The conversion ratio from intravenous (IV) hydromorphone to oral (PO) opioids in patients with cancer.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 197-197
Author(s):  
Akhila Sunkepally Reddy ◽  
Sara Dost ◽  
Marieberta Vidal ◽  
Saneese Stephen ◽  
Karen Baumgartner ◽  
...  
Keyword(s):  
Palliative Care ◽  
Linear Regression Analysis ◽  
Oral Morphine ◽  
Patient Characteristics ◽  
Conversion Ratio ◽  
Opioid Rotation ◽  
Patients With Cancer ◽  
Daily Dose ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

197 Background: Inpatients with cancer frequently undergo conversions from IV to PO hydromorphone (HM) or opioid rotation (OR) from IV HM to another PO opioid prior to discharge. Currently used conversion ratios (CR) between IV and PO HM range from 2-5 and opioid rotation ratios (ORR) between IV HM and oral morphine equivalent daily dose (MEDD) range from 10-20. This large variation in ratios may lead to uncontrolled pain or overdosing. Our aim was to determine the accurate CR from IV to PO HM and ORR from IV HM to PO morphine and oxycodone (measured as MEDD). Methods: We reviewed records of 4745 consecutive inpatient palliative care consults in our institute during 2010-14 for patients who underwent conversion from IV to PO HM or OR from IV HM to PO morphine or oxycodone. Patient characteristics, symptoms and opioid doses were determined in patients successfully discharged on oral opioids without readmission within 1 week. Linear regression analysis was used to estimate the CR or ORR between the 24 hour IV HM mg dose prior to conversion to PO and the oral opioid mg dose used in the 24 hours prior to discharge. Results: Among 394 eligible patients on IV HM, 147 underwent conversion to PO HM and 247 underwent OR to oral morphine (163) or oxycodone (84). Mean age was 54 years, 39% were male, and 95% had advanced cancer. Median time between conversion to PO and discharge was 2 days. In 147 patients the median CR (IQR) from IV to PO HM was 2.5 (2.1-2.7) and correlation of IV to PO dose of HM was .95 (P < .0001). The median CR was 2.5 in patients receiving < 30mg of IV HM/day and 2.1 in patients receiving ≥ 30mg of HM/day (P = .004). In 247 patients the median ORR (IQR) from IV HM to MEDD was 11.5 (10-13) and correlation of IV HM to MEDD was .93 (P < .0001). The median ORR was 11.5 in patients receiving < 30mg of IV HM/day and 9.9 in patients receiving ≥ 30mg of HM/day (P = .0004). ORR from IV HM to MEDDs obtained from morphine (11) and oxycodone (12.1) were significantly different (P = .0023). The CR and ORR were not significantly impacted by other variables. Conclusions: The median CR from IV to PO HM is 2.5 and ORR from IV HM to MEDD is 11.5. This implies that 1 mg IV HM is equivalent to 2.5 mg PO HM and 11.5 mg MEDD. HM may cause hyperalgesia at doses ≥ 30 mg/day and thereby requires a lower ORR to other opioids.

Opioid Rotation for Toxicity Reduction (DRAFT)

2018 ◽  
Author(s):  
Anna Cecilia Tenorio ◽  
Akhila Reddy
Keyword(s):  
Pain Management ◽  
Cancer Pain ◽  
Clinical Case ◽  
Cancer Pain Management ◽  
Opioid Rotation ◽  
Patients With Cancer ◽  
Daily Dose ◽  
Study Intervention ◽  
Morphine Equivalent

This chapter discusses the de Stoutz et al. retrospective review of patients with cancer pain who developed dose-limiting toxicities and underwent opioid rotation that resulted in improvement of symptoms related to opioid induced neurotoxicity, uncontrolled pain, and reduction in morphine equivalent daily dose. This study is the first to establish that opioid rotation, which is substituting one opioid with another using established equianalgesic conversion ratios, is a valuable tool in cancer pain management. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.

Is the limit of 60 mg of oral morphine equivalent daily dose still actual for the access to rapid onset opioids therapy?

