Beyond the end of the line: Case reports of conversion from dextromoramide to other opiates within addiction maintenance treatment

Abstract

Background: Interruption of supply of pharmaceutical opiates can cause major challenge to the continuity of management of opiate-dependent patients on maintenance treatment. Policy makers and practitioners need to learn lessons from the experiences of these occasional crises. Method: Through case report and clinical audit, we report on the opiate switch and dose conversion strategies with 14 patients previously receiving dextromoramide (Palfium®) as opiate addiction maintenance treatment. Results: Patients were switched to a wide range of different opiates, of which the most commonly-selected was morphine. Dose conversion ratios varied greatly between patients. Conclusion: Lessons need to be learnt from serendipitous experiments. In the absence of pre-existing guidance, great diversity of empirically derived practice occurred. Perhaps the most important lessons to be learnt are, first, that no rigid formula for conversion can be universally applied, second, that considerable between-subject variation will be observed and, third, that clinicians should consequently exercise increased caution with any existing tables being the beginning, and not the end, of the process of dose conversion.