Optimizing Opioid Doses

Optimizing Opioid Doses:

• Aim to utilize the smallest effective dosage of opioids, especially for patients new to opioid therapy, and adjust dosage gradually.
• While increasing doses may enhance symptom management, repeated dose escalations could signal misuse, and diversion, or even induce abnormal pain sensitivity like hyperalgesia and allodynia.
• When patients are using multiple opioids, calculate the total morphine equivalent doses (MED) to determine the combined dosage.
• Consider opioid rotation, switching from one opioid to another, for patients experiencing inadequate symptom relief despite dose adjustments or intolerable side effects.
• However, if the patient is benefiting from opioid treatment based on objective measures of function and pain, and there are no discernible adverse effects, it may be appropriate to maintain the dosage while ensuring rigorous patient monitoring.

 

Equianalgesic Doses (ED):

• Converting from one opioid to another involves estimating equianalgesic dosages . Due to significant patient variability in opioid response, it is recommended to reduce the calculated conversion dose by 50% to ensure safety.
• Opioid withdrawal symptoms, while unpleasant, are not typically life-threatening, unlike overdose. Patients and their families should be educated about signs of overdose, such as slurred speech, emotional instability, and drowsiness.
• Erring on the side of caution with lower doses is safer. Patients should be reevaluated shortly after switching to a new opioid to monitor pain relief and potential side effects.
• Prolonged or high-dose opioid use can lead to opioid-induced hyperalgesia. Initiate fentanyl patch therapy at the recommended dose and adjust every three days initially, then every six days thereafter to achieve adequate pain relief.
• Transitioning from a fentanyl patch to another opioid may result in an overestimation of the new agent’s dosage, potentially leading to overdosing.
• Most patients are effectively managed with a fentanyl patch administered every 72 hours. However, some may require shorter intervals, but this should be carefully evaluated before implementing. Doses exceeding 25 mcg/hr or intervals shorter than 72 hours require close monitoring or consultation with pain management or addiction medicine specialists.

Opioid Doses Equal to or Greater than 100mg/MED:

• Generally, daily opioid doses should not surpass 100 mg/oral MED, and for longer-term, low-dose therapy, the limit should generally be 50 mg/oral MED.
• The risk of overdose or adverse effects significantly rises with doses exceeding 100 mg/oral MED.
• Providers, except pain management or addiction medicine specialists, should avoid prescribing over 100 MED/day without evidence of pain relief, functional improvement, absence of aberrant behavior, or consultation with specialists
• Persistent doses exceeding 100mg/MED/day may prompt a secondary review by external consultants in pain management or addiction medicine.
• When patients are on multiple opioids, calculate the cumulative MED doses to determine the total dosage.
• The MED dose calculator from Washington State or Table 9 should not be used for dose determinations when switching opioids, especially for fentanyl and methadone conversions, due to their approximate nature and lack of accounting for various factors like genetics and pharmacokinetics.

Example: Calculating Morphine Equivalent Dose (MED):

• Suppose a patient consumes six hydrocodone 5 mg/acetaminophen 500 mg tablets and two 20 mg oxycodone extended-release tablets daily. To determine the cumulative dose using Morphine 30 mg as the standard reference, the calculation is as follows:
  1. Six tablets of Hydrocodone 5 mg = 30 mg per day.
  2. Two tablets of Oxycodone 20 mg = 40 mg per day.
  3. The combined dose is 30 mg (from hydrocodone) + 40 mg (from oxycodone) = 70 mg morphine equivalents per day.

Reasons to Discontinue Opioids and/or Refer to a Physician specializing in Addiction Medicine or Pain Management:

• Discontinuation or referral may be warranted if there’s no improvement in pain and function, significant adverse effects, or if the patient exhibits aberrant behaviors like drug-seeking or diversion activities such as forging prescriptions or unauthorized drug escalation.

 

General Guidelines for Opioid Tapering/Discontinuation:

• Gradual tapering of opioids, typically by reducing the dose by 10% weekly, is generally well-tolerated with minimal adverse effects. Some patients may tolerate faster tapering over six to eight weeks.
• Symptoms of opioid withdrawal, such as nausea and muscle pain, can be managed with medications like clonidine. Referral for counseling or support is advisable for patients experiencing significant behavioral issues.

 

Recognizing and Managing Behavioral Issues during Opioid Tapering:

• Special attention should be given to maintain the patient-physician relationship to avoid risky patient behaviors. Severe behavioral issues may necessitate appropriate referrals, such as immediate psychiatric consultation for suicidal ideation.

 

Specialty Consultations:

• Consultation with addiction/pain medicine specialists or psychiatrists may be necessary for high-risk patients, complex cases, or deteriorating psychological states during opioid withdrawal. Other consultations may include neurology, physical medicine, or oncology as clinically indicated. Inpatient treatment may be required for complex cases.