Review and Critique of Opioid Rotation Practices and Associated Risks of Toxicity

Pain Medicine

Volumn 13, Issue 4, 2012, Pages 562-570

  Webster, Lynn R ^a   Fine, Perry G ^b  

^a Lifetree Clinical Research   (United States)

^b UNIVERSITY OF UTAH SCHOOL OF MEDICINE   (United States)

Author keywords

Equianalgesic Dose Tables; Opioid Dose Conversion; Opioid Rotation

Indexed keywords

BUPRENORPHINE; COCAINE; CONTIN; DIAMORPHINE; FENTANYL; HYDROCODONE; HYDROMORPHONE; METHADONE; MORPHINE; MORPHINE SULFATE; NALOXONE; OPIATE; OXYCODONE; OXYMORPHONE; UNCLASSIFIED DRUG;

ANALGESIA; CANCER PAIN; CHRONIC PAIN; CLINICAL PRACTICE; CONTROLLED RELEASE FORMULATION; DOSE CONVERSION; DRUG CROSS TOLERANCE; DRUG DOSE; DRUG DOSE REDUCTION; DRUG FATALITY; DRUG FORMULATION; DRUG HALF LIFE; DRUG INFORMATION; DRUG LABELING; DRUG MECHANISM; DRUG METABOLISM; DRUG RELEASE; DRUG SAFETY; DRUG WITHDRAWAL; HUMAN; NEUROPATHIC PAIN; NONHUMAN; OPIOID ROTATION; PAIN; PRACTICE GUIDELINE; PROFESSIONAL COMPETENCE; RESPIRATION DEPRESSION; REVIEW; RISK ASSESSMENT; SEDATION; SIDE EFFECT;

EID: 84859784713     PISSN: 15262375     EISSN: 15264637     Source Type: Journal    
DOI: 10.1111/j.1526-4637.2012.01357.x     Document Type: Review

References (56)

