PCEP-PC Module 4 (Pain) Solutions To Case Problems

Module 4: Pain Management
Solutions to Case Problems
Changing routes of administration of opioids

When changing routes of administration, an equianalgesic table is a useful guide for initial dose selection. Significant
first-pass metabolism necessitates larger oral or rectal doses to produce analgesia equivalent to parenteral doses of the
same opioid. Equivalent dosing recommendations represent consensus from limited available evidence, so they are
guides only, and individual patients may require doses to be adjusted.
An equianalgesic table can be used on the horizontal axis to switch routes of administration and on the vertical axis to
switch between opioids.
Changing opioids
When converting to or from transdermal fentanyl patches, published data suggest that a 25-g patch is equivalent to 45
to 135 mg of oral morphine per 24 hours. However, clinical experience suggests that most patients will use the lower
end of the range of morphine doses (ie, for most patients, 25 g is about equivalent to 45 to 60 mg of oral morphine per
24 hours).
Opioid cross-tolerance
While pharmacologic tolerance may develop to the opioid in use, tolerance may not be as marked relative to other
opioids. Incomplete cross-tolerance is likely due to subtle differences in the molecular structure of each opioid and the
way each interacts with the patient’s opioid receptors. Consequently, when switching opioids, there may be differences
between published equianalgesic doses of different opioids and the effective ratio for a given patient. Start with 50% to
75% of the published equianalgesic dose of the new opioid to compensate for incomplete cross-tolerance and individual
variation, particularly if the patient has controlled pain. If the patient has moderate to severe pain, do not reduce the
dose as much. If the patient has had adverse effects, reduce the dose more.
An important exception is methadone, which appears to have higher than expected potency during chronic dosing
compared with published equianalgesic doses for acute dosing. Start with 10% to 25% of the published equianalgesic
dose and titrate appropriately to achieve pain control.
Problem solving
The following cases demonstrate common dosing conversions.
Case 1
Mrs D is a 45-year-old attorney who has breast cancer metastatic to bone. She is comfortable
on a continuous infusion of morphine at 6 mg/h SC. Your goal is to change to oral
medications before discharging her home. What should your prescription be?
Answer
1. Figure out total daily dose of IV morphine
6 mg/h x 24 hours = 144 mg/d IV morphine
1
2. Set up a ratio using values from the table
144 mg/d IV morphine = 1 mg IV morphine
X mg/d oral morphine = 3 mg oral morphine
3. Solve for X
X = 442 mg/d oral morphine
4. Divide by 2 for bid formulation of extended-release morphine, or divide by 6 for immediate-release morphine
administered every 4 hours.
Sig: 200 mg extended-release morphine po bid, or 70 mg immediate-release morphine po q 4 h RTC
5. Also prescribe a breakthrough dose of 5% to 15% of total daily dose

Sig: 20–60 mg immediate-release morphine po q 1 h prn
6. Do not forget a stimulant laxative!
Case 2
Mr T is a 73-year-old man with lung cancer, a malignant pleural effusion, and chronic
chest pain. He has undergone therapeutic thoracentesis and pleurodesis. He is currently
receiving meperidine, 75 mg IM q 6 h, for pain. You want to change to oral morphine.
Without adjusting for cross-tolerance, what dose and schedule would you choose?
Answer
1. Figure out total daily dose
4 x 75 mg IM meperidine = 300 mg/d IM meperidine
2. Set up ratio from the table

300 mg/d IM meperidine = 50 mg IM meperidine
X mg/d po morphine = 15 mg po morphine
3. Solve for X
X = 90 mg/d po morphine
4. Decide on schedule and formulation

Sig: sustained-release morphine, 45 mg po bid
Remember breakthrough dose

Sig: 5–15 mg po immediate-release morphine q 1 h prn
5. Remember the stimulant laxative
Case 3
Ms M is a 41-year-old teacher who has ovarian cancer with ascites and has been taking 2 tablets of
acetaminophen/hydrocodone (500 mg/5 mg) every 4 hours and 1 tablet of acetaminophen/oxycodone (325 mg/5 mg)
every 6 hours for pain relief. Morphine makes her nauseated. You are concerned about acetaminophen toxicity and
want to change to an alternative oral approach. Without adjusting for partial cross-tolerance, what dose of
hydromorphone would you choose?
Answer
1. Figure out total daily dose of each opioid
2 tablets x 5 mg hydrocodone/tablet x 6 = 60 mg/d hydrocodone
1 tablet x 5 mg oxycodone/tablet x 4 = 20 mg/d oxycodone
2. Set up ratios from the table

60 mg/d oral hydrocodone = 15 mg oral hydrocodone
X mg/d oral hydromorphone = 4 mg oral hydromorphone
20 mg/d oral oxycodone = 10 mg oral oxycodone .

