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Old 08-25-2008, 03:45 PM   #1
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Question about med. changes and conversions - Ex, Steve and others...

Ex, found the table you posted on conversions interesting. I have a some questions about conversions and changing medications.

Does the ratio you wrote include the reduction for "cross-tolerance" doctors often factor in?

Do you know if they should factor in cross-tolerance when switching if you are already take the same med as an SA or LA? Any idea how they determine what % to put in when they calculate cross-tolerance?

Can doctors [and patients] be relatively certain that using the conversion will prevent withdrawal symptoms or does this vary by patient?

I'm guessing that adjustments after a [correct] conversion are based on the patient's pain response to the new medication (rather than withdrawal symptoms). Is this assumption correct, or does it vary by individual and medication. For example, conversion tables for fentanyl give a wide range and methadone is supposed to be quite difficult to titrate.

I know, for example, that some of these conversions do not work for me - I remember that the pain relief was completely different. I don't remember if there was an issue with withdrawal during the conversion however.

The numbers seem higher than what I have seen published and what doctors use in their PDA tables- for example, I have heard that morphine/oxycodone have a 3/2 ratio approximately [I didn't personally find this to be a good conversion though].

What you wrote is just the initial conversion, right? Then the doctor should titrate the medication to the patient? For example, fentanyl gives wide ranges for conversion - I'm surprised your computer program and PM have a fixed ratio. [think I may be repeating myself a bit here..?]

I presume that if your doctor is way off when she/he makes a conversion, you should keep your mouth shut and just call later with symptoms if you experience them? I have found that doctors tend to use more conservative ratios when making a switch betw. meds. - most seem overly concerned about respiratory problems [my understanding is that respiratory problems are fairly rare when converting opioid tolerant patients].

Again, I have heard that fentanyl, and particularly methadone, are difficult to titrate correctly during a conversion and I know you or Steve have mentioned that methadone is sort of in a class of it's own - so different than the other meds that it is almost impossible to compare...what was meant by this?

This is perhaps a bit off the exact topic, but would you be hesitant to try methadone if you are at greater risk for cardiac problems [but do not actually have a cardiac problem?]

Ex, I know you mentioned that your doctor started you at a dose of morphine that was considerably lower than what you needed - was this using these tables? Did you have withdrawal symptoms or did you need a higher dose b/c the pain control wasn't as strong as the patch?

I may think of more med change/conversion questions, but for now I think I've but enough out there.

Thanks for your help.

Last edited by Confused089; 08-25-2008 at 03:50 PM.

 
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Old 08-25-2008, 04:12 PM   #2
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Confused089 View Post
Ex, found the table you posted on conversions interesting. I have a some questions about conversions and changing medications.

Does the ratio you wrote include the reduction for "cross-tolerance" doctors often factor in?

Do you know if they should factor in cross-tolerance when switching if you are already take the same med as an SA or LA? Any idea how they determine what % to put in when they calculate cross-tolerance?
I would imagine this is a starting point. Based on the numbers that's my guess. I usually allow about 25% for incomplete cross tolerance.

Quote:
Originally Posted by Confused089 View Post
Can doctors [and patients] be relatively certain that using the conversion will prevent withdrawal symptoms or does this vary by patient?
I don't think you can ever be absolutely certain. That's why in all cases of opioid switching plenty of BT meds should be prescribed. And, the doc should encourage communication during the titration period.

Quote:
Originally Posted by Confused089 View Post
Again, I have heard that fentanyl, and particularly methadone, are difficult to titrate correctly during a conversion and I know you or Steve have mentioned that methadone is sort of in a class of it's own - so different than the other meds that it is almost impossible to compare...what was meant by this?
Methadone is a beast. Especially when it comes to conversion tables. It seems the higher the previous opioid dose, the higher the conversion ratio. For instance, when taking a patient from 300mg daily of morphine, I've seen conversion ratios of between 5/1 or even 7/1. But take that morphine dose and raise it to say 600mg daily and you start seeing conversion ratios of 10/1, 12/1 even 15/1 by some. Again, the higher the previous opioid dose, the higher the conversion ratio. Don't ask me why this is, 'cause I don't know, except to say it has lots to do with incomplete cross tolerance.

