78 YO F with no PMH was admitted to the hospital for newly diagnosed pancreatic cancer. The patient has been requiring large amounts of Dilaudid (hydromorphone) IV during (totaling 8.1mg / 24 hrs). The patient is ready for discharge. What oral regimen should you send her home on?

Learn some key opioid factsLearn to convert common inpatient

opioids to common outpatient opioids

Renal Failure – Avoid morphine Choose: Fentanyl or Dilaudid

Fentanyl patches Cachexia, body temperature, delay in

onsetShort vs Long Acting

Dilaudid = Short only Morphine = Short or long (MS Contin)

Constipation

IM/IV POMorphine 10 30Dilaudid 1.5 7.5

Fentanyl100mcg/24h patch = 200mg PO

morphine

1) Total Amounts2) Convert3) Cross-Tolerance? 4) Choose appropriate PO5) PRN’s/breakthrough pain6) Bowel regimen

8.8 mg IV Dilaudid to PO morphine = 8.8 x 20 = 176 mg PO Morphine

Cross tolerance? YES! Reduce by 15%▪ PO Morphine = 150mg

MS CONTIN = BID Dosing. 150mg in BID dosing = 150/2 = 75mg MS Contin BID

Breakthrough dosing = minimum of 50% total = ▪ 150 * 0.50 = 75mg / day

75mg divided into q4h dosing = ▪ 75 / 6 = ~12 mg q4h PRN