When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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Palliative Care

Opioid Rotation & Conversion

Evidence-based approach to opioid rotation, equianalgesic dosing, and non-opioid adjuvant therapy for residents managing pain in palliative and inpatient settings.

💊 Opioid Rotation Protocol

→ Open the interactive Opioid Conversion calculator, computes OME, shows equivalents across morphine/oxycodone/hydromorphone/fentanyl patch + IV drip, and applies cross-tolerance reduction automatically. Methadone is intentionally blocked (non-linear; consult palliative care).

When to Rotate

Intolerable side effects (nausea, sedation, pruritus, myoclonus) despite dose adjustments
Inadequate analgesia despite dose escalation (true tolerance vs ceiling effect)
Renal failure (rotate away from morphine -M6G accumulates) McPherson et al., 2018
Route change required (PO → IV, or vice versa)

4-Step Conversion Process

Step 1

Calculate total 24h dose of current opioid (scheduled + PRN breakthrough actually used). Example: morphine 30 mg PO q4h (scheduled) + 15 mg PO × 4 breakthrough = 210 mg PO morphine/24h.

Step 2

Convert to equianalgesic dose of new opioid using conversion table (see Opioid Conversions). 210 mg PO morphine ÷ 30 × 20 = 140 mg PO oxycodone/24h equivalent.

Step 3

Reduce by 25–50% for incomplete cross-tolerance. Different opioids bind to different μ-receptor subtypes → previous tolerance doesn't fully transfer. 140 × 0.75 = 105 mg PO oxycodone/24h. Use 50% reduction if: elderly, frail, renal/hepatic impairment, or switching to methadone.

Step 4

Split into scheduled + PRN. Scheduled: 105 ÷ 24h = ~4.4 mg/hr → oxycodone ER 45 mg q12h (or round to nearest available). PRN breakthrough: 10–15% of total 24h dose = oxycodone IR 10–15 mg q3h PRN.

ALWAYS reduce the calculated equianalgesic dose by 25–50%. Skipping this step is the #1 cause of opioid rotation overdose. The cross-tolerance reduction is non-negotiable. McPherson et al., 2018 For methadone conversions: ALWAYS consult pharmacy or palliative care -methadone conversion is non-linear and complex. CDC Opioid Prescribing Guideline, 2022

Fentanyl Patch Conversion: Only for patients on stable opioid doses >= 60 mg oral morphine equivalents/day for >= 1 week. Calculate total 24h OME, then: patch mcg/hr ≈ total daily OME / 2. Example: 120 mg OME/day ≈ fentanyl 50 mcg/hr patch. Apply new patch, continue current short-acting opioid for 12-24h (absorption delay). Remove old opioid ER formulation when patch is applied.

Naloxone Co-prescribing: Co-prescribe naloxone (Narcan) for all patients on >= 50 mg oral morphine equivalents/day, concurrent benzodiazepines, history of overdose, or substance use disorder. Educate patient/family on use. Naloxone duration (30-90 min) may be shorter than opioid duration - observe for re-sedation. CDC Opioid Guideline, 2022

💊 Non-Opioid Adjuvants

Pain Type	Agent	Notes
Neuropathic	Gabapentin (Neurontin) 100–300 mg TID → titrate to 1200 mg TID or pregabalin (Lyrica) 75 mg BID → 300 mg BID	First-line for neuropathic pain. Start low, titrate slow (sedation, dizziness). Reduce dose in CKD. Also: duloxetine 30–60 mg daily (good for diabetic neuropathy). NeuPSIG (Finnerup), 2015
Bone metastases	Dexamethasone (Decadron) 4–8 mg daily + radiation therapy (single fraction effective) + NSAIDs if tolerated	Steroids reduce peri-tumor edema → rapid pain relief. Bisphosphonates/denosumab for skeletal events prevention.
Bowel obstruction	Dexamethasone (Decadron) 8–16 mg IV daily + octreotide (Sandostatin) 100–300 mcg SC TID + glycopyrrolate for secretions	Medical management for malignant bowel obstruction when surgery is not appropriate.
Visceral / somatic	Acetaminophen (Tylenol) 1g q6h (scheduled, not PRN) + NSAIDs (ibuprofen 400–600 mg TID or ketorolac 15 mg IV q6h × 5 days max)	Scheduled acetaminophen reduces opioid requirements by 20–30%. Elia et al., 2005 NSAIDs: avoid in CKD, GI bleed risk, CHF. Ketorolac: max 5 days (renal toxicity).
Muscle spasm	Baclofen 5–10 mg TID or tizanidine 2–4 mg TID	Avoid cyclobenzaprine in elderly (anticholinergic → delirium). Baclofen: reduce dose in CKD (renally cleared).

