Equianalgesic dose conversions are necessary when changing opioid drug therapy in

Policy the clinical setting.

Statement
Opioid analgesics vary in potency, side effect and pharmacokinetic profile. Therefore
Definitions the Opioid Conversion Guidelines has been developed to assist when changing opioid
drug therapy,

PROCEDURE
Policy
When rotating opioids for intolerable side effects or inadequate analgesia, it is
advisable to reduce the dose of the new opioid by 25-50% due to incomplete cross-
tolerance. There shouid be adequate provision made for breakthrough medication and
the patient should be monitored closely.

Please note that all conversions in these guidelines are a guide only.
Medication doses should be modified in response ~ the patients' clinical
condition and previous exposure to opioids.

Oral to Oral

I Oralt~O[.~I"'"'}e ., Ratio ,.,'

.,
,
,'Example
,

I
"';...'.'
" :'

I Oral Tr~madol to Oral Morphine to , 5:1 I Oral Tramadol

I - ---
50mg =Oral Morphine 10mg

, Oral Codeine to Oral Morphine I 8:1 , Oral Codeine 60mg = Oral Morphine 7.5mg

, Oral Morphine to Oral Methadone

I
1 !
? i Complex pharmacology,
!
discuss with Consultant.
Dose requires to be titrated.
I --------
~~~.
I
: Oral Morphine to Oral Oxycod6ne ; 1.5 : 1 , Oral Morphine 15mg = Oral Oxycodone 10mg
, I

; Oral Morphine to Oral Hydrcimoqjhone ; 5: 1 : Oral Morphine 5mg = Oral Hydromorphone 1mg

Oral to Subcutaneous

I o~artoSuDtuta~~ous . " : " "Ratio, ' : ~~ample "I

I Oral Morphine
,
to SC Morphine : 2-3 : 1 i Oral Morphine 20-30mg = SC Morphine 10mg

I, --~-----_._-~'
Oral Methado~e to SC Methadon~~ l~~.~-~
•• ------~'

I
-------------------~
Oral Methadone 20mg = SC Methadone 15mg

: Oral Hydromorphone to SC Hydromorphone

"
,4 :1 i Oral Hydromorphone 4 mg =
i ' SC Hydromorphone 1mg
i - ---------.----: ----.-~-~----._-.-----~ -- ~--~-j

I Oral Oxycodone to SC Oxycodone i2:1 I Oral Oxycodone 20mg = 5C Oxycodone 10mg

Subcutaneous to Subcutaneous

[subcutaneous to Subcutaneous . Ratio Example

SC Morphine to SC Hydromorphone 5 :1 SC Morphine 10mg = SC Hydromorphone 2mg

5C Fentanyl to SC Sufentanil , 10 : 1 SC Fentanyl 100mcg = SC Sufentanil 10mcg

SC Morphine to SC Fenta nyl 70-100 : 1 SC Morphine 10mg = SC Fentanyl 100-150mcg

SC Morphine to SC Oxycodone 1-1.5 : 1 SC Morphine 1O-15mg = SC Oxycodone lOmg

Opioid Conversion Guidelines

GRPCC-CPGOO2_1.0_2011
Page 2 of 4
Gippsland Region Palliative Care Consortium
I
~
S~bcutaneous to Subcutaneous.
.
i-Ratio '. Example
"', ,
; .'" v"

• 1M Pethidine to SC Morphine : 10: 1 ! 1M Pethidine 100mg= SC Morphine 10mg

Subcutaneous to Other Opioid Conversions

,
! Subcutaneous- to .Other ..
t.' :re.;'-.' •
.i, Ratio
,
-
" .
Example'
;

! sc or SL Fentanyl to TIS Fentanyl 1 :1 Fentanyl 600mcg/24 hr CSCI = Fentanyl patch

i
,
25mcg/hr
~,
--------------- ---------i- ---- ~.--------- --~~------------------
i SC Sufentanil to SL Sufentanil : 1 :1 Sufentanil 10mcg CSO = Sufentanil SL 10mcg

: TIS = Transdermal Therapeutic System . esCI = Controlled Subcutaneous Infusion

Opioid Patch & Equivalent Morphine IOxycodone Doses

rs~rength. Jus'. . + Delivery RateSC.bral ' Oral
:Medicatio~.. .,(micrograms/hour). 'Morphin~' '. 'Morphine' , Oxycodone ;
- , .. -...
" .,~ '.... .. (mgj24!' '.. -(mgj24 hours) .". (mgj24 hours) I
~,hours)
>.! " •
: Durogesic 12 I Fentanyl 1
12 110 - 20
..L-
: 20 - 60 I 15 - 40

i Durogesic 25 I Fentanyl 125 i,I 30 - 40 . 60 - 100 i 40 - 70

[ I
I
,I I
:
~ Durogesic 50 I Fentanyl 50 I 60 - 80
- ..
: 120 - 200 I 80 - 140
! .~_ .._-- -- -- -~c~~-.-- - - I I
i Durogesic 75 Fentanyl 75 90 - 120 I 180 - 300 ; 120 - 200
I
