Common practices for changing from one opioid to another, including use of published dose conversion ratios, may be contributing to the growing number of opioid-related fatalities, new research suggests.
The results from a scientific literature review and a case study using a new model of opioid rotation are presented in the April issue of Pain Medicine, the official journal of the American Academy of Pain Medicine (AAPM).
Patients may be rotated from one opioid to another for various reasons, including inadequate pain relief, intolerable side effects or lack of coverage by insurance companies of the original opioid. Opioid rotation has shown to be useful in 50 percent to 80 percent of patients. Yet, according to a recent report by the U.S. Centers for Disease Control and Prevention (CDC), nearly 15,000 people die every year as a result of overdoses involving prescription opioids. While many decedents were people who took opioids without being prescribed them, some patients die while under the care of physicians.
"Our goal is to reverse the national trend of unintentional overdose deaths while advocating for appropriate therapy for the one in three Americans who experience chronic pain," said Lynn R. Webster, MD, study co-investigator and president-elect of the AAPM.
Flaws uncovered in the current method of rotating opioids include prescriber error and use of inaccurate dose conversion ratios found in published protocols. Webster, who serves as medical director of Lifetree Clinical Research in Salt Lake City, Utah, completed the study with co-investigator Perry G. Fine, MD, immediate past president of AAPM and professor of Anesthesiology, Pain Research and Management Centers in the Department of Anesthesiology at the University of Utah.
Concluding that most fatal outcomes during opioid rotation are preventable, the researchers suggested three easy-to-remember steps that eliminate the need to use a conversion table:
- Reduce the original opioid dose by 10 percent to 30 percent while beginning the new opioid at the lowest available dose.
- Reduce the original opioid dose by 10 percent to 25 percent per week while increasing the dose of the new daily opioid dose by 10 percent to 20 percent based upon clinical need and safety.
- Provide sufficient immediate-release opioid throughout the rotation to prevent withdrawal and keep pain levels down so the patient is not tempted to take too much medication.
In most instances, the complete switch can occur within 3 to 4 weeks, which is longer than for most current methods, the researchers reported.
More research is needed to prove the new paradigm safe and effective in a broad population of patients, they added. The need for research into optimal therapies was highlighted in a recent report on pain from the Institute of Medicine, which found more than 100 million people in America live with chronic pain.
"It is time for professional societies, government agencies and industry to work together and correct the important flaws in current opioid rotation practices," Webster concluded. "All patients who have indications for opioid therapy must be assured that routine clinical practices are safe and have an evidentiary basis."