Better analgesic with opioid is our priority for cancer pain Inadequate analgesia or intolerable side effect was the reason for opioid rotation Many factors should be considered in opioid rotation because of individualize analgesic response

1. OPIOID ROTATION :
A WAY TO BETTER ANALGESIA
A.M.TAKDIR MUSBA
DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE
AND PAIN MANAGEMENT
FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
MAKASSAR INDONESIA

2. OBJECTIVES
• THE ROLE OF OPIOID IN CANCER PAIN
• OPIOID AND ANALGESIA RESPONSE
• THE IMPORTANT OF OPIOID ROTATION
• OPIOID ROTATION IN CLINICAL SETTING

3. THE ROLE OF OPIOID IN CANCER PAIN
• Opioid : the mainstay of cancer pain management
• Opioid : a preferred choice in treating cancer pain
of moderate to severe intensity
• Unfortunately : Cancer pain is undertreated, due to
fear of using opioid therapy

4. www.esmo.org

5. WORLD OPIOID CONSUMPTION, 2013
(mg/capita)
Sources: International Narcotics Control Board; United Nations population data

6. Opioid Consumption, ASEAN, 2013
Sources: International Narcotics Control Board; United Nations population data
INA: 0.100698
PHIL: 0.140324
MAL: 1.335027
SING: 1.167591
THAI: 1.076287
(mg/capita)

7. MYTHS OF USE OPIOID !!!!!!!
ADDICTION &
DEPENDENCE
TOLERANCE
DOSE INCREMENT
IS
CONSERVATIVE
NARCOTIC IN
OLDER
BE AVOIDED
ADEQUATE
PAIN CONTROL
PARENTERAL
MORE EFFECTIVE
AS NEEDED
BASIS
HEAVY
SEDATION
OPIOID EFFECTIVE
FOR ALL
PAIN CANNOT
BE RELIEVED
M Y T H S

8. Opioid in Indonesia
 Morphine  considered to be the standard opioid analgesic,
oral sustained release and IV prep. available
 Fentanyl  fast onset, more potent than morphine, less side
effect, transdermal sustained and IV prep. available
 Meperidine is not considered a first-line opioid analgesic
medication, just IV preparation
 Hydromorphone, semi-synthetic opioid agonist, more potent
than morphine, just oral sustained release prep.
 Codein, a weak opioid, is pro-drug of morphine, just oral
 Tramadol, a weak opioid that acts on mu-receptors, is another
reasonable alternative, oral and IV preparations

11. WHO Stepladder
FOR CANCER PAIN MANAGEMENT
• By the mouth
• By the ladder
• By the clock
• Individualized
for the patient
• Attention to detail

12. Work hard to relief pain
Analgesia
Response
Type and
temporal
pattern of
pain
Development
of tolerance
Pharmacokinetic
profile
Pharmacodynamic
factor
Disease
progressionSide effect
Individual
thinking

13. OPIOID RECEPTOR
More than 30-50 percent ranges of individual human
differences μ-opioid receptor densities
Ravert HT, Bencherif B, Madar I, et al: PET imaging of opioid receptors in pain:
Progress and new directions. Curr Pharm Des. 2004

14. Desensitisation and internalisation
 Opioid Tolerance

15. INDIVIDUAL OPIOID
RESPONSIVENESS ???

16. After you give the OPIOID,
some possibilities …
Pain is controlled but intolerable adverse effects
Pain is not adequately controlled, but it is impossible to
increase the dose due to adverse effects
Pain is not adequately controlled by rapid increasing the
dose of opioids, although the drug does not produce
adverse effects
Pain is controlled and no or tolerable adverse effects

17. OPIOID ROTATION
A CHANGE IN OPIOID DRUG OR ROUTE OF
ADMINISTRATION WITH THE GOAL OF
IMPROVING OUTCOMES
Retrospective studies:
opioid rotation rates 20-44%
Bruera EB.et al. Cancer. 1996
Fallon M. Palliat Med. 1997
Muller-Busch HC. Et al. Eur J Pain. 2005

18. OPIOID ROTATION
• Lack of efficacy
• Side effect
• Tolerance
• Opioid-induced
hyperalgesia
Switching
OPIOID
• Practical
consideration
• Patient’s condition
• Drug availability
Altering
administration
route of
OPIOID
Improving analgesic
response and/or
reducing adverse effects

