Oxymorphone and opioid rotation

Abstract

To obtain the durable benefits of opioid analgesia, physicians must develop strategies to manage the negative attributes of opioid therapy. Side effects, opioid tolerance, and toxicity limit the use of opioids, yet specific guidelines have not emerged for appropriate doses. Furthermore, there are wide variations in interindividual responsiveness to opioid analgesia. Opioid rotation is an effective, emerging strategy to help manage the negative effects of opioids by limiting doses required to obtain pain relief with tolerable side effects. Tolerance to one particular type of opioid does not necessarily develop at the same rate as tolerance to another opioid (incomplete cross-tolerance). Side effects may vary and generally are reduced at lower doses. Oxymorphone is a highly potent molecule that offers linear dose proportionality, multiple preparations (IV, immediate release, extended release) and good analgesic effect. Strategies for rotating a patient from an opioid to oxymorphone require dose calculation based on equianalgesia, a conversion period and dose titration. In addition to converting a patient from other oral opioids to oxymorphone, special strategies are needed for particular preparations (extended release to extended release; extended release to immediate release to extended release; cross-titration; in-patient titration). Issues in opioid rotation involving oxymorphone are common to other opioid rotation plans: side effects, in particular nausea and constipation, as well as toxicity concerns. While pain patients present a unique challenge to physicians, opioid analgesia involving oxymorphone and opioid rotation strategies have been shown to be effective in pain management in some patients with tolerable side effects. © 2009 American Academy of Pain Medicine.