Opioid rotation

Opioid rotation is the switch from one opioid to another to achieve a better balance between analgesia and treatment-limiting adverse effects. This practice is often used when escalating doses (greater than 1 g of morphine per day) become ineffective. In some settings opioid rotation is utilized routinely to prevent the development of analgesic tolerance.48... 

Mercadante S Opioid rotation for cancer pain Rationale and clinical aspects. Cancer 1999 86 1856. [PMID 10547561] Mercadante S, Arcuri E Opioids and renal function. J Pain 2004 5 2. [PMID 14975374]... 

The role of opioid rotation in cancer pain management has been described, highlighting the limitations of equianalgesic tablets and the need for monitoring and individualization of dose. This is particularly important when methadone is used as the opioid for conversion. The authors referred to a greater than expected potency of methadone, with excessive sedation and opioid-related adverse effects, if the switch is done on a one-to-one basis. They suggested that the calculated equianalgesic dose of methadone should be reduced by 75-90% and the dose then titrated upwards if necessary (47,48). 

Indelicato RA, Portenoy RK. Opioid rotation in the management of refractory cancer pain. J Clin Oncol 2002 20(l) 348-52. 

Watanabe S, Tarumi Y, Oneschuk D, Lawlor P. Opioid rotation to methadone proceed with caution. J Clin Oncol 2002 20(9) 2409-10. 

The role of opioid rotation in cancer pain management has been described, highlighting the limitations of equianalgesic tablets and the need for monitoring and individualization of dose. This is particularly important... 

Gagnon B, Bielech M, Watanabe S, Walker P, Hanson J, Bruera E. The use of intermittent subcutaneous injections of oxycodone for opioid rotation in patients with cancer pain. Support Care Cancer 1999 7(4) 265-70. 

Oxycodone has been available in oral form for at least 70 years and is rarely given by other routes. In a study of subcutaneous oxycodone hydrochloride 100 mg/ml for opioid rotation in 63 patients with cancer pain (maximum dose 4.5-660 mg in 24 hours for 1-49 days) there was local toxicity in only two cases, and this included central pallor of the skin at the needle site with surrounding erythema and bruising there was no necrosis (10). The design of the study made it difficult to compare the adverse effects profile of subcutaneous oxycodone with oral oxycodone or other opioids. Randomized controlled trials are needed to support the conclusions that subcutaneous oxycodone is free from adverse effects and is a better vehicle for analgesia in terminal cancer. 

Ensure adequate (often very high) doses of opioids to overcome tolerance temporarily. Additional methadone or opioid rotation often usefui. Non-opioid adjuncts may be usefui... 

Quang-Cantergrel, et al. Opioid rotation in non cancer pain. Anesthesia Analg 2000 90 933-937. 

Moryl N, Santiago-PalmaJ, KornickC, et al. Pitfalls of 30. opioid rotation substituting another opioid for methadone in patients with cancer pain. Pain 2002 96 325-328. 

Similar findings have been found in both men and women in a systematic review [I4M] authors recommended routine screening of patients taking long-term opioids and management of opioid-induced hypogonadism by opioid rotation, non-opi-oid pain management, or sex hormone supplementation. 

Leppert W. The role of methadone in opioid rotation—a Pohsh experience. Support Care Cancer 2009 17(5) 607-12. 

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