🔄 Updated Practice: Old teaching: pain is the "5th vital sign" -treat aggressively with opioids. This contributed to the opioid epidemic. Current practice: multimodal analgesia first (acetaminophen + NSAIDs/ketorolac + gabapentin/pregabalin + regional/local anesthesia). Opioids are for severe pain refractory to multimodal therapy, at the lowest effective dose, for the shortest duration. For chronic non-cancer pain, opioids should generally be avoided -evidence shows minimal long-term benefit with significant harm (addiction, hyperalgesia, overdose).

📋 On Rounds

Pimp Questions

Why do you reduce the equianalgesic dose by 25–50% when rotating opioids?

Incomplete cross-tolerance. Different opioids bind to slightly different μ-opioid receptor subtypes and have different receptor binding profiles (μ1, μ2, δ, κ). When a patient develops tolerance to one opioid, that tolerance does NOT fully transfer to a new opioid -the new drug will be more potent than the conversion table suggests.

When should you rotate opioids vs simply increase the dose of the current opioid?

Rotate (switch to a different opioid) when: (1) intolerable side effects despite dose adjustments (persistent nausea, myoclonus, pruritis, sedation -a different opioid may not cause the same side effect), (2) true analgesic tolerance with escalating doses and diminishing returns (switching resets cross-tolerance)

What is the most dangerous opioid rotation and why?

Rotation TO methadone is the most dangerous. Methadone has unique pharmacology that makes standard equianalgesic tables unreliable: (1) Long and variable half-life (15-60 hours) -steady state takes 5-7 days, so dose adjustments cause delayed toxicity. (2) Incomplete cross-tolerance is MORE pronounced with methadone than other opioids -the standard tables OVERESTIMATE the required methadone dose

What is the equianalgesic dose table and what are its limitations?

Key conversions (oral): Morphine 30 mg = Oxycodone 20 mg = Hydromorphone 6 mg = Hydrocodone 30 mg. IV conversions: Morphine 10 mg IV = Hydromorphone 1.5 mg IV. Oral-to-IV ratio: morphine 3:1 (30 mg PO = 10 mg IV), hydromorphone 5:1 (6 mg PO ≈ 1.5 mg IV). Limitations: (1) Tables are based on single-dose studies in opioid-naive patients -do NOT apply directly to chronic opioid patients

Why is morphine avoided in patients with renal failure?

Morphine is metabolized to morphine-6-glucuronide (M6G), a pharmacologically active metabolite that is renally cleared. In CKD/ESRD, M6G accumulates and causes prolonged sedation, respiratory depression, and myoclonus - effects that can persist for days. Hydromorphone (less active metabolite accumulation) or fentanyl (no active metabolites, hepatically cleared) are safer alternatives. McPherson et al., 2018

A patient on morphine 30 mg PO q4h (180 mg/day) needs rotation to IV hydromorphone. Calculate the dose.

Step 1: Total 24h oral morphine = 180 mg. Step 2: Convert to IV morphine (PO:IV = 3:1) = 60 mg IV morphine/day. Step 3: Convert to IV hydromorphone (morphine 10 mg IV = hydromorphone 1.5 mg IV) = 60 x 1.5/10 = 9 mg IV hydromorphone/day. Step 4: Reduce 25-50% for cross-tolerance = 4.5-6.75 mg/day. Final: hydromorphone ~0.2-0.3 mg/hr continuous or ~1 mg IV q4h with 0.5 mg q2h PRN.

What is opioid-induced hyperalgesia and how does it differ from tolerance?

Opioid-induced hyperalgesia (OIH) is paradoxical increased pain sensitivity caused by opioids themselves. Unlike tolerance (where the same dose produces less effect, requiring dose escalation for the SAME pain), OIH causes NEW or WORSENING pain that is often diffuse and qualitatively different from the original pain. The key distinction: with tolerance, increasing the dose helps. With OIH, increasing the dose makes it WORSE. Treatment: rotate opioids, reduce total dose, add NMDA antagonists (ketamine, methadone). opioid rotation and NMDA antagonists.">Lee et al., 2011

What are the unique dangers of fentanyl patch prescribing?

