Opioid rotation

Opioid rotation or opioid switching is a practice used in the management of severe chronic pain, usually though not exclusively in the context of treatment for cancer. Patients whose ongoing levels of pain require treatment with high doses of strong opioid analgesic drugs for extended periods of time, tend to develop tolerance to the effects of the drug, which then requires dose escalation to continue providing adequate levels of pain relief. Over the course of long term treatment however, dose escalation cannot be continued indefinitely as unwanted side effects of treatment often become intolerable once a certain dosage level is reached, even though pain may still not be adequately controlled. One solution to this is to switch the patient between different opioid drugs over time, usually every few months.[1]

Mechanism

Opioid analgesic drugs tend to exhibit incomplete cross-tolerance, so that even when a patient has developed a high level of tolerance to one drug from this class, they may find that a different opioid drug will still be effective. The reasons for this are still not completely understood, but are thought to result from variations in opioid receptor affinity and occupancy levels at equianalgesic doses, as well as additional mechanisms of action possessed by some drugs such as the NMDA antagonist action of methadone or levorphanol, or the SNRI activity of tramadol or tapentadol.[2][3]

Potential issues

While there is good evidence for the efficacy of opioid rotation as a treatment approach in general, there is less evidence for what particular opioid analgesics are most suitable, and in practice the choice of opioid drugs used depends on many factors such as patient characteristics, prescriber preferences and safety. Diversion of prescribed opioid drugs for illicit recreational use is also a particular concern in this field, as the drugs which are most effective for relieving suffering in palliative care also tend to be those most sought after by drug abusers. The choice of what opioid drug to use in which patient thus tends to be a balance between many different factors that must be considered, and the need for opioid rotation in chronic pain patients makes it advantageous for a wide range of different opioid drugs to be available, even though they may be broadly equivalent in action when used in shorter term treatment.[4][5][6][7][8][9]

See also

References

  1. ↑ Nalamachu SR. Opioid rotation in clinical practice. Adv Ther. 2012 Oct;29(10):849-63. doi: 10.1007/s12325-012-0051-7 PMID 23054690
  2. ↑ Smith HS, Peppin JF. Toward a systematic approach to opioid rotation. J Pain Res. 2014 Oct 17;7:589-608. doi: 10.2147/JPR.S55782 PMID 25378948
  3. ↑ Passik SD, Webster L. Opioid analgesics: does potency matter? J Opioid Manag. 2014 Jul-Aug;10(4):263-75. doi: 10.5055/jom.2014.0214 PMID 25162606
  4. ↑ Cheung CW, Qiu Q, Choi SW, Moore B, Goucke R, Irwin M. Chronic opioid therapy for chronic non-cancer pain: a review and comparison of treatment guidelines. Pain Physician. 2014 Sep-Oct;17(5):401-14. PMID 25247898
  5. ↑ Schug SA, Chandrasena C. Pain management of the cancer patient. Expert Opin Pharmacother. 2015 Jan;16(1):5-15. doi: 10.1517/14656566.2015.980723 PMID 25479712
  6. ↑ McLean S, Twomey F. Methods of Rotation From Another Strong Opioid to Methadone for the Management of Cancer Pain: A Systematic Review of the Available Evidence. J Pain Symptom Manage. 2015 Aug;50(2):248-59.e1. doi: 10.1016/j.jpainsymman.2015.02.029 PMID 25896106
  7. ↑ Gudin J, Fudin J, Nalamachu S. Levorphanol use: past, present and future. Postgrad Med. 2016 Jan;128(1):46-53. doi: 10.1080/00325481.2016.1128308 PMID 26635068
  8. ↑ Mercadante S, Bruera E. Opioid switching in cancer pain: From the beginning to nowadays. Crit Rev Oncol Hematol. 2016 Mar;99:241-8. doi: 10.1016/j.critrevonc.2015.12.011 PMID 26806145
  9. ↑ Dima D, Tomuleasa C, Frinc I, Pasca S, Magdo L, Berindan-Neagoe I, Muresan M, Lisencu C, Irimie A, Zdrenghea M. The use of rotation to fentanyl in cancer-related pain. J Pain Res. 2017 Feb 9;10:341-348. doi: 10.2147/JPR.S121920 PMID 28223843
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