Transition from morphine to buprenorphine is easily accomplished because of the number of spare binding sites, which act as a receptor reserve (see Fig. IV-7). When wanting to switch high dose morphine to buprenorphine the following conversion scale is only used as a rough estimate at start, which is followed by a titration period up to the desired effect (Fig. IV-21).
Successful conversion from high dose morphine to transdermal buprenorphine in chronic pain patients was demonstrated in 47 patients with chronic pain. Only a 5% of all patients were satisified with their current medication and after successfully switching to transdermal buprenorphine 77% reported a good to very good pain relief (Fig. IV-22).
In summary a transdermal opioid patch is indicated in the following category of patients with chronic pain:
1. in whom peak plasma levels of the opioid should be avoided,
2. who object to the daily intake of their medication,
Oxycodone 1:2 — Morphine—100:1 Fentanyl
Figure IV-21. Chart for equivalent dosages when rotating from morphine to either fentanyl, hydromorphine or buprenorphine. Patients using very high daily dosages of morphine of < 240mg/day and experience significant side effects, a 30% reduction of the buprenorphine dose at start of the titration period is advocated
3. who are unable to take a tablet orally,
4. who present malabsorption within the gastro-intestinal tract,
5. who repetitively experience emesis, nausea or hallucinations,
6. who ask for a long duration of action of up to 3 days,
7. where the first-pass effect through the liver is to be avoided,
8. where compliance of drug intake needs to be increased,
9. where administration by the clock is too cumbersome,
10. where due to progression of the underlying disease, a potent analgesic is indicated,
11. where breakthrough pain was effectively treated with an agent of the same molecular structure (i.e. fentanyl OTFC).
before rotation after rotation before rotation after rotation
However, at the same time, the following contraindication should be considered when wanting to use a transdermal patch:
1. Painful conditions, which can be treated with another class of analgesics.
2. Dermatological conditions with an allergic reaction to the patch.
3. During pregnancy and during breast feeding.
4. Patients who do not present a stable painful condition.
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