2018 ◽  
Vol 42 (3) ◽  
pp. 367-368 ◽  
Author(s):  
Luca Miceli ◽  
Rym Bednarova ◽  
Luigi Vetrugno ◽  
Marco Cascella ◽  
Arturo Cuomo
Keyword(s):  
Oral Morphine ◽  
Rapid Onset ◽  
Daily Dose ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

scholarly journals OP0088 INITIATING TNF INHIBITORS IN INFLAMMATORY ARTHRITIS DOES NOT DECREASE THE AVERAGE OPIOID ANALGESIC CONSUMPTION

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 58.2-59
Author(s):  
O. Palsson ◽  
T. Love ◽  
J. K. Wallman ◽  
M. C. Kapetanovic ◽  
P. S. Gunnarsson ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Psoriatic Arthritis ◽  
Inflammatory Arthritis ◽  
Opioid Analgesic ◽  
Oral Morphine ◽  
Undifferentiated Arthritis ◽  
First Line ◽  
The Mean ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Background:TNFα-inhibitor (TNFi) therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain in patients with arthritis. Opioids are often prescribed for chronic pain, a common issue in inflammatory joint disease.Objectives:To explore the impact of the initiation of TNFi therapy as a first-line biologic disease-modifying anti-rheumatic drug (DMARD) on the prescription rates of opioids in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA) in Iceland.Methods:All patients receiving biologic DMARD therapy for rheumatic diseases in Iceland are registered in a nationwide database (ICEBIO). The Icelandic Directorate of Health operates a Prescription Medicines Register that includes over 90% of all drug prescriptions in Iceland. The study group included patients with RA, PsA, AS, and UA registered in ICEBIO and for each of them five randomly selected comparators from the general population matched on age, sex, and calendar time. On February 1st2016 we extracted data on all filled opioid analgesic prescriptions two years before and two years after the date of TNFi initiation.Results:Data from 359 RA, 217 AS, 251 PsA and 113 UA patients and 4700 comparators were collected. In total, 75% of patients compared to 43% of comparators received ≥1 opiate prescription during the study period. The proportion of patients using opioids (regardless of dose) two years prior to TNFi initiation was 41%, increasing to 49% the following year. After TNFi initiation the proportion returned to 40% (Figure 1). Despite this, the mean yearly opiate dose used by the patients followed a rising trajectory throughout the study period (Figure 2). In total, patients were prescribed nearly 6 times more opioids than the comparators, corresponding to a bootstrapped mean (95% CI) dose of 818 (601-1073) mg MED per patient and year compared to 139 (111-171) mg for comparators.Figure 1.Percental distributions of opioid analgesic use by dose (according to dispensed prescriptions) among patients with inflammatory arthritis (A) and matched comparators (B). All doses are oral morphine equivalent dose (MED) in milligrams.Figure 2.Bootstrapped mean oral morphine equivalent dose per person per year for patients with inflammatory arthritis (above) and age and sex matched comparators (below). Box edges represent 25-75thpercentiles and whiskers 95% confidence intervals.Conclusion:Three out of four patients with inflammatory arthritis in Iceland use opioid analgesics in the two years prior to and/or after the initiation of TNFi therapy and the mean doses were significantly higher than in matched comparators. The proportion of patients receiving opioids increased before TNFi therapy and then decreased again to the previous level. The initiation of the first-line TNFi did not reduce opioid consumption by dose at the group level. On the contrary, there was a trend towards increasing doses over time in both patients and comparators, possibly reflecting the development of opiate tolerance.Table 1.Baseline demographic data. Mean ± SD unless specified. * defined from diagnosis to baselAll patientsRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisUndifferentiated arthritisTotal n (%)940 (100)359 (38)251 (27)217 (23)113 (12)Age (years)49 ± 1453 ± 1449 ± 1343 ± 1344 ± 15Disease duration (years)*7.8 ± 8.58.2 ± 8.27.4 ± 7.88.3 ± 10.26.3 ± 6.6Female58%73%59%34%52%Disclosure of Interests:Olafur Palsson: None declared, Thorvardur Love: None declared, Johan K Wallman Consultant of: Consultant for AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma., Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

scholarly journals Patterns of Opioid Prescription, Use, and Costs Among Patients With Advanced Cancer and Inpatient Palliative Care Between 2008 and 2014