19. THE MAJOR INDICATION
• Lack of efficacy
▫ Worsening of existing pain or underlying disease
▫ Development of opioid analgesic tolerance
▫ Inability to tolerate side effects
• Development of intolerable side effects
▫ Gastrointestinal (constipation, nausea, vomiting)
▫ CNS (sedation, somnolence, dysphoria,
hallucinations, myoclonus)
▫ Cardiovascular (orthostatic hypotension due to
histamine release)

20. OTHER INDICATION
• Change in patient's status
▫ Inability to swallow
▫ Poor peripheral vascular status
▫ Poor absorption of transdermal medications
▫ Requirements of high-dose opioids not practically
administered by oral, rectal, transdermal routes
• Practical considerations
▫ Availability in local pharmacies
▫ Cost
▫ Amount of opioid needed
▫ Route of administration
▫ Opioiphobia

21. HOW TO DO THE ROTATION ???
• Opioid dose conversion
• Some consideration
▫ Pk/Pd drugs
▫ Available preparation

22. Equianalgesic Opioid Dosing
• Provides evidence-based values for the relative
potencies among different opioid drugs & routes
• Only a broad guide for dose selection
• Reduce the risk of relative over or underdosing
• Larger interpatient variability
• Incomplete cross tolerance

23. Equianalgesic Opioids Dosing
Oral dose
( mg )
Opioid Parenteral
iv/sc/im ( mg )
400 Meperidine 100
120 Tramadol 100
200 Codeine 130
30 Morphine 10
7.5 Hydromorphone 1.5
- Fentanyl 0.15 – 0.20
- Sufentanyl 0.02
Oral morphine (mg/day) by approximately dividing the oral morphine dose by 2.
e.q. Morphine 50 mg PO in 24 hrs = Fentanyl patch 25 mcg/hr
McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For
Effective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010
Vadalouca A. et al. Opioid rotation in patients with cancerournal of Opioid
Management 4:4 2008

24. Switching from Morphine to Fentanyl,
vice versa
Morphine to
TDS Fentanyl
• Calculate total daily dose of
the current opioid
• Calculate the equianalgesic
24-hour morphine dose
• Determine the equivalent
transdermal fentanyl dose
• Continue the previous
opioid for 8-12 hours
• Order adequate
breakthrough dosing
TDS Fentanyl to
Morphine
• Calculate the equivalent
dose of the new opioid
• Calculate the scheduled
interval and breakthrough
dose of the new opioid
• Remove the patch and start
the new opioid 12 hrs later
• Order adequate
breakthrough dosing

25. Morphine Sustained Release to Transdermal Fentanyl
Waktu
Konsentrasiopioid
-
-
Analgesic window
Kondisi stabil
(dalam 12 jam)
IV
ER: sustained release opioid
IV : intravena opioid
TD : transdermal opioid
ER
TD

26. Equianalgesic Opioids Dosing
Oral dose
( mg )
Opioid Parenteral
iv/sc/im ( mg )
400 Meperidine 100
120 Tramadol 100
200 Codeine 130
30 Morphine 10
7.5 Hydromorphone 1.5
- Fentanyl 0.15 – 0.20
- Sufentanyl 0.02
Oral morphine (mg/day) by approximately dividing the oral morphine dose by 2.
e.q. Morphine 50 mg PO in 24 hrs = Fentanyl patch 25 mcg/hr
•McPherson ML. Demystifying Opioid Conversion Calculations: A Guide For
Effective Dosing. Amer Soc of Health-Systems Pharm, Bethesda, MD, 2010
•Vadalouca A. et al. Opioid rotation in patients with cancer. Journal of Opioid
Management 4:4 2008

27. Opioid drugs

28. Conclussion
• Better analgesic with opioid is our priority for
cancer pain
• Inadequate analgesia or intolerable side effect was
the reason for opioid rotation
• Many factors should be considered in opioid
rotation because of individualize analgesic response
In My Opinion : Anesthesiologist can do it perfectly !

29. Thank you very much
for your kind attention
Together relief Pain