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OPIOID CONVERSIONS. Sarah Beth Harrington, MD October 2, 2007 Resident Skills Session. Objectives. Review basic principles for prescribing for long and short acting po opioids. Demonstrate competence in calculating opioid dose conversions using standard published conversion ratios.

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Opioid conversions

OPIOID CONVERSIONS

Sarah Beth Harrington, MD

October 2, 2007

Resident Skills Session


Objectives

Objectives

  • Review basic principles for prescribing for long and short acting po opioids.

  • Demonstrate competence in calculating opioid dose conversions using standard published conversion ratios.

  • Calculate starting dose of methadone using common clinical scenerios

  • Compare costs of different opioids when making prescription decisions


Opioid conversions

  • Equianalgesic ratios serve as rough clinical guides

  • Always take into account:

    • Age

    • Renal/Hepatic/Pulmonary function

    • Opioid tolerance/ naivety


Prescribing long acting opioids

PRESCRIBING LONG-ACTING OPIOIDS

  • Short Long acting when pain well-controlled

    PP: Use equianalgesic dosing

    Avoid combo agents

    Bowel regimen!

    Instructions:

  • Calculate mg opioid in 24 hrs  convert to SR

  • Calculate rescue dose (IR); ~ 10-20% total daily dose


Mr smith case 1

Mr. Smith (Case 1)

Case 1:

10mg oxycodone 6 times/day = 60mg oxycodone in 24 hrs

Equivalent SR oxycodone= Oxycontin 30mg q12h

Rescue dose – 10% (60mg) = 6 mg

20% (60mg) = 12mg

ANSWER:

Oxycontin 30mg q12h with Oxycodone 5-10mg q4h prn


Prescribing long acting opioids1

PRESCRIBING LONG-ACTING OPIOIDS

  • Short  Long-acting at higher dose

    - Use for: unrelieved/partially relieved chronic pain

    Instructions:

    1. Calculate mg opioid used in 24 hrs and convert to

    long-acting opioid

    2. Increase long-acting opioid by 50%

    3. Check pill dose availability

    4. Adjust rescue dose [10-20% new daily dose]


Mr smith case 2

Mr. Smith (Case 2)

10mg oxycodone 6 times/day = 60mg oxycodone in 24 hrs

*Increase by 50%

[ 60mg +(60mg X 50%)] =60+30= 90mg oxycodone in 24h

Equivalent SR oxycodone = 45mg q12h

Check pill availability = Oxycontin 40mg q12h

Adjust rescue dose 10% 80mg = 8 mg

20% 80mg = 16mg

Oxycontin 40mg q12h with 10-15mg Oxycodone q4h prn


Prescribing long acting opioids2

PRESCRIBING LONG-ACTING OPIOIDS

  • Using rescue doses to increase SR-opioid

    PP: Can safely escalate opioid dose in pt with constant pain after 24-48 hrs

    If total drug taken as rescue dose in 24hr is > 25% total SR dose, increase the SR dose by that amount


Mr smith case 3

Mr. Smith (Case 3)

Total Oxycodone/day =

80mg (SR) + 40mg (IR) = 120mg oxycodone/day

New Oxycontin dose = 60mg q12h

Rescue dose 10% 120mg = 12 mg

20% 120mg = 24 mg

Oxycontin 60mg q12h with 15-20mg oxycodone q4h prn


Opioid conversions

Ms. X

15mg Morphine IR X 8 doses = 120mg

morphine/day

SR = MS Contin 60mg q12h

Rescue doses 10% 120mg = 12mg

20% 120mg = 24mg

MS Contin 60mg q12h + MS IR 15-20mg q3h prn


Opioid conversions

Ms. Y

20 mg oxycodone X 5 doses = 100mg

oxycodone/day

Increase by 50% =

100mg + (50% (100mg)) = 100 +50 = 150mg

oxycodone/day

Check pill availability - 80mg Oxycontin q12h

Rescue dose – 10% 160mg = 16mg

20% 160mg = 32 mg

Answer:

Oxycontin 80mg q12h + 15-30mg oxycodone q4h prn


Opioid conversions

Mr. Z

60mg (SR) +60mg (IR) = 120mg total MS/day

Convert to long-acting = MS Contin 60mg q12h

Rescue dose – 10% (120mg) = 12 mg

20% (120mg) = 24 mg

Answer:

MS Contin 60mg q12h + 15-20mg MS IR q4h prn


Changing opioid agents

CHANGING OPIOID AGENTS

PP: Remember - Incomplete cross-tolerance

between different opioids

Start new opioid at ½-⅔ of the calculated

equianalgesicdose.