2019 ◽  
Vol 15 (1) ◽  
pp. e74-e83 ◽  
Author(s):  
Sriram Yennurajalingam ◽  
Zhanni Lu ◽  
Suresh K. Reddy ◽  
EdenMae C. Rodriguez ◽  
Kristy Nguyen ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Symptom Assessment ◽  
Patient Characteristics ◽  
Opioid Prescription ◽  
Patients With Cancer ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale ◽  
Symptom Changes

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

Patients With Fibrotic Interstitial Lung Disease Receive Supportive and Palliative Care Just Prior to Death

2020 ◽  
Vol 38 (2) ◽  
pp. 154-160
Author(s):  
Natasha Smallwood ◽  
Jennifer Mann ◽  
Hui Guo ◽  
Nicole Goh
Keyword(s):  
Palliative Care ◽  
Symptom Relief ◽  
Oral Morphine ◽  
Forced Expiratory Volume ◽  
Interstitial Lung Diseases ◽  
Teaching Hospitals ◽  
Early Palliative Care ◽  
Retrospective Audit ◽  
Oral Morphine Equivalent ◽  
Symptom Palliation

Background: Fibrotic interstitial lung diseases (f-ILDs) are often progressive and incurable. As patients experience significant symptoms and have a poor prognosis, early palliative care referral is recommended. Objective: To examine the care delivered to patients with f-ILD during the terminal hospital admission and the past 2 years of life. Methods: A retrospective audit was performed for consecutive patients who died from f-ILD at 2 Australian teaching hospitals between January 1, 2012, and December 31, 2016. Results: Of 67 patients, 44 (66%) had idiopathic pulmonary fibrosis. Median age was 78 years. Median respiratory function: forced expiratory volume in 1 second 69.0% predicted (interquartile range [IQR]: 58.0%-77.0%), forced vital capacity 64.0% predicted (IQR = 46.8%-74.3%), and diffusing capacity of carbon monoxide 36.0% predicted (IQR = 31.0%-44.0%). In the 2 years prior to the terminal admission, 38 (57%) patients reported severe breathlessness and 17 (25%) used opioids for symptom relief. Twenty-four (36%) patients received specialist palliative care (SPC) and 11 (16%) completed advance care planning. During the terminal admission, 10 (15%) patients were admitted directly under SPC. A further 33 (49%) patients were referred to SPC, on average 1 day prior to death. Sixty-three (94%) patients received opioids and 49 (73%) received benzodiazepines for symptom management. Median starting and final opioid doses were 10 and 23 mg oral morphine equivalent/24 hours, respectively. Opioids were commenced on average 2 (IQR 1-3) days prior to death. Conclusions: Although most patients were identified as actively dying in the final admission, referral to SPC and use of palliative medications occurred late. Additionally, few patients accessed symptom palliation earlier in their illness.

scholarly journals β-blocker Use is Associated with a Reduction in Opioid Use 30 Days After Total Knee Arthroplasty

2019 ◽  
Vol 5 (22;5) ◽  
pp. E395-E406
Author(s):  
Jordan Starr
Keyword(s):  
Total Knee Arthroplasty ◽  
Oral Morphine ◽  
Veterans Affairs ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Total Knee ◽  
Β Blocker ◽  
Β Blockers ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Background: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative opioid use. There are few evidence-based interventions to prevent these outcomes. Recently, β-blockers have emerged as possible novel analgesics. Objectives: The objective of this study was to determine whether perioperative β-blocker use is associated with reduced prolonged postoperative opioid use after TKA. Study Design: This study used a retrospective cohort design. Setting: The research took place within Department of Veterans Affairs hospitals in the United States between April 2012 and April 2016. Methods: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA) patients undergoing TKA. Patients using opioids 60 days before surgery were excluded. Intervention: The intervention being investigated was perioperative β-blocker use, overall and by class. Measurement: Oral morphine equivalent usage through postoperative day 1 and prescription opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created controlling for relevant demographic and comorbidity covariates. A secondary analysis examined the same outcomes separated by β-blocker class. Results: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs that comprised the cohort, 2,604 (22.4%) were performed on patients using β-blockers. After adjustment, β-blocker use was associated with reduced opioid use through 30 days after surgery (odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective β-blockers were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and nonselective β-blockers were associated with reduced oral morphine equivalent usage through postoperative day 1 (β = -17.9 [95% CI, -29.9 to -5.8], P = .004). Limitations: Generalizability of these findings is uncertain, because this study was performed on a cohort of predominantly white, male VA patients. This study also measured opioid use, but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an objective measure of pain persistence in a national cohort for which patient-reported outcomes are otherwise unavailable. Conclusions: Perioperative β-blocker use was associated with reduced prescription opioid use at 30 days after surgery. Both selective and nonselective β-blockers were associated with reduced opioid use when analyzed individually. Key words: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists, pain management

