{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T09:23:02Z","timestamp":1793784182048,"version":"4.6.1"},"reference-count":27,"publisher":"BMJ","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2025,5,22]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Chronic intrathecal opioid use via intrathecal drug delivery system (IDDS), while effective in some patients, can lead to serious complications and side effects. Complications related to IDDS include mechanical\/device malfunction, intrathecal catheter problems, infections, and provider errors. These issues often require urgent surgical intervention, IDDS removal, and abrupt discontinuation of the analgesic infusion. In these scenarios, the safe and effective transition to alternative opioid delivery routes such as intravenous or oral administration is critical. However, an accurate calculation of equianalgesic doses to ensure adequate pain control while minimizing the risk of withdrawal is not well documented.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case report<\/jats:title>\n                    <jats:p>A patient in their 60s with a complex medical history, including chronic low back pain managed with IDDS for 30 years, presented with severe pain unresponsive to dose adjustments. Imaging revealed a catheter-related granuloma at thoracic 8 level, leading to intrathecal therapy discontinuation. A rapid weaning protocol reduced the intrathecal morphine dose by 10% daily, transitioning to systemic opioids based on pain severity and short-acting opioid needs. The final intrathecal-to-oral morphine conversion ratio by the time the pump was empty on day 10 was approximately 1:10.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Current guidelines for intrathecal-to-systemic opioid conversion vary widely, with outdated literature suggesting a 1:300 ratio, whereas real-world cases report ratios between 1:2.5 and 1:70. Given this variability, a conservative, patient-specific approach is essential. Clinicians should consider pharmacokinetics, tolerance, and comorbidities, starting with lower conversion ratios and titrating carefully.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rapm-2025-106550","type":"journal-article","created":{"date-parts":[[2025,7,3]],"date-time":"2025-07-03T13:40:16Z","timestamp":1751550016000},"page":"rapm-2025-106550","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Lost in conversion: navigating the challenges of converting intrathecal opioids to oral equivalents\u2014a case report and literature review"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7126-5768","authenticated-orcid":false,"given":"Ratan K","family":"Banik","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3155-0550","authenticated-orcid":false,"given":"Justin Sangwook","family":"Ko","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea (the Republic of)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Jimenez Ruiz","sequence":"additional","affiliation":[{"name":"Anesthesiology, University of Florida, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danielle Bodzin","family":"Horn","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3419-9209","authenticated-orcid":false,"given":"Eellan","family":"Sivanesan","sequence":"additional","affiliation":[{"name":"Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5680-0811","authenticated-orcid":false,"given":"Michael","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5928-2127","authenticated-orcid":false,"given":"Steven Paul","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Physical Medicine & Rehabilitation, Neurology, Psychiatry and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA"},{"name":"Physical Medicine & Rehabilitation and Anesthesiology, Uniformed Services University, Bethesda, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,7,3]]},"reference":[{"key":"2026032309551104000_rapm-2025-106550v2.1","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2021-103041"},{"key":"2026032309551104000_rapm-2025-106550v2.2","doi-asserted-by":"crossref","first-page":"171","DOI":"10.2217\/pmt-2016-0058","article-title":"Rare presentation of intrathecal morphine withdrawal psychosis","volume":"7","author":"Aiyer","year":"2017","journal-title":"Pain Manag"},{"key":"2026032309551104000_rapm-2025-106550v2.3","doi-asserted-by":"crossref","first-page":"978","DOI":"10.1111\/papr.13258","article-title":"The use of ketamine infusion to dramatically reduce opioid requirements in a patient whose high-dose intrathecal opioid pump was inadvertently cut during surgery","volume":"23","author":"McDonald","year":"2023","journal-title":"Pain Pract"},{"key":"2026032309551104000_rapm-2025-106550v2.4","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1111\/papr.13187","article-title":"Loss of effectiveness with an implanted drug delivery system for intrathecal pain therapy due to corrosion","volume":"23","author":"Reining","year":"2023","journal-title":"Pain