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. Author manuscript; available in PMC: 2014 Jun 20.
Published in final edited form as: J Pain Symptom Manage. 2009 Sep;38(3):418–425. doi: 10.1016/j.jpainsymman.2009.06.002

Table 1.

Guideline for Opioid Rotation

Step 1

  • Calculate the equianalgesic dose of the new opioid based on the equianalgesic table.

  • If switching to any opioid other than methadone or fentanyl, identify an “automatic dose reduction window” of 25% to 50% lower than the calculated equianalgesic dose.

    • ◇

      If switching to methadone, identify this window at 75% to 90% lower than the calculated equianalgesic dose. For individuals on very high opioid doses (e.g., 1,000 mg morphine equivalents/day or higher), great caution should be exercised in converting to methadone at doses of 100 mg or greater per day; consider inpatient monitoring, including serial EKG monitoring.

    • ◇

      If switching to transdermal fentanyl, calculate dose conversions based on the equianalgesic dose ratios included in the package insert for these formulations.

  • Select a dose closer to the lower bound (25% reduction) or the upper bound (50% reduction) of this automatic dose reduction window on the basis of a clinical judgment that the equianalgesic dose table is relatively more or less applicable, respectively, to the specific characteristics of the opioid regimen or patient.

    • ◇

      Select a dose closer to the upper bound (50% reduction) of the reduction if the patient is receiving a relatively high dose of the current opioid regimen, is not Caucasian, or is elderly or medically frail.

    • ◇

      Select a dose closer to the lower bound (25% reduction) of the reduction if the patient does not have these characteristics or is undergoing a switch to a different route of systemic drug administration using the same drug.

Step 2

  • Perform a second assessment of pain severity and other medical or psychosocial characteristics to determine whether to apply an additional increase or decrease of 15-30% to enhance the likelihood that the initial dose will be effective for pain, or conversely, unlikely to cause withdrawal or opioid-related side effects.

  • Have a strategy to frequently assess initial response and titrate the dose of the new opioid regimen to optimize outcomes.

  • If a supplemental “rescue dose” is used for titration, calculate this at 5-15% of the total daily opioid dose and administer at an appropriate interval; if an oral transmucosal fentanyl formulation is used as a rescue dose, begin dosing at one of the lower doses irrespective of the baseline opioid dose.