scholarly journals Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

2021 ◽  
Vol 2021 ◽  
pp. 1-12
Author(s):  
Nian-Qiang Hu ◽  
Qi-Qi He ◽  
Lu Qian ◽  
Ji-Hong Zhu
Keyword(s):  
Randomised Controlled Trials ◽  
Breast Surgery ◽  
Meta Analysis ◽  
Oral Morphine ◽  
Mean Difference ◽  
Serratus Anterior ◽  
Randomised Controlled ◽  
Oral Morphine Equivalent ◽  
Anterior Plane ◽  
Morphine Equivalent

Objective. Serratus anterior plane block (SAPB) provides effective thoracic analgesia. This systematic review and meta-analysis was conducted to assess the safety and efficacy of SAPB for postoperative analgesia after breast surgery. Methods. A systematic literature search was performed using Embase, PubMed, Web of Science, and the Cochrane Library for eligible randomised controlled trials. The primary outcomes involved the administration of intraoperative and postoperative opioids. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for rating the quality of evidence for making recommendations. Results. Overall, 13 studies comprising 826 patients met the inclusion criteria (412 in the SAPB group and 414 in the control group). Patients treated with SAPB exhibited a significantly lower postoperative opioid consumption (mean difference, −38.51 mg of oral morphine equivalent; 95% confidence interval (CI), −60.97 to −16.05; P < 0.01 ; I2 = 100%), whereas no difference was observed in the intraoperative opioid consumption (mean difference, −9.85 mg of oral morphine equivalent; 95% CI, −19.52 to −0.18; P = 0.05 ; I2 = 94%). In addition, SAPB significantly decreased the occurrence of postoperative nausea and vomiting (risk ratio, 0.32; 95% CI, 0.19–0.55; P < 0.05 ;I2 = 38%) and reduced pain scores during the postoperative period (1 h: standardised mean difference (SMD), −1.23; 95% CI, −2.00 to −0.45; I2 = 92%; 2 h: SMD, −0.71; 95% CI, −1.00 to −0.41; I2 = 48%; 4 h: SMD, −1.52; 95% CI, −2.77 to −0.27; I2 = 95%; 6 h: SMD, −0.80; 95% CI, −1.51 to −0.08; I2 = 81%; 8 h: SMD, −1.12; 95% CI, −1.98 to −0.27; I2 = 92%; 12 h: SMD, −0.78; 95% CI, −1.21 to −0.35; I2 = 83%; and 24 h: SMD, −0.71; 95% CI, −1.20 to −0.23; I2 = 87%; P < 0.05 for all). Conclusion. SAPB was safe and effective after breast surgery to relieve postsurgical pain. However, additional well-developed trials are required to validate these findings.

