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.
- 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.
- 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.
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