When I was switched from methadone to MS Contin, my PM recommended that my GP write me for 2 60mg MS Contin tablets upon waking, 2 60mg MS Contin tablets at mid-day and 1 60mg MS Contin tablet at bedtime. However she wanted me to work up to this dose, starting with 1 tablet 3 times per day and going up as I could tolerate it. I was to completely stop my methadone intake at the end of the first titration day. She also recommended 1-2ml of concentrated morphine liquid (20mg/ml) every 6 hours as needed, and that during titration I could use it as much as every 4 hours. So this was essentially a 1/4 conversion ratio as my methadone intake was 80mg daily. I never experienced a single twinge of WD. Ultimately I titrated to a final daily MS Contin dose of 3 60mg tabs 3 times per day. But this had as much to do with disease progression as it did with conversion.

steve

Last edited by forginon; 08-25-2008 at 04:16 PM.

 
Old 08-25-2008, 08:07 PM   #3
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Re: Question about med. changes and conversions - Ex, Steve and others...

Steve is right....A 25% cross tolerance is a good starting point. However, my Doc tries to keep it very simple by using that 6/3/3/1 chart I explained in a previous post.

Yes, I was started too low on the oral morphine. When I questioned him about it the following appt (every 2 weeks when transitioning), he told me that he'd rather make a patient a little uncomfortable than give them cardiac arrest. I appreciated his candor. He also said that even the most experienced PM patient with lots of tolerance can have a bad experience or reaction when transitioning to a different med....Especially one they've never tried before.
Furthermore, this is why one needs a good supply of BT meds during the process like Steve said....And, my Doc did that...Thankfully.

The reason why there is such a wide range on the fentanyl conversion is due to the wide variability between patients. Also, because the med is so darn potent, the manufacturer wants to be very safe and conservative. It's a lot easier to go up than down, especially when one has had a bad reaction.

Hope this helps.

Regards,

Ex

 
Old 08-25-2008, 08:46 PM   #4
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Executor View Post

Yes, I was started too low on the oral morphine. When I questioned him about it the following appt (every 2 weeks when transitioning), he told me that he'd rather make a patient a little uncomfortable than give them cardiac arrest.Ex
Did you mean cardiac or respiratory here? (In as sense, the same thing..no respiration will lead to cardiac arrest..)Did you have withdrawal symptoms on the initial low conversion or just more pain?

Quote:
Originally Posted by Executor View Post
Furthermore, this is why one needs a good supply of BT meds during the process like Steve said....And, my Doc did that...Thankfully.Ex
Not sure why I haven't been given BT meds before - would you suggesting requesting them?

If you or anyone else knows how or whether a dr. modifies the conversion ratio if you have already been taking one of the meds as an LA or SA, would appreciate knowing. No way to undo what's been done, but some guidance for specific issues would be helpful.

Also, I would appreciate advice on what to say and what not to say - how much to keep my mouth shut during a conversion if the conversion seems wrong, or if not BTs are given. I know this depends in part on the relationship you have with your dr. Would you just suggest asking for BTs in case dose needs adjusting?

Have your dr.s written the scrip for 2 weeks or a month when making a change?

I've read that dr.'s should have substantial experience w/ methadone before transferring a patient to this medication. Agree, disagree? Any thoughts on the cardiac stuff with methadone?

Thanks for your help Executor. Grateful as always. Any help people can give in the way of experience or knowledge would be greatly appreciated. She may make a switch soon, so I'd like to know as much as possible.

Last edited by Confused089; 09-10-2008 at 10:30 AM.

 
Old 08-26-2008, 07:04 AM   #5
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Confused089 View Post
Did you mean cardiac or respiratory here? (In as sense, the same thing..no respiration will lead to cardiac arrest..)Did you have withdrawal symptoms on the initial low conversion or just more pain?
What the Doc meant was that it's better to have the patient a little uncomfortable (meaning slight WD) than cardiac arrest (OD).


Quote:
Not sure why I haven't been given BT meds before - would you suggesting requesting them?
I guess it depends on whether or not you think you need them. I thought you took BT meds in addition to your patch?

Quote:
If you or anyone else knows how or whether a dr. modifies the conversion ratio if you have already been taking one of the meds as an LA or SA, would appreciate knowing. No way to undo what's been done, but some guidance for specific issues would be helpful.
No, they do not. Because a person can have a bad reaction to any med regardless of how long they've been on it or what they've been on before. Also, one should use extra caution when moving to a completely new med that they've never tried before. So, to answer your question, the chart is for everyone.

