William's story - Switching to Durogesic DTrans patches when a patient has already been using morphine

William is a 53 year old man with an advanced colon cancer. He has been using 30 mgs of sustained release morphine every 12 hours to control his pain. He also has 10 mgs of normal release morphine to take for breakthrough pain if required. Currently William’s pain is stable and he has not needed to take any breakthrough doses. Although William has found this to be effective the routine of taking his tablets has begun to irritate him and he has asked if there is an alternative. When told about the option of Durogesic DTrans patch William is very keen to try it.

Follow these three steps

1. Add up William’s total 24 hour requirement of morphine, including any breakthrough doses.

William has been taking 60mgs orally in 24 hours

2. Use the conversion chart to calculate the equivalent Durogesic DTrans patch strength

The equivalent Durogesic DTrans patch strength is 25 mcgs per hour

3. Apply the Durogesic DTrans patch.

Remember the time taken for the Durogesic DTrans patch to reach a therapeutic level. (6-12 hours)

The Durogesic DTrans patch should be applied at the same time as the last sustained release morphine dose. Remember to then discontinue the sustained release tablet but leave William on his 10 mgs of morphine for his breakthrough pain.

Arrangements should be made the next morning to check on how the change to Durogesic DTrans has gone and followed up a couple of days later.

Patients may be on different formulations of morphine prior to changing to Durogesic DTrans and the following provides guidance about when to discontinue their morphine.

If the patient is on a high dose of morphine then the process should be carried out under close observation. SEEK ADVICE FROM SPECIALIST PALLIATIVE CARE.

Consider any amount greater than 250 mgs of morphine daily, as a 'high dose'.

4 hourly morphine
Apply the Durogesic DTrans patch and give the next 3 ‘four hourly doses of morphine’ then stop regular morphine formulation.

12 hourly morphine
Apply the Durogesic DTrans patch at the same time as the last 12 hourly morphine dose then stop 12 hourly morphine formulation.

24 hourly morphine
Apply the Durogesic DTrans patch 12 hours after the last 24 hourly morphine dose then stop 24 hourly morphine formulation.

Continuous Subcutaneous Infusion morphine
Apply the Durogesic DTrans patch continuing the infusion for a further 12 hours only

N.B. The above are guidelines and should permit safe transference but careful monitoring of the individual patient’s response is necessary.

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