The Opioid Rotation Ratio of Hydrocodone to Strong Opioids in Cancer Patients

Abstract

Purpose. Cancer pain management guidelines recommend initial treatment with intermediate‐strength analgesics such as hydrocodone and subsequent escalation to stronger opioids such as morphine. There are no published studies on the process of opioid rotation (OR) from hydrocodone to strong opioids in cancer patients. Our aim was to determine the opioid rotation ratio (ORR) of hydrocodone to morphine equivalent daily dose (MEDD) in cancer outpatients. Patients and Methods. We reviewed the records of consecutive patient visits at our supportive care center in 2011–2012 for OR from hydrocodone to stronger opioids. Data regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected from patients who returned for follow‐up within 6 weeks. Linear regression analysis was used to estimate the ORR between hydrocodone and MEDD. Successful OR was defined as 2‐point or 30% reduction in the pain score and continuation of the new opioid at follow‐up. Results. Overall, 170 patients underwent OR from hydrocodone to stronger opioid. The median age was 59 years, and 81% had advanced cancer. The median time between OR and follow‐up was 21 days. We found 53% had a successful OR with significant improvement in the ESAS pain and symptom distress scores. In 100 patients with complete OR and no worsening of pain at follow‐up, the median ORR from hydrocodone to MEDD was 1.5 (quintiles 1–3: 0.9–2). The ORR was associated with hydrocodone dose (r = −.52; p < .0001) and was lower in patients receiving ≥40 mg of hydrocodone per day (p < .0001). The median ORR of hydrocodone to morphine was 1.5 (n = 44) and hydrocodone to oxycodone was 0.9 (n = 24). Conclusion. The median ORR from hydrocodone to MEDD was 1.5 and varied according to hydrocodone dose.

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic

“…This is consistent with previous findings in which hydrocodone was identified as the most frequently prescribed and abused opioid . It was traditionally considered a weak opioid, but several studies have indicated that it may be equally as potent as morphine or oxycodone . In view of the significant potential for its abuse, in October 2014, the US Drug Enforcement Agency recategorized hydrocodone as a Schedule 2 drug, hence increasing the level of scrutiny and caution regarding its prescription by clinicians.…”

“…61 It was traditionally considered a weak opioid, 62 but several studies have indicated that it may be equally as potent as morphine or oxycodone. [63][64][65][66][67][68] In view of the significant potential for its abuse, in October 2014, the US Drug Enforcement Agency reca-tegorized hydrocodone as a Schedule 2 drug, [69][70][71] hence increasing the level of scrutiny and caution regarding its prescription by clinicians. Our findings support the appropriateness of this decision.…”

The Conversion Ratio From Intravenous Hydromorphone to Oral Opioids in Cancer Patients

“…The possible occurrence of hyperalgesia with high doses of opioids has been previously reported. 35,43 It is important to note that the sample size of patients receiving >30 mg of IV hydromorphone/ day was very small. Further prospective studies should try to confirm this finding.…”

The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients

“…The MEDD was calculated using standard ORRs 42 ; an ORR of 5.0 was used to calculate the MEDD of methadone, 46 and 1.5 was used to calculate the MEDD of hydrocodone. 44 The net MEDD was used for calculation of the ORR from other strong opioids to TDF. Net MEDD is the MEDD before OR minus the MEDD of the breakthrough opioid used along with TDF after OR.…”