i Durogesic 10'0 Fentanyl 100
--
120 - 160
----,
i 240 - 400 I 180 - 270
-
I
i '.

I Norspan5 Buprenorphine .5
I i 9 - 13 : 5 - 10
, ---- ._------ ,
I Norspan 10 - .
,Buprenorphine 10
II ' 10 - 20
~--l
----~ I

I Norspan20 . Buprenorphine 20 ,, 36 - 53 i 25.40 I

I After application of the fentanyl patch peak plasma levels are achieved 24 hours (significant N plasma levels
I occur in 12 to 16 hours). Buprenorph.ine patch takes 3 days to achieve its steady state.
: On removal serum elimination half lives are: fentanyl 15 - 20 hours: buprenorphine 12 hours. Oral opiates should
, not be started until at least 12 hours following removal of either patch (excluding breakthroughs). Regular oral
analgesia needs to be continued for 12-24 hours after commencing either patch.

!. FORMULAfor calculating SUFENTANIL Break-Through Doses (BTD) for a given Fentanyl Patch
.

For a given Fentanyl Patch of x mcg/hr:

BTD = x/5 micrograms of Sufentanil 2 hourly
e.g. for Durogesic 25: BTD = 25/5 i.e 5 microgram Sufentanil 2 hourly
U Break-Through Doses should not exceed 40 micrograms Sufentanil

U Sufentanil is available as 250 mcg/5mi - i.e. 50 mcg/ml

Opioid Conversion Guidelines

GRPCC-CPG002.1.0.2011
Gippsland Region Palliative Care Consortium Page 3 of 4
 Oral Analgesic Preparations
! D~ug' " , " "rade i'Jaine .
. ,.

; Release Rate
,
0;. \", .'

,.
Usual, frequency
.

Presentation

I Buprenorphine i Temgesic ~mmediate i Every 6-8 hours J 200mcg tablets i

---j
i Fentanyl Transmucosal I Actiq I Immediate I Every 2 -3 h;~r;- i 2ClO,400,600,
I I ! 800mcg lozenges
I I i ---~--- ------j---.~------l

I HYdromorPhone: Dilaudid I Immediate ! Every 2-3 hours I 2,4,8mg tabs, 1mg/ml

i : _' mlxt _ J

L :Jurnista ~Iow Release ' Every 24 hours I 8,16,32,64 mg tablets

, Methadone ! Physeptone I Immediate , Every 12 hours 10mg tablets, Smg/ml

i i, ! I . mixt ,
,
[ Morphine I MS Contin ; Slow Releasel Every 12 hours II' 5, 10, 15, 30, 60, lOo,-l
I I 200mg tab ' i
i,

MS Contin Slow Release I Every~2 hour~ 120, 30, 100mg sachet '!
Suspension , _J
,
",.1 MS Mono I Slow Release I Every 24 hours I 30, 60, 90, 120mg
I capsule
I
I Kapanol :, Slow Release Every 12-24 hours I
I
10, 20, 50, 100mg
i I capsule
Ii Anamorph I

! Immediate
!
I Every 4-6 hours , 30mg ta blet
,L
I Sevredol
;
I Immediate I
I
Every 4-6 hou rs ; 10, 20mg tablets l
! Ordine : Immediate I Every 2-4 hours ~ 1mg,2mg, I
I[
,I ; Smg,10mg/ml mixt~

I Oxycodone i OxyContin
,
I Slow Release l Every 12 hours I 5, 10, 20, 40, 80mg
I tablet
:
I
I I
I I Endone
I
I Immediate i Every 4-6 hours Ismg tablet .
i ,
I

I, i, OxyNorm : Immediate i Every 4-6 hou rs I 5,

10, 20mg capsule.

I , i [tSmg/sml Liquid

I Tramadol I Tramal/Zydol t Every 4-6 hours , SOmgtablet

I I
I Tramal SR / Zydol : Every 12 hours I 100mg, lS0mg,
I SR I 200mg tablet

1. Analgesic Therapeutic Guidelines. Edition 4. Melbourne. 2002

2. Palliative Care Therapeutic Guidelines. Edition 2. Melbourne 2005.
References I
3. Australian Medicines Handbook. 2007
Supporting 4. Product information. Mims [On-Line] Available: httD:/Imims.hcn.net.au [2007,May]
Framework 5. Palliative Care Formulary, www.palliativedrugs.com
6. Narcotic analgesic, equianalgesic doses and pharmacokinetic comparison.
7. Micromedex [On-Line] Available: http://micromedex.hcn.net.au [2007, May]
8. Opioid Conversion Ratios' Guide to Practice 2010, Eastern Metropolitan Region
Palliative Care Consortium. Melbourne 2010. Available online at:
http://www.emrocc.org.aulviewresources.asp 7id~7 [20 11, Feb)

Opioid Conversion Guidelines

GRPCC-CPG002,1,O.2011
Gippsland Region Palliative Care Consortium Page4of4