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An example oral opioid switch from morphine to oxycodone

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Topics: MorphineOxycodonePalliative and End of Life CareSwitching

An example scenario to support you when switching or advising on switching between morphine and other oral opioids in cancer and palliative care.

This article forms part of a series
  1. Switching between morphine and other opioids in palliative care
    1. Estimating dose equivalence from oral morphine to other opioids
    2. An example oral opioid switch from morphine to oxycodone

Contents

  1. Using our advice
  2. Scenario: morphine to oxycodone
    1. Calculate current total daily opioid dose
    2. Estimate an equivalent dose
    3. Consider applying a dose reduction
    4. Choose a MR oxycodone preparation
    5. Prescribe as required oxycodone
    6. Monitor patient and titrate doses
  4. Update history

Using our advice

If you have not done so already, refer to the first article in this series before reading this scenario.

Switching between morphine and other opioids in palliative care

Switching between oral morphine and other oral opioids requires care and thoughtful application of a stepped process.

Scenario: morphine to oxycodone

Patient is taking:

  • modified-release (MR) morphine tablets 30mg twice daily
  • morphine oral solution 10mg 4 hourly when required (‘prn’) – patient reports needing to take breakthrough (‘prn’) doses on average twice daily

Their consultant suggests switching morphine to oxycodone.

We have provided an example of how to apply our equivalence advice (SPS page) to determine an appropriate dose of oxycodone for this patient.

    • Modified-release morphine: 30 x 2 = 60mg
    • ‘prn’ morphine: 10 x 2 = 20mg

    Answer

    Total daily morphine dose = 60 + 20 = 80mg

  2. To switch from morphine to oxycodone our tool (SPS page), recommends dividing the total daily morphine dose by 1.5 to 2.

    For example:

    80mg ÷ 1.5 = 53mg
    80mg ÷ 2 = 40mg

    Answer

    Giving an approximate equivalent total daily dose of 40mg to 53mg of oral oxycodone

  3. A dose reduction is often recommended when switching opioids. The reason why a dose reduction may be required, is discussed in switching between morphine and other opioids in palliative care (SPS page).

    For a 25% dose reduction:

    0.25 x 40mg = 10mg (40mg – 10mg = 30mg)
    0.25 x 53mg = 13.25mg (53mg – 13.25mg = 39.75mg)

    Answer

    Resulting total oxycodone daily dose: 30mg to 39.75mg.

  4. Consult the BNF, SmPC or your local prescribing formulary to see what is available.

    Prescribe for regular use at a dose as close as possible to the calculated total daily dose in suitable divided doses. Use a dose frequency as recommended in the BNF or SmPC.

    Answer

    For example, oxycodone modified-release tablets 15mg twice daily (total daily dose of 30mg). This is a cautions dose equivalence going to the bottom of the range.

  5. Consult BNF or SmPC to choose an appropriate ‘immediate-release’ preparation and check usual dose recommendations.

    Scottish Palliative Care Guidelines advise an appropriate ‘prn’ dose is one-sixth to one-tenth of the total daily dose,

    1/6 x 30 = 5mg

    1/10 x 30 = 3mg

    Answer

    For example, oxycodone oral solution 3 to 5mg every 4 hours ‘prn’ for breakthrough pain.

  6. Following conversion, monitor the patient and if required gradually titrate doses up or down according to clinical response and side effects.

    This includes regular doses as well as ‘prn’ doses for breakthrough pain.

Update history

  1. Republished
  2. Full review and update complete. Minor changes to structure and wording.
  1. Originally published
  2. Minor amendments following user feedback
  1. Published