Mary Lynn McPherson, PharmD, BCPS, CPE, is Professor and Vice Chair in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore. She has maintained a practice in both hospice and ambulatory care her entire career. Earlier this year she published “Demystifying Opioid Conversion Calculations: A Guide to Effective Dosing”, through the American Society of Health-System Pharmacists. PainEDU will review this new book soon.

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Questions

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Kevin L. Zacharoff, MD:

What do you need to think about when you are increasing a dose of opioid medication?

Mary Lynn McPherson, PharmD, BCPS, CPE: When you are escalating a dose of medication you want to have a clear idea of the improvement you are trying to achieve. Whenever you consider increasing the dose of a medication, you need to consider the benefit vs. the potential harm. Since this varies from patient to patient, you can’t use a cookie cutter approach and you always need to personalize your changes. Having an absolute ceiling dose may be convenient, but all patients are different. You should likely be aiming to achieve an improvement in function. If you think about it, function is more important than a raw pain score. So my advice is to work toward the patient’s functional goals, for example, being able to take a short walk, rather than toward the goal of getting the pain score from a 7 to a 6.

If you are not nearing the goal that you want to achieve with the patient, then pause and consider. Often with higher doses you may have increased side effects. You really have to look at the individual and have determined that the medicine is helpful, before you decide to increase it, and then be prepared to manage the increased side effects.

KZ: What is the rationale behind opioid rotation?

MLM: If you have increased the dose of the opioid, and you are still not seeing an improvement towards desired goals of therapy, then you may want to consider changing to a different opioid. Patients often do respond differently to a different opioid. The reasons for this variation could be many, and include anything from genetic factors, to coexisting disease, and medication effects from other drugs the patient may be taking. At times, the side effects from a specific opioid may be so severe that you may consider rotating to another opioid. If going from drug X to drug Y is not helpful, you could try a 3rd drug, or consider whether the pain is not opioid-responsive. You may then want to try a co-analgesic or another form of therapy.

If there is no good response but increased side effects of significant severity, you may want to rotate the patient to another opioid, or lower the amount, or wean the patient off of the drug. Of course, it’s very important when weaning an opioid, to keep an eye out for possible signs of withdrawal.

KZ: What should you keep in mind when transitioning from one opioid to another opioid?

MLM: When you are considering transitioning from one opioid to another one, a good rule of thumb is to do a total reassessment of the pain and its treatment. Consider if adding a co-analgesic would be helpful. You really want to check the accuracy of the total daily dosage that the patient is taking. For example, you need to know if they are really taking the drug every 2 hours around the clock, or are there times when they are sleeping and not taking a dose?

Once the decision is made to rotate to another opioid, you should use an equianalgesic chart to find the right dose. Get the number from the chart, and then modify it for the patient and monitor them. You should be looking at subjective information (e.g., is the patient getting closer to their pain goal), and objective information (e.g., how many doses the patient is actually taking from pill counts, etc.,) and keep an eye out for side effects. It’s important to make decisions based on doses that were working, not necessarily some arbitrary “maximum dose.”

I also stress that it can be very helpful to teach family members how to monitor a patient, and what to look for. For example, if you are concerned about increased sedation, teach a family member how to assess the patient for it.

KZ: How do you differentiate aberrant drug-related behavior from lack of efficacy?

MLM: For me, a red flag usually goes up when a patient complains that they are not satisfied with the treatment that they are receiving, but then continues to ask for the drug prescription. It’s important to keep in mind that even with end-of-life care there is a fair amount of diversion. The elderly patient may have high-school or college age grandchildren that could be potential sources of diversion of controlled substances. In our community, for home-based hospice care we often use lock boxes and ask for more frequent nursing visits to make sure that the opioid is present and accounted for.

KZ: Is it common to change the opioid and breakthrough medication simultaneously, or to just change one or the other?

MLM: It depends on the situation. If you think that neither is really doing the right job, then you might want to change both together. In some situations, it can lead to a better outcome, and increased utilization of the regularly scheduled medication, with a lower need for breakthrough meds.

KZ: How much patience is required to increase a patient’s opioid dose or change to a new opioid?

MLM: Most often, opioid rotation is simple. You stop the old medication and start the new one. When setting up a medication dosing schedule you want to be conservative in calculating the regularly scheduled dose, but be more liberal with the breakthrough dose. I consider the use of a pain diary in this situation to be mandatory.

What’s most important to remember is to tailor the change to the patient, and then take the time to monitor the patient very closely.