Overdose Deaths Demand a New Paradigm for Opioid Rotation


  • Financial Disclosure: Lynn Webster, MD, has received funding from the following companies as compensation for clinical research or as honoraria: Adolor, Alkermes, Allergan, AlphaBioCom, American Academy of Pain Medicine, American Board of Pain Medicine, AstraZeneca, Bayer, BioDelivery Sciences International, Boston Scientific, Cephalon, Collegium Pharmaceuticals, Covidien, Eisai, Elan Pharmaceuticals, Gilead Sciences, GlaxoSmithKline, Identigene (Sorenson), King Pharmaceuticals, Meagan Medical, Medtronic, Merck, Naurex, Nektar Therapeutics, NeurogesX, Nevro Corporation, Novartis, Pfizer, SchaBar, Shionogi USA, St. Renatus, SuCampo Pharma Americas, Takeda, TEVA Pharmaceuticals, Theravance, Vanda, Vertex, and Xanodyne Pharmaceuticals.

  • Perry Fine, MD, over the last 12 months has received honoraria for serving on advisory boards for Ameritox, Archimedes, Nuvo, Covidien, Purdue Pharma, and Pricara/OrthoMcNeil, and he has received consulting fees for medical-legal consultation for Johnson & Johnson, Cephalon, and Mylan.

Lynn R. Webster, MD, FACPM, FASAM, Lifetree Clinical Research, 3838 South 700 East, #202, Salt Lake City, UT 84106-6102, USA. Tel: 801-892-5140; Fax: 801-261-3341; E-mail: lrwebstermd@gmail.com.


Objective.  An increasing number of deaths have been inferred to be associated with current opioid rotation practices and evidence is mounting that the use of widely accepted protocols for opioid rotation is an important contributing factor. Based on the findings of a literature review published in conjunction with this article, we propose a new paradigm for a potentially safer method of opioid rotation and present a case study illustrating the paradigm. This new paradigm suggests three easy-to-remember steps in opioid rotation and obviates the need to use a conversion table.

Design.  Report of a clinical case of a patient undergoing opioid rotation using this new paradigm.

Summary.  The patient was successfully rotated from extended-release oxycodone to extended-release hydromorphone. The dose of oxycodone was slowly decreased, while the hydromorphone dose was slowly titrated. A critical element to this approach involved providing sufficient immediate-release opioid to treat breakthrough pain and to reverse acute abstinence signs and symptoms if the dosing changes prove insufficient.

Conclusion.  A safer new paradigm for opioid rotation may provide an important incremental step forward in reducing adverse public health consequences of inappropriate opioid dosing.