hydromorphone 1.5
- Fentanyl 0.15 – 0.20
- Sufentanyl 0.02
Oral morphine (mg/day) by approximately dividing the oral morphine dose by 2. e.q. Morphine 50 mg PO in 24 hrs = Fentanyl patch 25 mcg/hr
•McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For Effective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010•Vadalouca A. et al. Opioid rotation in patients with cancer. Journal of OpioidManagement 4:4 2008
Opioid drugs
Conclussion
• Better analgesic with opioid is our priority for cancer pain
• Inadequate analgesia or intolerable side effect was the reason for opioid rotation
• Many factors should be considered in opioidrotation because of individualize analgesic response
In My Opinion : Anesthesiologist can do it perfectly !
Thank you very much for your kind attention
Together relief Pain