Parenteral Opioid Rotation in Advanced Cancer

Reviewer: Thomas Dilling, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: May 18, 2002

Presenter: F.A. Mahmoud
Presenter's Affiliation: Cleveland Clinic Foundation
Type of Session: Scientific


  • Opioid side effects sometimes can limit upward titration of dosage to levels adequate for effective pain relief.
  • Opioid rotation, utilizing equianalgesic amounts of medication, has been reported as efficacious in these situations.

Materials and Methods

  • An analysis was performed of 275 consecutive admissions to evaluate usage of opioid rotation as well as clinical outcomes.
  • Prior exclusions included patients who had received recent palliative chemotherapy/radiation treatment, were utilizing parenteral medication, had recent celiac plexus block, or similar maneuvers.


  • Of the original cohort of 275 patients, 40 (15%), received opioid rotation.
  • Of those 40 patients, 20 (50%) had severe neurotoxicity, 6 (15%) had severe nausea/vomiting, and 35% had opioid unresponsive pain.
  • Predominant rotation schemes included morphine to fentanyl (n=19) and morphine to methadone (n=12). The balance of patients (n=9) rotated from morphine to oral oxycodone, methadone to fentanyl, methadone to intrathecal morhpine, fentanyl to oral oxycodone, fentanyl to methadone, and morphine to hydromorphone.
  • All patients with opioid unresponsive pain or opioid toxicity benefitted from opioid rotation.
  • Pain conrol improved with opioid equivalents lower than predicted to be equianalgesic.

Author's Conclusions

  • Opioid rotation was underutilized in this cohort of patients (compared with prevalence data in the palliative care literature).
  • Opioid rotation was efficacious in these patients, diminishing pain and neurotoxicity.
  • Patients received this benefit on diminished amounts of morphine-equivalents.

Clinical/Scientific Implications

  • Pain in cancer patients can be effectively palliated with the current armementarium of opioid medications.
  • Opioid rotation is highly effective, but underutilized, at least in the cohort of patients studied at the researchers' institution.

Oncolink's ASCO Coverage made possible by an unrestricted Educational Grant from Bristol-Myers Squibb Oncology.