1. American Pain Society (APS) Bulletin. Pain hurts-Individuals, significant others, and society! Volume 16(1), Winter 2006. Available at: (accessed March 1, 2012).
2. Center for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults-United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50(7):120-5. Available at: (accessed March 1, 2012).
3. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. J Am Med Assoc 2003;290:2443-54.
4. Turk DC, Dworkin RH, Revicki D, etal. Identifying important outcome domains for chronic pain clinical trials: An IMMPACT survey of people with pain. Pain 2008;137:276-85.
5. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.
6. Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing "best practices" for opioid rotation: Conclusions of an expert panel. J Pain Symptom Manage 2009;38:418-25.
7. Mercadante S, Bruera E. Opioid switching: A systematic and critical review. Cancer Treat Rev 2006;32:304-15.
8. Mercadante S, Ferrera P, Villari P, etal. Frequency, indications, outcomes, and predictive factors of opioid switching in an acute palliative care unit. J Pain Symptom Manage 2009;37:632-41.
9. Quang-Cantagrel ND, Wallace MS, Magnuson SK. Opioid substitution to improve the effectiveness of chronic noncancer pain control: A chart review. Anesth Analg 2000;90:933-7.
10. Center for Disease Control and Prevention. Prescription painkiller overdoses in the US. CDC Vital Signs, November 2011. Available at: (accessed March 1, 2012).
11. Bohnert AS, Valenstein M, Bair MJ, etal. Association between opioid prescribing patterns and opioid overdose-related deaths. J Am Med Assoc 2011;305:1315-21.
12. Dhalla IA, Mamdani MM, Sivilotti ML, etal. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009;181:891-6.
13. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:618-27.
14. Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Arch Intern Med 2007;167:1752-9.
15. Boockvar KS, Liu S, Goldstein N, etal. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care 2009;18:32-6.
16. American Pain Foundation, Pain Safe Program. Frequently asked questions about opioid safety. 2011. Available at: (accessed March 1, 2012).
17. Webster LR, Cochella S, Dasgupta ND, etal. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med 2011;12:S26-35.
18. Knotkova H, Fine PG, Portenoy RK. Opioid rotation: The science and the limitations of the equianalgesic dose table. J Pain Symptom Manage 2009;38:426-39.
19. Mercadante S, Caraceni A. Conversion ratios for opioid switching in the treatment of cancer pain: A systematic review. Palliat Med 2011;25:504-15.
20. Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: Are they all equally dangerous? J Pain Symptom Manage 2009;38:409-17.
21. Dale O, Moksnes K, Kaasa S. European palliative care research collaborative pain guidelines: Opioid switching to improve analgesia or reduce side effects. A systematic review. Palliat Med 2011;25:494-503.
22. Chou R, Fanciullo GJ, Fine PG, etal. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30.
23. Patanwala AE, Duby J, Waters D, Erstad BL. Opioid conversions in acute care. Ann Pharmacother 2007;41:255-66.
24. Quigley C. Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev 2004;(3):D004847.
25. Pasternak GW. Incomplete cross tolerance and multiple mu opioid peptide receptors. Trends Pharmacol Sci 2001;22:67-70.
26. Pasternak GW. Molecular insights into mu opioid pharmacology: From the clinic to the bench. Clin J Pain 2010;26:S3-9.
27. Pasternak GW. Multiple opiate receptors: Déjà vu all over again. Neuropharmacology 2004;47:312-23.
28. Caplehorn JR. Deaths in the first two weeks of maintenance treatment in NSW in 1994: Identifying cases of iatrogenic methadone toxicity. Drug Alcohol Rev 1998;17:9-17.
29. Center for Substance Abuse Treatment. Methadone-Associated Mortality: Report of a National Assessment, May 8-9, 2003. SAMHSA Publication. NO.04-3904. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004.
30. Cousins G, Teljeur C, Motterlini N, etal. Risk of drug-related mortality during periods of transition in methadone maintenance treatment: A cohort study. J Subst Abuse Treat 2011;41:252-60.
31. Modesto-Lowe V, Brooks D, Petry N. Methadone deaths: Risk factors in pain and addicted populations. J Gen Intern Med 2010;25:305-9.
32. US Food and Drug Administration. Public Health Advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. November 27, 2006. Available at: (accessed March 1, 2012).
33. Hunt G, Bruera E. Respiratory depression in a patient receiving oral methadone for cancer pain. J Pain Symptom Manage 1995;10:401-4.
34. Regnard C, Pelham A. Severe respiratory depression and sedation with transdermal fentanyl: Four case studies. Palliat Med 2003;17:714-6.
35. Fishbain DA, Cutler RB, Cole B, etal. Medico-legal rounds: Medico-legal issues and alleged breaches of "standards of medical care" in opioid rotation to methadone: A case report. Pain Med 2003;4:195-201.
36. Twycross RG. A comparison of diamorphine-with-cocaine and methadone. [Letter]. Br J Clin Pharmacol 1977;61:691-3.
37. Moksnes K, Dale O, Rosland JH, etal. How to switch from morphine or oxycodone to methadone in cancer patients? A randomised clinical phase II trial. Eur J Cancer 2011;47:2463-70.
38. Eddy NB, Halbach H, Braenden OJ. Synthetic substances with morphine-like effect: Clinical experience; potency, side-effects, addiction liability. Bull World Health Organ 1957;17:569-863.
39. Beaver WT, Wallenstein SL, Houde RW, Rogers A. A clinical comparison of the analgesic effects of methadone and morphine administered intramuscularly, and of orally and parenterally administered methadone. Clin Pharmacol Ther 1967;8:415-26.
40. Webster LR, Brewer R, Morris D, Cleveland JM, Setnik B. Opioid titration and conversion in patients receiving morphine sulfate and naltrexone hydrochloride extended release capsules. Postgrad Med 2011;123:155-64.
41. Mercadante S, Arcuri E. Hyperalgesia and opioid switching. Am J Hosp Palliat Care 2005;22:291-4.
42. Likar R, Krainer B, Sittl R. Challenging the equipotency calculation for transdermal buprenorphine: Four case studies. Int J Clin Pract 2008;62:152-6.
43. Clemens KE, Klaschik E. Clinical experience with transdermal and orally administered opioids in palliative care patients. Jpn J Clin Oncol 2007;37:302-9.
44. Bowens CD, Thompson JA, Thompson MT, etal. A trial of methadone tapering schedules in pediatric intensive care unit patients exposed to prolonged sedative infusions. Pediatr Crit Care Med 2011;12:540-11.
45. Slatkin NE. Opioid switching and rotation in primary care: Implementation and clinical utility. Curr Med Res Opin 2009;25:2133-50.
46. Rich BA, Webster LR. A review of forensic implications of opioid prescribing with examples from malpractice cases involving opioid-related overdose. Pain Med 2011;12(suppl 2):s59-65.
47. Borgsteede SD, Rhodius CA, De Smet PAGM, etal. The use of opioids at the end of life: Knowledge level of pharmacists and cooperation with physicians. Eur J Clin Pharmacol 2011;67:79-89.
48. Plagge H, Ruppen W, Ott N, etal. Dose calculation in opioid rotation: Electronic calculator vs manual calculation. Int J Clin Pharm 2011;33:25-32.
49. Chaitowitz M, Tester W, Eiger G. Use of a comprehensive survey as a first step in addressing clinical competence of physicians-in-training in the management of pain. J Opioid Manage 2005;1:98-108.
50. Buss MK, Lessen DS, Sullivan AM, etal. Hematology/oncology fellows' training in palliative care: Results of a national survey. Cancer 2011;117:4304-11.
51. Rurup ML, Rhodius CA, Borgsteede SD, etal. The use of opioids at the end of life: The knowledge level of Dutch physicians as a potential barrier to effective pain management. BMC Palliat Care 2010;9:23-34.
52. McCaffery M, Ferrell BR. Opioid analgesics: Nurses' knowledge of doses and psychological dependence. J Nurs Staff Dev 1992;8:77-84.
53. Lewthwaite BJ, Jabusch KM, Wheeler BJ, etal. Nurses' knowledge and attitudes regarding pain management in hospitalized adults. J Contin Educ Nurs 2011;42:251-7.
54. Scott E, Borate U, Heitner S, etal. Pain management practices by internal medicine residents-A comparison before and after educational and institutional interventions. Am J Hosp Palliat Care 2009;25:431-9.
55. Hanks S. The law of unintended consequences: When pain management leads to medication errors. P T 2008;33:420-5.
56. Crosby VL, Corcoran R. Modes of administration of morphine in cancer pain. Some doctors lack basic knowledge about prescribing morphine. Br Med J 1996;313:687.