Fentanyl patches are for STABLE opioid requirements only - never for opioid-naive patients or acute pain (FDA black box). Key dangers: (1) 12-24 hour delay to peak effect - fatal if dose is too high. (2) Drug continues releasing 12-24h AFTER removal. (3) Heat exposure (fever, heating pads, hot baths) dramatically increases absorption and can cause fatal overdose. (4) Patches can be accidentally transferred to caregivers or children through skin contact. (5) CYP3A4 inhibitors increase fentanyl levels. Nelson & Schwaner, 2009

When should you consult palliative care for pain management?

Consult palliative care when: (1) Pain refractory to standard multimodal therapy despite appropriate dose escalation. (2) Methadone rotation needed (complex non-linear conversion, QTc risk). (3) Total opioid dose exceeds 200 mg oral morphine equivalents/day (CDC threshold for specialist input). (4) Significant opioid side effects requiring complex management. (5) Mixed pain syndromes (neuropathic + nociceptive + psychosocial). (6) Goals-of-care discussions needed alongside pain management. CDC Opioid Guideline, 2022

Morphine to Hydromorphone Rotation

Presentation: 72M with advanced pancreatic cancer on morphine SR 60 mg PO BID + morphine IR 15 mg PO q4h PRN (using 4 doses/day). Complaints: severe nausea, myoclonus (arm jerks), and pruritus despite antiemetics. Cr 1.8 (baseline 0.9). Total 24h morphine: 120 mg SR + 60 mg PRN = 180 mg PO/day.

Conversion: 180 mg PO morphine / 5 = 36 mg PO hydromorphone equivalent. Apply 25% reduction (rising Cr) = 27 mg/day. New regimen: hydromorphone ER 12 mg PO q12h (24 mg scheduled) + hydromorphone IR 3 mg PO q3h PRN (10-15% of TDD). Bowel regimen: PEG 3350 + senna (docusate removed per AGA-ACG 2023 - no benefit). AGA-ACG, 2023

Outcome: Nausea and myoclonus resolved within 48h (morphine-specific side effects). Pain controlled with 1-2 breakthrough doses/day.

PCA to Oral Conversion at Discharge

Presentation: 45F post-exploratory laparotomy, POD 3, tolerating PO. Current: hydromorphone PCA - basal rate 0 mg/hr, demand dose 0.2 mg q10min. Over past 24h: used 18 demands (3.6 mg IV hydromorphone/day). Ready for PO transition.

Conversion: 3.6 mg IV hydromorphone x 4 (IV:PO ratio) = 14.4 mg PO hydromorphone/day. No cross-tolerance reduction needed (same drug, just route change). New regimen: hydromorphone 2 mg PO q4h scheduled (12 mg/day) + hydromorphone 2 mg PO q3h PRN. Also: scheduled acetaminophen 1g q6h (reduces opioid requirement 20-30%), ibuprofen 400 mg TID if no contraindications. Taper plan: reduce by 25% every 2-3 days as surgical pain resolves.

Key point: Always add multimodal adjuvants when converting to oral. PCA-to-PO conversion is based on actual PCA usage, not the demand settings.

Dangerous Methadone Conversion

Presentation: 58M with metastatic lung cancer on oxycodone ER 80 mg BID + oxycodone IR 20 mg q4h PRN (using 4 doses/day). Total: 240 mg oxycodone/day. Attending requests rotation to methadone due to cost and neuropathic pain component (methadone has NMDA antagonist activity).

Conversion: 240 mg oxycodone = ~360 mg oral morphine equivalents (oxycodone x 1.5). At this high dose (>300 mg OME), methadone conversion is NOT 1:1 - the ratio is approximately 12:1 to 20:1 (morphine:methadone). Using 15:1 ratio: 360/15 = 24 mg methadone/day. Further reduce 50% for safety = 12 mg/day. Start methadone 5 mg PO TID (15 mg/day) with oxycodone IR 10 mg q4h PRN for breakthrough during transition.

