Managing Chronic Pain: Practical Considerations to Improve Treatment Outcomes - Episode 10

Risks and Rewards of Opioid Rotation

The panelists discuss the risks and rewards of rotating opioid therapies for chronic pain patients.

According to Christopher Gharibo, MD, there is “tremendous rationale” behind using opioid rotation as a course of treatment. Although Gharibo notes there will be “a gradual lack of response over time” in addition to other potential side effects, he says it can also be helpful.

“As we lose that efficacy … we used to go up on the dose, but I think we’re entering a new era where opioid rotation is going to be more and more important,” he says. “So, instead of continuing to go up on the same compound that the patient responded to, our new strategy should be opioid rotation … to another opioid molecule.”

However, Gharibo says clinicians who opt to use opioid rotation must educate patients about it.

“That conversion may take anywhere from a couple of weeks to a month or so, but the effect will ultimately be comparable,” he explains. There will also be side effects that must be considered, though he says they “will dissipate over time, and the pharmacodynamics and the efficacy will improve over time,”

Joseph Pergolizzi, MD, agrees that educating both patients and other doctors in the field about opioid rotation is important, especially in spotting “the difference between tolerance and other things like opioid-induced hyperalgesia.” However, Vitaly Gordin, MD, warns against a “cookbook approach” to this course of treatment, given the number of opioids in the market.

“We know that each opioid has unique properties and binds to a unique subset of new receptors and other opioid receptors, so I really would like to use the conversion tables,” Gordin says. “We all know that they’re imperfect, (so) we all know that you need to exercise caution when you convert.”