Weaning opioids and steroids

Cite this article as:
Marc Anders. Weaning opioids and steroids, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3890

Withdrawal from drugs (principally opioids) prolongs hospital admissions and causes morbidity!

Gradual weaning of drug dosing aims to prevent the onset of withdrawal abstinence syndromes:

  • regime one: 10% reduction in original dose per day weaning over 10 days or
  • regime two: 20% reduction in original dose per day weaning over 5 days
  • regime three: 20% reduction in original dose every 2nd day weaning over 10 days

All are equally effective and the shorter 5-day wean is not associated with any increased withdrawal symptoms requiring reinstitution of drug therapy 

The choice of regime is typically arbitrary based on length of therapy and clinician choice.


Dose conversion of IV and enteral:

Dose escalation and/or opioid rotation are both effective ways to combat tolerance (although there is an inevitable amount of cross tolerance) but not physical dependence.

Converting between opioids and route of administration involves documenting the total 24-hour dose being administered and then using the conversion table and calculating a total daily dose of the new drug via the new route.

Drug IV equivalent IV : morphine ratio enteral equivalent IV : enteral ratio
Morphine 10mg 1 : 1 30 mg 1 : 3
Codeine 100mg 10 : 1 200mg 1 : 2
Oxycodone 10mg 1 : 1 20mg 1 : 2
Fentanyl 100mcg 0.01 : 1 n/a n/a
Methadone 10mg 1 : 1 20mg 1 : 2

Dose conversion for IV midazolam into oral diazepam:

[Midazolam IV [rate in mcg/kg/min] x weight x 24 ] x 0.5 = Diazepam oral

References:

[1] Brunton, L et al (2010), Goodman and Gillman’s the Pharmacological Basis of Therapeutics 12th Edition, McGraw Hill Medical, New York

[2] Macintyre, PE et al (2010), Acute Pain Management: Scientific Evidence 3rd Edition, Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, Melbourne

[3] Miller, RD et al (2009), Miller’s Anesthesia 9th Edition, Churchill Livingstone Elsevier, Philadelphia

[4] Peck, TE & Hill, S (2008), Pharmacology for Anaesthesia and Intensive Care 3rd Edition, Cambridge University Press, Cambridge

[5] Sasada, M & Smith, S (2003), Drugs in Anaesthesia and Intesive Care 3rd Edition, Oxford University Press, Oxford

[6] Stoelting, RK & Hillier, SE (2005), Pharmacology and Physiology in Anesthetic Practise 4th Edition, Lippincott, Williams and Wilkins, Philadelphia

[7] Pediatrics 2010 May;125(5):e1208-25: Anand et al: Tolerance and withdrawal from prolonged opioid use in critically ill children.


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About Marc Anders

AvatarMarc Anders is a paediatric intensivist.

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Author: Marc Anders Marc Anders is a paediatric intensivist.

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