7/29/2019 6Opioid Rotation and Dose Equivalence Mar 2013

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J:\HIPS\CLINICAL\Clinical Practice Guidelines\Opioid rotation and dose equivalence_Mar 2013.doc

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Opioid rotation and dose equivalenceHealth Professional ResourcesHunter Integrated Pain ServiceMarch 2013

1. Opioid rotationi. Individual opioids have different structures and act via different receptor mechanisms.

Therefore cross-tolerance is incomplete and adverse effects vary.

ii. Opioid rotation can be used to treat tolerance or adverse effects. At least for a timeimproved analgesia and fewer adverse effects may be achieved with a new opioid at a lowerequivalent dose.

iii. Opioid rotation can also be used as a means of facilitating dose reduction and progressiontoward cessation.

iv. There are many methods of opioid rotation; two are outlined here. Firstly and mostly simplythe existing opioid can be ceased and the new agent started at a dose equivalent 20-30%lower. If withdrawal features are troublesome they can be treated with modest doses of ashort acting opioid for several days. A second more complex method can be used if thepatient is fearful of the rotation process and/or a larger dose equivalent reduction is planned.In this situation a crossover period of approximately 1 week can be used. The original opioidis tapered and ceased over the week while simultaneously the new agent is commenced atlow dose and built up to a target level that is typically 50% lower in dose equivalent terms.

v. Oral clonidine (50-150 mcg 2-3 times daily) can be used to cover the process of opioidrotation to reduce sympathetically mediated withdrawal effects. This is particularly helpful ifthe opioid dose is very high (>300mg daily oral morphine equivalent) or if > 50% doseequivalent reduction is undertaken.

2. Dose equivalencei. There is considerable variation in published dose equivalence ratios so these provide a

rough guide only. The conversion ratios shown below in Table 1 (oral administration unlessotherwise specified) are considered equivalent for the purpose of calculating opioid rotationtargets when the initial maintenance opioid dose is 100mg of morphine.

ii. Table 2 shows the oral and transdermal opioids currently available in Australia. These canall be considered as options for rotation.

iii. Buprenorphine dose in mcg/hr is approximately equal to the same twice daily dose of longacting morphine in mg: 5 mcg/hr = approximately MS Contin 5mg bd

10 mcg/hr = approximately MS Contin 10mg bd20 mcg/hr = approximately MS Contin 20mg bd

iv. Methadone conversion ratios vary according to dose. Morphine to methadone conversionratios of up to 10:1 may be appropriate at high opioid dose levels.

7/29/2019 6Opioid Rotation and Dose Equivalence Mar 2013

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Table 1. Opioid conversion ratios

Opioids Conversion ratio Examplesmorphine : oxycodone 1.5 : 1 morphine 30mg = oxycodone 20mg

morphine : methadone 3 : 1 morphine 30mg = methadone 10mg

oxycodone : methadone 2 : 1 oxycodone 20mg = methadone 10mg

morphine : hydromorphone 5 : 1 morphine 20mg = hydromorphone 4mg

morphine : tramadol 1 : 5 morphine 10mg = tramadol 50mg

morphine : codeine 1 : 6 morphine 10mg = codeine 60mg

morphine : fentanyltransdermal

150 : 1 fentanyl 25 mcg/hr = morphine 90mg daily

morphine : buprenorphinetransdermal

75 : 1 buprenorphine 10 mcg/hr = morphine 18mg daily

Table 2. Oral and transdermal opioids available in Australia

Generic name Long acting agents Short acting agentsMorphine MS Contin tabs 5,10,15,30,60,100,200mg

MS Mono caps 30,60,90,120mgKapanol caps 10,20,50,100mg

Ordine liquid 1,2,5,10 mg/mlSevredol tabs 10,20 mgAnamorph tabs 30 mg

Oxycodone Oxycontin tabs 5,10,15, 20, 30, 40, 80mgTargin tabs (oxycodone/naloxone) 5/2.5,10/5, 20/10, 40/20mg

Endone tabs 5 mgOxynorm caps 5,10,20 mg and liquid 1,10mg/mlProladone suppositories 30 mg

Methadone Physeptone tabs 10mg

Hydromorphone Jurnista 4, 8, 16, 32, 64mg Dilaudid tabs 2,4,8 mg and liquid 1 mg/ml

Fentanyl Durogesic patch 12, 25,50,75,100mcg/hr

Buprenorphine Norspan patch 5, 10, 20mcg/hr Temgesic sublingual tabs 200 mcg

Tramadol Tramal SR tabs 100, 150, 200mgDurotram XR 100, 200, 300mg

Tramal caps 50 mg