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Authors

  1. Lee, Vanessa Y. BSN, RN
  2. Kowalski, Sonya L. DNP, RN, ACNS-BC

Abstract

As a result of the opioid epidemic, strategies have been implemented to reduce opioid consumption. These include regulatory policies, reduced opioid production, and nonopioid approaches for pain management. Although these policies may reduce opioid prescribing, there has been an unintended consequence for patients with severe cancer pain. Opioids are foundational for cancer pain management and are often required for patients during end-of-life care. Shortages of some opioid medications require knowledge of equianalgesic dosing. Equianalgesia is the conversion of comparable pain-relieving effects from one medication to another. There is a lack of consensus with regard to conversion standardization so researchers have created dosing principles that clinicians can follow. This article will describe some of these dosing principles and provide readers with sources for on-line dosage calculators.

 

Article Content

In 2017, the U.S. Department of Health and Human Services declared a public health emergency to address the national opioid crisis. As a result, strategies have been implemented to reduce opioid consumption. These include nonopioid approaches for pain management, regulatory policies, and reduced opioid production. Although these policies may have an outcome of reduced opioid prescribing, there has been an unintended consequence for patients with severe cancer pain. According to the American Society of Clinical Oncology (2016), recent regulations restricting access to prescription opioids should not be applied to patients with cancer due to the unique nature of their disease and treatment.

  
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Opioids are foundational for cancer pain management and are often required for patients during end-of-life care (Groninger & Vijayan, 2014). However, since 2016, cancer patients have been increasingly unable to access opioid pain medications (American Cancer Society, 2018). One large study of outpatient oncology patients with advanced cancer found that, between 2010 and 2015, the median morphine equivalent daily dose decreased from 78 mg to 40 mg (Haider et al., 2017). Some of the reasons for this include reduced opioid production, revised preferred drug lists, prior authorization requirements, quantity limits, and drug utilization review.

 

Inadequate pain and symptom control in cancer patients may contribute to negative outcomes. Almost 6% of patients with cancer develop suicidal ideation that has been found to be associated with inadequately controlled pain (Eldridge, 2019). Inadequate pain control may also lead to increased symptoms of depression, a negative psychological state, and reduced quality of life for both patients and family members (Park et al., 2016). As members of home care and hospice teams, nurses must advocate for patients who experience inadequate pain relief (American Cancer Society, 2019).

 

Recent shortages of opioids related to reduced production have resulted in alternative dose substitutions, which may increase medication errors and put patients at risk (Bartalone, 2018). The changes in care environments between hospital and home, coupled with the shortages of some opioid medications, require knowledge of equianalgesic dosing. Equianalgesia is the conversion of comparable pain-relieving effects from one medication to another (Gaguski & Karcheski, 2013). Equianalgesic dosing is necessary when patients experience intolerable side effects, inadequate analgesia, a change in health status, or reduced drug availability. The goal of equianalgesic dosing is to provide pain control that is either equivalent to, or improved over the previous medication. Unfortunately, there is variability among conversion tables, which has led to significant safety concerns (Syrmis et al., 2014). Due to a lack of sufficient research, government and professional societies have not proposed one official equianalgesic conversion table (Rennick et al., 2016). Lack of standardized equianalgesia can result in overmedication, which may lead to excessive sedation and respiratory depression, or undermedication, which may lead to significant pain. In response to the lack of consensus about conversion standardization, researchers have attempted to eliminate this gap by creating dosing principles that clinicians can follow.

 

The most prescribed opioid for uncontrolled cancer pain is hydrocodone. Prior to 2015, it was followed by oxycodone and transdermal fentanyl. However, the use of tramadol has increased and surpassed oxycodone and fentanyl since the reclassification of hydrocodone as a schedule II opioid and the tramadol as a schedule IV opioid (Haider et al., 2017).

 

For opioid-naive patients, low doses of morphine are better for pain relief and tolerability than codeine or tramadol (Bandieri et al., 2016). The multiple morphine formulations have a similar efficacy but differ in duration of action and therefore dose frequency. Thirty milligrams of immediate-release morphine given as 10 mg every 4 hours, is equivalent to 30 mg of controlled-release morphine given every 12 hours and 30 mg of extended-release morphine given as 60 mg every 24 hours (New Hampshire Medical Society, 2012).

 

Intravenous (IV) hydromorphone is commonly used in cancer pain management. Historically, hydromorphone 1 mg IV has been considered equivalent to 7.5 mg of oral hydromorphone, 30 mg of oral morphine, and up to 20 mg of oxycodone (Gaguski & Karcheski, 2013; Groninger & Vijayan, 2014; Therapeutic Research Center, 2012). However, more recent research has shown that 1 mg IV of hydromorphone is equivalent to 2.5 mg of oral hydromorphone, 11.5 mg of oral morphine, and 8 mg of oxycodone (Reddy et al., 2017).

 

Methadone has a high risk of conversion variability and, although not commonly prescribed, has one of the highest risks for opioid overdose compared with other equianalgesia conversions. Methadone should only be managed in consultation with a pain or palliative care specialist (Rennick et al., 2016).

 

Transdermal opioids such as fentanyl and buprenorphine are not recommended as first-line treatments for pain management (Wood et al., 2018). Fentanyl patches should not be used for opioid-naive patients; however, buprenorphine patches at the lowest strength of 5 mcg/hour may be used. Studies regarding equianalgesia between transdermal fentanyl and oral morphine are variable and require the patient to be closely monitored. A general conversion equivalency is considered to be the daily dose of morphine divided by 2 indicates the approximate dose of transdermal fentanyl in micrograms per hour and the transdermal micrograms per hour multiplied by 2 gives the approximate total daily dose of oral morphine (Reddy et al., 2016). A 25 mcg/hour transdermal fentanyl would be equivalent to 60 to 90 mg/24 hours dosage of oral morphine. A 25 mcg/hour transdermal buprenorphine would be equivalent to 40 to 60 mg/24 hours dosage of oral morphine (Wood et al.).

 

Although reported equianalgesic dosage calculations do contain variability among sources, on-line dosage calculators from respected, evidence-based resources are available to assist in determining if opioids prescribed are in a safe range for patients. The Centers for Disease Control and Prevention has a downloadable mobile opioid guideline application with a dosage calculator that may be accessed at https://www.cdc.gov/drugoverdose/prescribing/app.html. ClinCalc is also an on-line conversion calculator based on the American Pain Society Guidelines that is simple to use and may be accessed at https://clincalc.com/Opioids/.

 

Guidelines have traditionally indicated that, due to incomplete cross-tolerance among drugs, initial conversion dosages should begin with a 50% dosage reduction and then be titrated for effect (Therapeutic Research Center, 2012). More recent research, however, suggests that a more rapid titration of opioids may be necessary for adequate pain relief (Reddy et al., 2017).

 

Federal and hospice guidelines require that efforts be made to assure that the hospice patient's pain is controlled (Hospice Patients Alliance, n.d.). Home care clinicians are obligated to advocate for the most vulnerable populations, which includes pain control for hospice and cancer patients. Adequate pain management requires that clinicians understand the principles of opioid equianalgesia. Resources are available to assist in determining safe opioid dosing; however, due to differences in patient's conditions and pharmacological responses, an individualized plan of care is necessary.

 

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