Quote:
Also, I would appreciate advice on what to say and what not to say - how much to keep my mouth shut during a conversion if the conversion seems wrong, or if not BTs are given. I know this depends in part on the relationship you have with your dr. I do think I have made my dr. nervous with my knowledge in the past and need to be far more cautious. Would you just suggest asking for BTs in case dose needs adjusting?
Please remind me what you're on & why and then I'll comment. Thxs.

Quote:
Have your dr.s written the scrip for 2 weeks or a month when making a change?
When making changes, my Doc's protocol is that you have appts every 2 weeks until stable and then they put you back on a month (or two) at a time. Each script is only good for the 2 weeks...Meaning they only give you two weeks worth. This way, if you need a change, they don't have extra meds floating around out there, or have to mess around with you returning them for destruction.

Regards,

Ex

 
Old 08-26-2008, 11:19 AM   #6
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Confused089 View Post
Not sure why I haven't been given BT meds before - would you suggesting requesting them?Also, I would appreciate advice on what to say and what not to say - how much to keep my mouth shut during a conversion if the conversion seems wrong, or if not BTs are given. I know this depends in part on the relationship you have with your dr. I do think I have made my dr. nervous with my knowledge in the past and need to be far more cautious. Would you just suggest asking for BTs in case dose needs adjusting?
Confused,I'm not going to try to tackle the conversion questions. Ex and Steve have this more than covered, and it is certainly not my area of expertise anyway. But I can try to give advice about how best to approach your doctor when asking questions about meds and/or questions in general.

IMHO, the best approach is always a professional, but non-threatening one. In my many years of working in HMO's, I worked very closely with several physicians on a day to day basis. Even the most experienced, competent doctors defer to their chosen physician, when it comes to diagnosing and prescribing. It is more a matter of respect and courtesy for a fellow practitioner and personal physician, than debating or conferring with a collegue. Of course, I'm not saying that there is always 100% consensus, but there is a great deal of emphasis put on not stepping on another's professional "toes" or questioning his/her judgement.

While extensive research can be a valuable tool, you have to be very careful not to insult your doctor's intelligence, training, experience and degree. None of us likes to feel like our clients, or in this case patients, consider themselves more knowledgeable about our chosen field, nor do we appreciate being told how to do our job(s). I am not trying in any way to insult you, or admonish you, but you have admitted yourself, that you can be quite contrary when dealing with past physicians, and even your current one.No matter what you've learned about your condition(s) or about the meds/modalities used to treat them, simply relaying how these conditions affect your day to day life and how your currently prescribed meds/modalities are either working for you or not, will sit better with your doctor and allow him/her to feel that you trust their judgement and experience. More like you are working as a team.

When a patient goes into an appointment, self diagnosing and self prescribing, it tends to (understandably) put most doctors in a defensive and sometimes suspicious posture. I'm sure it makes the doctor question why you are coming to them in the first place. "Is this patient here, just to obtain prescriptions?" This can create a very adversarial doctor/patient relationship, right off the bat. We need to let our doctors, be doctors. And we need to keep in mind, that we are the patients.

I hope I haven't offended. It is certainly not my intention to do that. I just wanted to give you my opinion, based on my own experience with what I've seen work and not work, especially with pain management. I wish you the very best of luck with your next appointment. I hope you and your doctor can come up with a regimine/schedule that is comfortable and successful for both of you. Please keep us updated, as you progress. Take care, CMP/MM

Last edited by cmpgirl; 08-26-2008 at 11:22 AM. Reason: sp

 
Old 08-26-2008, 11:55 AM   #7
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Executor View Post
I thought you took BT meds in addition to your patch? Ex
I think I was asking if the doctor gave you additional B/T meds during a conversion - since most people have b/t meds and there has been considerable discussion about being able to take plenty of B/T meds during a conversion, I was wondering if doctors gave *additional* b/t meds, or if doctors usually allowed you to use more B/T meds during a conversion.

Quote:
Originally Posted by Executor View Post
No, they do not. Because a person can have a bad reaction to any med regardless of how long they've been on it or what they've been on before. Also, one should use extra caution when moving to a completely new med that they've never tried before. So, to answer your question, the chart is for everyone. Ex
Thanks, that's helpful.

