Review and critique of opioid rotation practices and associated risks of toxicity

Pain Med. 2012 Apr;13(4):562-70. doi: 10.1111/j.1526-4637.2012.01357.x. Epub 2012 Mar 28.


Objectives: A dramatic increase in unintentional deaths from opioids has occurred over the past decade with strong inference that many of these deaths may be resulting from prescriber's error. Recent evidence suggests that the use of dose conversion ratios published in equianalgesic tables may lead to fatal or near-fatal opioid overdoses. The objective of this review was to determine whether the current practice of opioid rotation may be contributing to high rate of unintentional deaths.

Methods: We performed a focused literature review to identify reports of fatal or near-fatal outcomes that have occurred in conjunction with opioid rotation, to evaluate clinician competence in opioid rotation, and to identify inconsistencies in published protocols for opioid rotation. Further information was obtained by reviewing dosing instructions contained in product labels for extended-release formulations of several opioids.

Results: An increasing body of literature suggests that widely used opioid rotation practices, including the use of dose conversion ratios found in equianalgesic tables, may be an important contributor to the increasing incidence of opioid-related fatalities. These errors may be due, in part, not only to inadequate prescriber's competence but also to proliferation of inconsistent guidelines for opioid rotation, conflation of equianalgesic tables as conversion tables, and limitations inherent in the equianalgesic dose tables.

Conclusions: Most of the fatal outcomes occurring during opioid rotation are preventable. The current process being used for opioid rotation has important flaws that must be corrected.

Publication types

  • Review

MeSH terms

  • Analgesics, Opioid* / administration & dosage
  • Analgesics, Opioid* / poisoning
  • Drug Dosage Calculations*
  • Drug Tolerance / physiology*
  • Humans
  • Medication Errors* / prevention & control
  • Pain Management / standards*
  • Pain, Intractable / drug therapy*
  • Prescription Drug Misuse*
  • Risk Factors


  • Analgesics, Opioid