Part 4 - Everything We Were Taught About High Doses Was Wrong, and the Same Hand-Crafted Graph

by Drew Rosielle (@drosielle)A Series of Observations on Opioids By a Palliative Doc Who Prescribes A Lot of Opioids But Also Has Questions.This is the 4th post in a series about opioids, with a focus on how my thinking about opioids has changed over the years. See also:Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid DosesPart 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted GraphThis is Part 4 – Everything We Were Taught About High Doses Was Wrong, And The Same Hand-Crafted GraphI no longer consider opioid dosing and conversions as a linear matter. That is, my approach to both opioid dose adjustments and rotations changes markedly the higher the dose of opioid a patient is on.Most of us have long been familiar with the idea that methadone ’s ‘equianalgesic’ relationship to other opioids is non-linear. Ie, the higher the dose of another opioid you’re on, methadone becomes relatively more potent (you use relatively less methadone) – the equianalgesic ratio changes.I now believe this is true of all opioids both with conversions and with titrations, and I imagine a lot of you believe this too.To give you an example: if someone is on 4 mg of oral hydromorphone PRN and has severe uncontrolled pain, there ’s a dece...
Source: Pallimed: A Hospice and Palliative Medicine Blog - Category: Palliative Care Tags: opioids pain rosielle The profession Source Type: blogs