Quote:
Originally Posted by Executor View Post
When making changes, my Doc's protocol is that you have appts every 2 weeks until stable and then they put you back on a month (or two) at a time. Each script is only good for the 2 weeks...Meaning they only give you two weeks worth. This way, if you need a change, they don't have extra meds floating around out there, or have to mess around with you returning them for destruction. Ex
Was curious what the standard protocol was.

Thank you for all the help. I really appreciate the time you've taken to respond to my questions.

Last edited by Confused089; 09-10-2008 at 10:32 AM.

 
Old 08-26-2008, 12:10 PM   #8
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by cmpgirl View Post
But I can try to give advice about how best to approach your doctor when asking questions about meds and/or questions in general. I hope I haven't offended. It is certainly not my intention to do that. I just wanted to give you my opinion, based on my own experience with what I've seen work and not work, especially with pain management. [CMP/MM
Definitely no offense taken. I appreciate the advice. The questions I put out there are really so that I know what to expect (in addition, I have an insatiable curiosity and enjoy researching things). I asked for advice dealing with doctors, so I appreciate any tips people share. I have learned what I am doing wrong and how I can have better relationships with doctors from the people on the board. I have changed my behavior in recent appts - with other doctors as well. I still need help knowing where the line is sometimes - what to bring up and what to keep to myself, or even the best way to express something. So, most of what I have asked if for myself and I don't plan to say much except describe what is happening and some of the problems I am having right now. Thank you for the advice :-).

Quote:
Originally Posted by cmpgirl View Post
No matter what you've learned about your condition(s) or about the meds/modalities used to treat them, simply relaying how these conditions affect your day to day life and how your currently prescribed meds/modalities are either working for you or not, will sit better with your doctor and allow him/her to feel that you trust their judgement and experience. More like you are working as a team.[CMP/MM
This is basically my plan - reinforcement helps!

Last edited by Confused089; 08-26-2008 at 12:15 PM.

 
Old 08-26-2008, 12:44 PM   #9
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Confused089 View Post
When switching to an entirely new med...
Doesn't matter. The percentage applies regardless.

Quote:
Originally Posted by Confused089 View Post
Any suggestions on how to "talk" to the doctor if no BT dose is given? "I've heard that B/T meds are often used to help when converting from one med to another, is that right?" Still need diplomacy/dr. communication guidance...
Please refer to CMP/MMs reply on this one.

Quote:
Originally Posted by Confused089 View Post
Pretty interesting - would like to hear about your experience going on methadone if you have time. . . Did you have to miss work during either of these conversions? Sounds like you didn't when you went from methadone to MSC. What about when you went on to methadone...
I didn't have to miss any work either time. When I started on methadone I was opioid naive - it was after that awful detox experience, and then being denied suboxone refill and being dropped by that doc, so I started methadone with nothing else on board.

steve

 
Old 08-26-2008, 01:56 PM   #10
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Re: Question about med. changes and conversions - Ex, Steve and others...

Quote:
Originally Posted by Confused089 View Post
I think I was asking if the doctor gave you additional B/T meds during a conversion - since most people have b/t meds and there has been considerable discussion about being able to take plenty of B/T meds during a conversion, I was wondering if doctors gave *additional* b/t meds, or if doctors usually allowed you to use more B/T meds during a conversion.
I wasn't given "extra" upfront per se, but what he did do was re-filled my BTs early....Which was the extra I needed. My appts were every 2 weeks and if I ran out of BTs, he refilled them. Essentially, he was refilling my BTs about every 23-25 days due to the increase. Once I became stabilized, then we went to a month prescription on everything....All my dates changed of course.


Quote:
For some reason, current PM has written for a month when converting. Was curious what the standard protocol was.
Not sure what his thinking was. I'm assuming he's thinking that the conversion will be easy, or a 1 for 1 type thing. Also, as I've mentioned, my Doc sees patients every 2 weeks when converting. If things go great, you only have the one appt @ 2 weeks, and then go to a month from there on. If there are still issues after the first 2 week appt., you keep coming back in 2 week intervals until you are stabilized. In my case, sometimes the appts were in 11-12 day intervals because I couldn't get an appt @ exactly 2wks.

Regards,

Ex

Last edited by Executor; 08-26-2008 at 01:58 PM.

 
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