Instructions:

  • If working with SR opioid, calculate 24 hr current opioid dose

  • Use equianalgesic ratio to calculate new opioid dose

  • Reduce dose by ½-⅔ for cross tolerance


Mrs t

Mrs. T

80mg oxycontin q12h=160mg total oxycodone/day

⅔ (160mg) ≈ 100 mg morphine/day

(Check pill availability) – MS Contin 45mg q12h

Rescue dose 10% 90mg = 9 mg

20% 90mg = 18mg

MS Contin 45mg q12h + MS IR 15mg q4h prn


Quick tip

Quick TIP

  • OXYCODONE  MORPHINE

    Easy! Take current dose and reduce by ½-⅔


Opioid conversions

Mr. X

200mg morphine (SR) + 100mg (IR) = 300mg total

morphine/day

Reduce for cross tolerance: ½ (100mcg/hr patch) =

50mcg/hr Fentanyl patch


Opioid conversions

Mr. Z

Convert MS IR  Dilaudid

4-5 mg po morphine = 1mg podilaudid

⅔ (6mg) = 4 mg podilaudid

4mg po dilaudid q4h prn


Opioid conversions

Ms. B

⅔ (225 mg) ≈ 150 mg morphine/day

75 mg MS Contin q12h

Breakthrough - 10% 150 = 15 mg

20% 150 = 30 mg

MS Contin 75 mg q12h with 15-30mg MS IR prn


Opioid conversions

Mr. C

Oxycodone in 24 hrs =

40mg (SR) + 20mg (IR) = 60mg oxycodone/day

60mg oxycodone/day = 60mg morphine/day

½ (60mg ) =30mg po morphine/day

=15mg MS Contin q12h

Breakthrough – 10% 30mg = 3 mg

20% 30mg = 6 mg

Answer: MS Contin 15 mg q12h + MS IR 5 mg prn


Methadone

METHADONE

PP: Cheap, effective, neuropathic pain

Long-acting, would wait 3 days before

titrating dose

Pay attention to ratios

Decrease by 50% for cross tolerance


Opioid conversions

Mr. D

400mg (SR)+200mg (IR) = 600mg morphine/day

10mg po morphine = 1mg po methadone

50% (60mg methadone/day) = 30mg methadone/day

10mg po methadone q8h


Opioid conversions

Mr. X

900mg MS Contin q12h = 1800mg morphine/day

50% (90 mg methadone) = 45mg po methadone/day

Methadone 15mg q8h


Opioid conversions

Ms. Y

24 hr morphine = 60mg X 6 doses = 360mg po

morphine/day

50% (36 mg) = 18 mg po methadone/day

18mg + 15 mg = 33mg po methadone/day

New dose of methadone = 10mg q8h


Multiple opioid conversions

Multiple opioid conversions

PP: Convert everything to morphine

Decrease for cross tolerance at the end


Opioid conversions

Mr. Y

MS Contin 100mg q8h = 300mg morphine/day

Oxycodone 30mg/day = 30mg po morphine/day

Dilaudid po16mg/day = 80mg po morphine/day

Fentanyl patch 50mcg/hr = 150mg morphine/day

-------------------------------------------------------------------

Total morphine equivalent/day = 560mg/day


Opioid conversions

50% (56 mg methadone/day) = 28 mg methadone/day

Answer: 10mg po methadone q8h +4-8mg po dilaudid prn


Changing opioid route same drug

CHANGING OPIOID ROUTE: SAME DRUG

PP: Do NOT stop long-acting opioid

Start equivalent parenteral basal dose


Opioid conversions

Ms. T

60mg MS Contin q12h = 120mg po morphine/day

40mg IV morphine/24 hr = 1.6mg IV morphine/hr


Opioid conversions

Mr. M

EASY!!

20mg po methadone q8h

10mg IV methadone q8h


Changing opioid route different drug

CHANGING OPIOID ROUTE: DIFFERENT DRUG

PP:

Easiest to convert to morphine 1st

Remember to reduce ½-⅔ for X-tolerance


Opioid conversions

Mr. A

Oxycontin 120mg q12h = 240mg oxycodone/day

240mg 240 mg 80mg IV morphine/

oxycodone/day po morphine/day day

16 mg IV dilaudid/24h = 0.67 mg IV dilaudid/hr

⅔ (0.67mg/hr) = 0.4 mg IV dilaudid/hr


Miss d

Miss D

90 mg po 30mg IV 6 mg IV

morphine morphine dilaudid

⅔ (6mg) = 4 mg IV dilaudid **


Opioid conversions

Ms. P

60mg IV 300mg IV 900 mg po

dilaudid/day morphine/day morphine/day

50% (90 mg) = 45mg po methadone/day

Answer:15 mg po methadone q8h


Opioid conversions

Ms. P

Other answers:

300mg MS Contin q12h + 60mg MS IR prn

Fentanyl patch 200 mcg/hr

WHY is Methadone the better choice??


Cost comparison

Cost Comparison


Cost comparison1

Cost Comparison


Conclusion

Conclusion

  • Avoid combo agents

  • Bowel regimen

  • Rescue dose -10-20% total daily dose

  • Incomplete X-tolerance between opioids

  • When changing agents, reduce by ½-⅔

  • Methadone = good

  • Do not ever stop a pt’s long-acting opioid

  • Remember $$


Resources

Resources

Palliative Care Consult Team

  • Call N4N (6-1295)

  • Page–Dr. Swetz, Dr. Patel, Pat Coyne

  • Place consult in Cerner – Pain CNS


  • Login