Analgesic efficacy of cannabinoids for acute pain management after surgery: a systematic review and meta-analysis

2020 ◽  
Vol 45 (7) ◽  
pp. 509-519 ◽  
Author(s):  
Faraj W Abdallah ◽  
Nasir Hussain ◽  
Tristan Weaver ◽  
Richard Brull
Keyword(s):  
Postoperative Pain ◽  
Meta Analysis ◽  
Oral Morphine ◽  
Analgesic Efficacy ◽  
Acute Postoperative Pain ◽  
Acute Pain Management ◽  
Cannabinoid Compounds ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

BackgroundEvidence regarding the role of cannabinoids in managing acute postoperative pain is conflicting. The purpose of this systematic review and meta-analysis was to determine the analgesic efficacy of perioperative cannabinoid compounds for acute pain management after surgery.MethodsOriginal research articles evaluating the addition of cannabinoids to standard opioid-based systemic analgesia (Control) in the postoperative period were sought. Our primary outcomes were cumulative oral morphine equivalent consumption and rest pain severity at 24 hours postoperatively. We also assessed analgesic consumption in the postanesthesia care unit (PACU), pain scores in PACU, 6 and 12 hours postoperatively, and opioid-related and cannabinoid-related side effects, patient satisfaction, and quality of recovery as secondary outcomes.ResultsEight randomized controlled trials (924 patients) and four observational studies (4259 patients) were analyzed and included. There were insufficient data to pool for quantification of differences in cumulative oral morphine equivalent consumption and rest pain severity at 24 hours postoperatively with the addition of cannabinoids in comparison to Control. Qualitative synthesis revealed no differences in cumulative oral opioid consumption or pain at rest 24 hours postoperatively with the addition of cannabinoids in comparison to Control. Patients receiving cannabinoids appeared to have an increased weighted mean difference 95% CI of pain at 12 hours by 0.83 cm (0.04 to 1.63) (p=0.04). Patients receiving cannabinoids also appeared to have 3.24 times increased odds of developing hypotension postoperatively (95% CI 1.12 to 9.36) (p=0.03). Qualitative and quantitative synthesis revealed no differences in any other secondary outcomes.ConclusionsOur quantitative and qualitative review of the literature suggests that the analgesic role of perioperative cannabinoid compounds is limited, with no clinically important benefits detected when cannabinoids are added to traditional systemic analgesics compared with traditional systemic analgesics alone. Notably, there appears to be a signal towards increased postoperative pain and hypotension associated with the addition of perioperative cannabinoids to traditional systemic analgesics. These results do not support the routine use of cannabinoids to manage acute postoperative pain at the present time.

Opioid rotation from transdermal fentanyl to continuous subcutaneous hydromorphone in a cachectic patient: A case report and review of the literature

2020 ◽  
pp. 107815522092941 ◽  
Author(s):  
Lawrence D Jackson ◽  
Rachel Wortzman ◽  
Debbie Chua ◽  
Debbie Selby
Keyword(s):  
Case Report ◽  
Oral Morphine ◽  
Metastatic Breast ◽  
High Dose ◽  
Transdermal Fentanyl ◽  
Academic Medical Centre ◽  
Opioid Rotation ◽  
Transdermal Fentanyl Patch ◽  
Oral Morphine Equivalent ◽  
End Stage

Opioid rotation from transdermal fentanyl to an alternate opioid is often necessitated in advanced disease, but is fraught with uncertainty due to variable absorption from the patch in end-stage illness and the lack of a clearly established opioid rotation ratio. The manufacturer of transdermal fentanyl provides opioid rotation recommendations only for rotation from the oral morphine equivalent daily dose (MEDD) of opioid to the patch, not in the opposite direction. This is a case report of a single patient with cancer and cachexia admitted to the palliative care unit of a large academic medical centre in Canada. The patient is a 50-year-old female with widely metastatic breast cancer who developed opioid toxicity when maintenance transdermal fentanyl patch therapy (100 μg patch applied every 72 h) was rotated to subcutaneous hydromorphone infusion to improve pain control. Hydromorphone was initiated at a rate of 1 mg/h by continuous infusion based on an opioid rotation ratio for transdermal fentanyl (μg/h):MEDD (mg/day) of 1:2.4. Opioid toxicity eventually resolved with downward titration of hydromorphone to only 30% of the initially estimated equianalgesic dose. This case highlights the need for close follow-up of all patients undergoing opioid rotation from transdermal fentanyl and reinforces the need to reduce the initial dose of the new opioid by 30%–50% of the calculated MEDD, especially when rotating from a high dose of transdermal fentanyl, or if there are factors potentially impairing absorption from the patch such as age, cachexia and weight loss, or if rotation is performed for reasons other than uncontrolled pain.

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