Switching from one painkilling opioid to another, even at recommended dosage levels, may be contributing to the growing number of opioid-related fatalities. And many of those deaths may be the result of doctor errors, according to two prominent physicians in the field of pain management.
“A dramatic increase in unintentional deaths from opioids has occurred over the past decade with strong inference that many of these deaths may be resulting from prescriber’s error,” wrote Lynn R. Webster, MD, and Perry Fine, MD, in the April issue of Pain Medicine, the journal of the American Academy of Pain Medicine (AAPM). Webster is medical director of Lifetree Clinical Research in Salt Lake City, Utah and president elect of the AAPM. Fine is a professor of anesthesiology at the University of Utah and the immediate past president of the AAPM.
According to the U.S. Centers for Disease Control and Prevention, nearly 15,000 Americans die each year as a result of overdoses from prescription opioids, including morphine, codeine, oxycodone and other poppy based medicines. Opioids are fast acting and can produce a feeling of euphoria, which can lead to misuse and addiction.
Patients may be rotated from one opioid to another for a variety of reasons, including inadequate pain relief, side effects or lack of coverage by insurance companies. When prescribing a different opioid, doctors rely on dose conversion ratios and other guidelines, often provided by pharmaceutical companies, to select appropriate dosages.
Webster and Fine studied reports of fatal or near-fatal outcomes that occurred during opioid rotation. They concluded that most of the fatal outcomes were preventable, and that the conversion guidelines were inconsistent and had “important flaws that must be corrected.”
“Our goal is to reverse the national trend of unintentional overdose deaths while advocating for appropriate therapy for the one in three Americans who experience chronic pain,” said Webster.
The researchers recommend three steps for doctors to wean their patients from their original opioid without the use of a conversion table:
- Reduce the original opioid dose by 10% to 30% while starting the new opioid at the lowest available dose.
- Reduce the original opioid dose by 10% to 25% per week while increasing the dose of the new daily opioid dose by 10% to 20% based upon clinical need and safety.
- Provide sufficient immediate-release opioid throughout the rotation to prevent withdrawal and keep pain levels down so the patient is not tempted to take too much medication.
Webster and Fine believe a complete switch from one opioid to another can occur within 3 to 4 weeks. They add that more research is needed to prove that their technique would be safe and effective in a broad population of patients.
“It is time for professional societies, government agencies and industry to work together and correct the important flaws in current opioid rotation practices,” Webster concluded. “All patients who have indications for opioid therapy must be assured that routine clinical practices are safe and have an evidentiary basis.”