X mg/d oral hydromorphone = 4 mg oral hydromorphone
2
3. Solve for X in each case
X = 16 mg/d po hydromorphone
X = 8 mg/d oral hydromorphone
4. Add them together for a total of 24 mg/d oral hydromorphone
5. Decide on schedule
Sig: Hydromorphone, 4 mg po q 4 h RTC
6. Don’t forget breakthrough

Sig: Hydromorphone, 1–2 mg po q 1 h prn
7. Do not forget a stimulant laxative
Case 4
Mrs A is hospitalized and receiving adequate pain control with meperidine, 120 mg intramuscularly every 3 hours. She
is now able to take nutrition and medications by mouth. Correcting 25% for incomplete cross-tolerance, what dose and
schedule of oral hydromorphone would you prescribe to provide her with an approximately equal amount of analgesia?
a. 2 mg po q 4 h
b. 4 mg po q 4 h
c. 8 mg po q 4 h
d. 12 mg po q 4 h
Answer
c. 8 mg po q 4 h
Calculating the Answer

1. Figure out total daily dose of each opioid
120 mg x 8 = 960 mg/d IM meperidine
2. Set up ratios from the table

960 mg/d IM meperidine . = 50 mg IM meperidine .
X mg/d oral hydromorphone 4 mg oral hydromorphone
3. Solve for X
X = 76.8 mg/d po hydromorphone
12 mg po q 4 h
5. Adjust 25% for incomplete cross-tolerance

Sig: Hydromorphone, 8 mg po q 4 h
Case 5
Mr B has been taking 3 capsules containing oxycodone (5 mg per capsule) and acetaminophen every 3 hours at home
for relief of bone pain from metastatic lung cancer. He is now admitted to the hospital with a chemotherapy-induced
aplasia. You do not want him taking an antipyretic (acetaminophen). Without correcting for partial cross-tolerance,
how much oral morphine elixir would you prescribe to provide analgesia similar to that which he received from the
oxycodone?
a. 5 mg po q 4 h
b. 10 mg po q 4 h
c. 20 mg po q 4 h
d. 30 mg po q 4 h
Answer
d. 30 mg po q 4 h

1. Figure out total daily dose of opioid
3 tablets x 5 mg oxycodone/tablet x 8 = 120 mg/d oxycodone
3
2. Set up ratio from the table
120 mg/d oral oxycodone = 10 mg oral oxycodone .
X mg/d oral morphine 15 mg oral hydromorphone
3. Solve for X
X = 180 mg/d oral morphine
Sig: Morphine, 30 mg po q 4 h RTC
Case 6
Mrs C has been taking codeine, 60 mg by mouth every 4 hours, and methadone, 40 mg orally every 6 hours, to
adequately control abdominal pain from bulky retroperitoneal metastases. She is now admitted with a chemotherapy-
induced stomatitis. Your attending physician suggests that you place her on a constant infusion of intravenous
morphine.
Without adjusting for partial cross-tolerance, what hourly rate of intravenous morphine will you choose to continue to
keep her pain well controlled?
a. 1 mg/h
b. 2 mg/h
c. 4 mg/h
d. 8 mg/h
Answer
c. 4 mg/h

Methadone, 40 mg po = 20 mg IV = morphine, 20 mg IV
Codeine, 60 mg po = 40 mg IV = morphine, 3 mg IV
Total daily dose:
Methadone, 40 mg po X 4 = morphine, 80 mg IV
Codeine, 60 mg po X 6 = 18 mg IV
Total morphine/24 h = 98 mg
98 mg 24 h = 4 mg/h
Acknowledgement
The Philippine Palliative Care Education Program. Curriculum for Primary Care. PCEP-PC, 2008. Adapted
from Emanuel LL, von Gunten CF, Ferris FD, eds. The Education in Palliative and End-of-life Care (EPEC)
Curriculum: The EPEC Project, 1999, 2003.

PCEP-PC Module 4 (Pain) Solutions To Case Problems

Uploaded by

Copyright:

Available Formats

PCEP-PC Module 4 (Pain) Solutions To Case Problems

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PCEP-PC Module 4 (Pain) Solutions To Case Problems

Uploaded by

Copyright:

Available Formats

Module 4: Pain Management

Solutions to Case Problems

Changing routes of administration of opioids

5. Also prescribe a breakthrough dose of 5% to 15% of total daily dose

6. Do not forget a stimulant laxative!

2. Set up ratio from the table

4. Decide on schedule and formulation

Remember breakthrough dose

5. Remember the stimulant laxative

2. Set up ratios from the table

20 mg/d oral oxycodone = 10 mg oral oxycodone .

4. Add them together for a total of 24 mg/d oral hydromorphone

6. Don’t forget breakthrough

7. Do not forget a stimulant laxative

Calculating the Answer

2. Set up ratios from the table

5. Adjust 25% for incomplete cross-tolerance

Calculating the Answer

Calculating the Answer

You might also like