Critical teaching: Methadone reaches steady state in 5-7 days due to long half-life. Do NOT increase methadone dose during the first week. Deaths occur when clinicians increase the dose on day 2-3 because the patient reports pain - the methadone hasn't peaked yet. QTc monitoring required (obtain baseline ECG, repeat at steady state). Weschules & Bain, 2008

📣 Sample Presentation

One-Liner

"Mr. Lee is a 64-year-old with metastatic prostate cancer on sustained-release morphine 60 mg BID + morphine IR 15 mg q4h PRN (using 4 doses/day) being rotated to hydromorphone due to intolerable nausea, myoclonus, and pruritus."

Key Points to Cover on Rounds

Current 24h opioid: morphine SR 120 mg + IR 60 mg = 180 mg oral morphine/day. Equianalgesic conversion: oral morphine 180 mg → oral hydromorphone (÷5) = 36 mg/day. Apply 25% reduction for incomplete cross-tolerance → 27 mg/day. New regimen: hydromorphone ER 12 mg PO BID (24 mg scheduled) + hydromorphone IR 3 mg PO q3h PRN (10-15% of TDD for breakthrough). Bowel regimen continued: PEG 3350 + senna. Antiemetic PRN. Plan: monitor for first 48-72h, adjust based on pain scores and breakthrough use. Expect resolution of morphine-specific side effects.

Monitoring Parameters -Opioid Rotation

Parameter	Frequency	Target / Action
Pain scores	q4h + 1h after each PRN dose	Target ≤ 4/10 or functional goals (e.g., able to ambulate, sleep). Track breakthrough use -if > 3 PRN doses/day, increase scheduled dose.
Sedation (Pasero Opioid-Induced Sedation Scale)	q4h with vitals (q1–2h first 24h post-rotation)	S = sleep, easy to arouse; 1 = awake, alert (acceptable); 2 = slightly drowsy (acceptable); 3 = frequently drowsy (hold dose, reduce); 4 = somnolent (hold, consider naloxone). Naloxone (Narcan) must be at bedside.
Respiratory rate	q4h (q1h first 24h of new opioid)	RR < 10 → hold opioid. RR < 8 or unresponsive → naloxone 0.04–0.4 mg IV (titrate to respirations, not consciousness). Monitor closely × 48–72h after rotation.
Bowel regimen	Daily assessment (BM frequency)	Start bowel regimen with ALL opioids, PEG 3350 (MiraLAX) 17g daily + senna 8.6 mg BID. No BM × 3 days → add bisacodyl or methylnaltrexone (Relistor) 12 mg SC if refractory. Tolerance does NOT develop to constipation. Do not use docusate (no better than placebo, AGA-ACG 2023).
Pruritus	Each assessment	Common opioid side effect (histamine release). Rotation may resolve it. Treat with low-dose nalbuphine 2.5 mg IV or hydroxyzine 25 mg PO. Avoid diphenhydramine (additive sedation).
Nausea	Each assessment	Often resolves with rotation. Ondansetron 4 mg IV/PO q8h PRN. Haloperidol 0.5–1 mg PO/IV for refractory opioid-induced nausea.
Functional status	Daily	Can the patient ambulate, participate in PT, perform ADLs? Pain management goal is function, not a number. Reassess total opioid requirements and consider multimodal adjuncts.

Monitor closely × 48–72h after any opioid rotation. Incomplete cross-tolerance means the new opioid may be unexpectedly potent. Have naloxone (Narcan) at bedside for all patients on opioid drips or after recent rotation. Adjust based on pain scores, breakthrough use, and side effect profile.

🔍 Overview

Overview -Opioid Rotation & Pain Management

See the tabs above for the complete clinical reference: Workup, Management, Medications, Monitoring, Rounds, Summary, and One Pager.