Pract"},{"key":"2026032309551104000_rapm-2025-106550v2.5","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1097\/ADM.0000000000000359","article-title":"A Case of Opioid Overdose and Subsequent Death After Medically Supervised Withdrawal: The Problematic Role of Rapid Tapers for Opioid Use Disorder","volume":"12","author":"Chang","year":"2018","journal-title":"J Addict Med"},{"key":"2026032309551104000_rapm-2025-106550v2.6","doi-asserted-by":"publisher","DOI":"10.1016\/S0090-3019(96)00466-1"},{"key":"2026032309551104000_rapm-2025-106550v2.7","doi-asserted-by":"crossref","first-page":"E75","DOI":"10.36076\/ppj\/2015.18.E75","article-title":"Sudden discontinuation of chronic high dose intrathecal hydromorphone and its withdrawal implications","volume":"18","author":"Costello","year":"2015","journal-title":"Pain Physician"},{"key":"2026032309551104000_rapm-2025-106550v2.8","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1080\/J354v16n04_02","article-title":"Clinical pharmacokinetics of morphine","volume":"16","author":"Lugo","year":"2002","journal-title":"J Pain Palliat Care Pharmacother"},{"key":"2026032309551104000_rapm-2025-106550v2.9","doi-asserted-by":"publisher","DOI":"10.1016\/0006-8993(76)91009-X"},{"key":"2026032309551104000_rapm-2025-106550v2.10","doi-asserted-by":"publisher","DOI":"10.1016\/S0165-6147(00)01616-3"},{"key":"2026032309551104000_rapm-2025-106550v2.11","doi-asserted-by":"crossref","first-page":"823","DOI":"10.1111\/ner.12936","article-title":"Conversion of Intrathecal Opioids to Fentanyl in Chronic Pain Patients With Implantable Pain Pumps: A Retrospective Study","volume":"22","author":"Kim","year":"2019","journal-title":"Neuromodulation"},{"key":"2026032309551104000_rapm-2025-106550v2.12","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1016\/j.spmd.2003.10.001","article-title":"The dilemma of opioid conversion in intrathecal therapy","volume":"1","author":"Du Pen","year":"2003","journal-title":"Seminars in Pain Medicine"},{"key":"2026032309551104000_rapm-2025-106550v2.13","doi-asserted-by":"publisher","DOI":"10.1016\/0885-3924(96)00010-3"},{"key":"2026032309551104000_rapm-2025-106550v2.14","doi-asserted-by":"crossref","first-page":"1157","DOI":"10.1111\/ner.13517","article-title":"Initial Intrathecal Dose Titration and Predictors of Early Dose Escalation in Patients With Cancer Using a 100:1 Oral to Intrathecal Morphine Conversion Ratio","volume":"24","author":"Sindt","year":"2021","journal-title":"Neuromodulation"},{"key":"2026032309551104000_rapm-2025-106550v2.15","unstructured":"Opioid conversion calculator morphine equivalents -advanced. 2024. Available: https:\/\/globalrph.com\/medcalcs\/opioid-pain-management-converter-advanced"},{"key":"2026032309551104000_rapm-2025-106550v2.16","doi-asserted-by":"publisher","DOI":"10.1053\/rapm.2002.31937"},{"key":"2026032309551104000_rapm-2025-106550v2.17","doi-asserted-by":"publisher","DOI":"10.1177\/104990910402100214"},{"key":"2026032309551104000_rapm-2025-106550v2.18","doi-asserted-by":"publisher","DOI":"10.1016\/S0885-3924(01)00294-9"},{"key":"2026032309551104000_rapm-2025-106550v2.19","doi-asserted-by":"publisher","DOI":"10.1016\/S0885-3924(01)00271-8"},{"key":"2026032309551104000_rapm-2025-106550v2.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpainsymman.2009.06.002"},{"key":"2026032309551104000_rapm-2025-106550v2.21","doi-asserted-by":"publisher","DOI":"10.1136\/bmjebm-2017-110853"},{"key":"2026032309551104000_rapm-2025-106550v2.22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr7103a1","article-title":"CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022","volume":"71","author":"Dowell","year":"2022","journal-title":"MMWR Recomm Rep"},{"key":"2026032309551104000_rapm-2025-106550v2.23","doi-asserted-by":"publisher","DOI":"10.1111\/ner.12146"},{"key":"2026032309551104000_rapm-2025-106550v2.24","doi-asserted-by":"publisher","DOI":"10.1124\/mol.119.119107"},{"key":"2026032309551104000_rapm-2025-106550v2.25","doi-asserted-by":"publisher","DOI":"10.1053\/apmr.2002.32820"},{"key":"2026032309551104000_rapm-2025-106550v2.26","doi-asserted-by":"crossref","DOI":"10.1136\/bcr-2015-210325","article-title":"Clonidine withdrawal induced sympathetic surge","volume":"2015","author":"Shaw","year":"2015","journal-title":"BMJ Case Rep"},{"key":"2026032309551104000_rapm-2025-106550v2.27","doi-asserted-by":"crossref","unstructured":"Romito JW , Turner ER , Rosener JA , et al . Baclofen therapeutics, toxicity, and withdrawal: A narrative review. SAGE Open Med 2021;9. doi:10.1177\/20503121211022197","DOI":"10.1177\/20503121211022197"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2025-106550","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T16:55:20Z","timestamp":1774284920000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2025-106550"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,3]]},"references-count":27,"alternative-id":["10.1136\/rapm-2025-106550"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2025-106550","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,3]]}}}