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Opioid Rotation: Mechanisms, Concepts, and Benefits

For patients experiencing side effects from opioids, switching the delivery and type of pharmaceutical can often provide relief.
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The last few decades have witnessed a surging interest in pain assessment and management. Yet, pain remains one of the most under treated symptoms. The American Geriatrics Society suggests that 45 to 80 percent of long-term residents have substantial untreated pain.1 In another study, a random selection of hospitalized medical and surgical patients revealed that 80 percent reported pain with 45 percent describing it as “excruciating.”2

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has set standards for appropriate assessment and treatment of pain. The surge in interest in the pain management field is accompanied by a rise in the use of opioids throughout the United States. It is therefore necessary that pain clinicians become familiar with opioids and their characteristics.

Morphine remains the gold standard for the treatment of moderate to severe pain. This ancient opioid has been very well studied and thus will be used as the prototype for this class of medications in the remaining text. In addition, the majority of equianalgesic charts use morphine as the basis on which they build their dosing.

Opioid rotation (OR) involves switching one opioid to another, and when applicable, a route to another, to optimize analgesia and lessen side effects. The rotation can be performed between different long-acting opioids, or from short- acting to long-acting opioids to establish stable analgesia, and minimize the risks of tolerance and addiction.3 The routes that are commonly switched are from Intravenous (IV) to subcutaneous (SQ), oral (PO) to SQ, or IV to PO.4 A listing of studies related to opioids rotation is shown in Table 1.

Study and year # of Patients Design Previous Opioid(s) New Opioid(s) Outcome
Szeto et al, 1977 14 Prospective Demerol Morphine Improved
Sawe et al, 1981 14 Open Multiple Methadone Near Complete Relief
Kaiko et al, 1983 67 Prospective Demerol Morphine Improved
Eisendrath et al, 1987 6 Retrospective Demerol Morphine Improved
Eisendrath et al, 1987 6 Retrospective Demerol Morphine Improved
Parkinson et al, 1990 1 Case report Morphine Hydromorphone Morphine Sufentanil Improved
Steinberg et al, 1992 1 (renal failure) Case report Fentanyl patch Morphine Improved
MacDonald et al, 1993 3 Case report Morphine Morphine Methadone Improved
Sjogren et al, 1993 3 Retrospective Morphine Methadone Sufentanil Improved
Crews et al, 1993 6 Case report Morphine Hydromorphone Methadone Good Pain Relief
Sjogren et al, 1994 2 Case report Morphine Methadone Improved
Bruera et al, 1995 37 Prospective open Hydromorophone Methadone Better Pain Control
Thomas et al, 1995 1 Case report Hydromorphone Methadone Improved
De Stoutz et al, 1995 80/191 Retrospective Multiple Multiple Improved
Paix et al, 1995 4/11 Retrospective Morphine Fentanyl Improved
Moss, 1995 1 Case report Anileridine Morphine Improved
Maddocks et al, 1996 13/19 Prospective Morphine Oxycodone Improved
Vigano et al, 1996 1 Case report Hydromorphone Methadone Improved
Mercadante et al, 199 24 Open Multiple Methadone Good Pain Control
De Conno et al, 1996 196 Open Multiple Methadone Good Pain Control
Bruera et al, 1996 65 Retrospective Hydromorphone Methadone Good Pain Control
Watanabe et al, 1996 50 Retrospective Multiple Methadone Good Pain Control
Lawlor et al, 1997 1 Case report Morphine Methadone Good Pain Control
Hagen & Swanson, 1997 3/5 Case reports Morphine Hydromorphone IV Levorphanol PO Morphine Good Pain Control
Lawlor et al, 1998 14 Retrospective Morphine Methadone Good Pain Control
Ripamonti et al, 1998 51 Retrospective Multiple Methadone Good Pain Control
Kloke et al, 2000 273 Retrospective Multiple Multiple 65% Pain Relief

TABLE 1: Listing of studies related to opioid rotation

Indications for Opioid Rotation

The decision to rotate opioids remains almost purely clinical. However, there are at least three situations where OR may be indicated:

Last updated on: December 20, 2011