🧪 Workup

Pre-Rotation Assessment -Opioid Rotation

Pain assessment -numeric rating scale (0–10), functional goals ("What would you like to be able to do?"), pain quality (nociceptive vs neuropathic), exacerbating/relieving factors. The number alone is insufficient.
Current opioid regimen -exact drug, dose, route, frequency (scheduled + PRN). Calculate total 24h opioid consumption including all breakthrough doses actually taken.
Equianalgesic calculation -convert current total 24h dose to oral morphine equivalents (OME), then convert to the new opioid using equianalgesic table. Apply 25–50% reduction for incomplete cross-tolerance.
Reason for rotation -intolerable side effects (nausea, myoclonus, pruritus, sedation), analgesic tolerance despite dose escalation, cost/formulary, route change needed (PO → IV or vice versa)
Renal function (BMP, CrCl) -affects opioid metabolism. Morphine: avoid in CKD (active metabolite M6G accumulates → prolonged sedation/respiratory depression). Hydromorphone: safer in CKD but metabolite H3G can accumulate. Fentanyl: safest in renal failure (no active metabolites).
Hepatic function (LFTs) -most opioids are hepatically metabolized (CYP3A4, CYP2D6). Severe liver disease → reduced clearance → dose reduce and extend intervals. Methadone especially affected.

⚡ Management

Management -Opioid Rotation

See the Rotation Steps tab above for the full 4-step conversion process with equianalgesic calculations and cross-tolerance reduction guidance.

💊 Medications

Equianalgesic Conversion Table

Opioid	PO Dose (equianalgesic)	IV Dose	PO:IV Ratio	Notes
Morphine (MS Contin)	30 mg	10 mg	3:1	Reference standard. Avoid in CKD (M6G accumulates). IR: q4h. ER: q8–12h.
Hydromorphone (Dilaudid)	6 mg	1.5 mg	4–5:1	Preferred in renal impairment. 5× more potent than morphine PO. IR: q3–4h. ER: q12–24h.
Oxycodone (OxyContin)	20 mg	N/A (no IV form)	-	1.5× more potent than morphine PO. IR: q4–6h. ER: q12h.
Fentanyl patch (Duragesic)	12 mcg/hr patch ≈ 30 mg PO morphine/24h	Variable	-	For stable opioid requirements ONLY (not acute pain). Takes 12–24h to reach peak effect. No active metabolites -safest in CKD/ESRD. Mercadante & Bruera, 2016
Methadone (Dolophine)	Non-linear conversion	Variable	~2:1	DANGER t½ = 15–60h. QTc prolongation. NMDA antagonist. Use dedicated methadone conversion tables -NOT the standard equianalgesic table. Weschules & Bain, 2008 Consult pharmacy or palliative care.

After calculating the equianalgesic dose, reduce the new opioid by 25–50% for incomplete cross-tolerance. This is non-negotiable. Use the 50% reduction for: elderly, hepatic/renal impairment, methadone conversions, or high-dose rotations (> 200 mg OME/day). Methadone has additional unique risks -always consult an experienced prescriber.

⚡ Summary

Summary

Why Rotate

Tolerance, intolerable side effects (nausea, myoclonus, pruritus), renal failure (morphine metabolites accumulate), poor pain control.

Equianalgesic

Oral morphine 30 = oxycodone 20 = hydromorphone 6. IV morphine 10 = hydromorphone 1.5. Always apply 25-50% reduction for incomplete cross-tolerance.

Methadone Danger

Non-linear conversion. Long half-life (15-60h). QTc prolongation. Use dedicated methadone tables. Start low, titrate over days. Experienced prescribers only.

Fentanyl Patch

For stable opioid requirements only (not acute pain). Calculate 24h oral morphine equivalent → divide by 2 (approximately) = mcg/hr fentanyl.

Cross-Tolerance

Previous opioid exposure means partial tolerance -but cross-tolerance is INCOMPLETE between different opioids. Always reduce calculated dose by 25-50%.

Monitor After Rotation

Closely monitor × 48-72h after rotation. New opioid may be more or less potent than expected. Adjust based on pain scores and breakthrough use.

📄 One Pager

Opioid Rotation -Quick Reference Card

Print this page (Ctrl/Cmd + P) for a condensed reference card.

OPIOID ROTATION -AT A GLANCE

📋 When to rotate: Intolerable side effects, tolerance, poor pain control, renal failure (morphine metabolites).
📊 Equianalgesic: PO morphine 30 = oxycodone 20 = hydromorphone 6. IV morphine 10 = hydromorphone 1.5.
⚠️ Cross-tolerance: Always reduce calculated dose by 25–50% -cross-tolerance is INCOMPLETE.
🚨 Methadone: Non-linear conversion, long t½ (15–60h), QTc risk. Use dedicated tables. Experienced prescribers only.
📈 Monitor: Closely × 48–72h after rotation. Pain scores, sedation, RR. Narcan at bedside.