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CONVERSION BETWEEN OPIOID ANALGESICS A practical guide from the University of Alberta Multidisciplinary Pain Centre

(A simpler scheme, used by the Regional Palliative Care Program can be found here)
Use this page to help solve the common problem of figuring out how to convert from one opioid to another, or from more than one drug to a new opioid. It should be noted that good generalisable data in this area is hard to get. The table is a simplified composite of published data, clinical impressions and informal consensus.
1. Make a list of the total amounts of each opioid drug currently being taken orally, rectally or transdermally in a 24 hr period. Count milligrams of each drug, whether being given as long- or short-acting preparations, scheduled or breakthrough. Injectable opioids get added in later. If there is only one drug, that's fine! 2. Look at the table below. Multiply the amount of each drug by its bioavailability (column 4), to get a smaller number. This is the number of milligrams that actually gets into the bloodstream. Remember that a 100 MICROGRAM fentanyl patch is 0.1 MILLIGRAMS of fentanyl PER HOUR. 3. Convert each number in your list to i.v. morphine equivalents, by using column 2. For example, if the bioavailable codeine dose is 100 mg, the i.v. morphine equivalent is 10mg 4. If any opioids are being given parenterally, add them to the list at this point, and convert them to i.v .morphine equivalents as well. 5. Add up the i.v. morphine equivalents. You should now have a single number in milligrams. 6. Reduce this number by 30% 7. Select your new drug. 8. Use column 2 to obtain the equivalent parenteral dose of the new drug. For example, if your reduced i.v. morphine dose was 50mg, the equivalent i.v. hydromorphone dose is 10mg.

9. Divide this number by the bioavailability of the new drug to get a bigger number, that being the oral 24 hour dose of the new drug. Some rounding of numbers is fine. 10. Divide this dose into long- and short-acting fractions as you see fit.

11. Use these steps as only a starting point. Apply careful clinical judgement and be prepared to
adjust the dose of the new drug according to response. Remember that because of incomplete cross-tolerance, the starting dose of the new opioid should be reduced by about 30%.

DRUG

PARENTERAL DOSE (MG) EQUIVALENT TO 10 MG IV MORPHINE 10 25 100 5 0.1 2 2 80 2-10 10

ORAL DOSE EQUIVALENT TO 30 MG ORAL MORPHINE 30 75 300 12.5 3 4 250 2-10 12

BIOAVAILABILITY DOSING OF ORAL INTERVAL DOSAGE FORM (HRS)

MORPHINE ANILERIDINE (LERITINE) CODEINE DIAMORPHINE (HEROIN) FENTANYL HYDROMORPHONE (DILAUDID) LEVORPHANOL MEPERIDINE (DEMEROL) METHADONE OXYCODONE (PERCOCET OXYCONTIN) PROPOXYPHENE (DARVON) SUSTAINED RELEASE MORPHINE (MS CONTIN)

0.3 0.3 0.3 0.4 0.6 0.5 0.3 1.0 0.8

3 3 3 3 1 3 6-12 3 8-12 3

50 -

100 60

0.5 0.5

4 8-12

Palliative conversion table

Extracted from Alberta Hospice Palliative Care Resource Manual Second edition (2001)

http://www.palliative.org/PC/ClinicalInfo/ACB%20PC%20resource%20manual.pdf NB: The table below is a guideline only. Patient-to-patient variability occurs. Patients should therefore be monitored closely when their opioids are being switched. Drug Morphine Codeine Oxycodone Hydromorphone Methadone Fentanyl IV or Patch PO Dose 10 mg 100 mg 5 mg 2 mg 1 mg Check manufacturers instructions SC / IV Dose 5 mg 50 mg 1 mg Too irritating 100 mcg

Note the ratio from oral to SC / IV is 2:1 on most occasions Back Home

http://www.uofapain.med.ualberta.ca/Palliativeconversiontable.htm4/30/2007 2:50:55 PM