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Oral morphine to other oral analgesics

Opioid Conversion Ratios - Guide to Practice 2013

Updated as Version 2 - November 2014
2013. The EMR PCC grants permission to reproduce parts of this publication for clinical and educational use only, provided that the Eastern Metropolitan Region Palliative
Care Consortium is acknowledged. Requests to reproduce this document, for purposes other than those stated above, should be addressed to:
Consortium Manager Eastern Metropolitan Region Palliative Care Consortium

There have been no changes to the drug ratios in Version Two - November 2014, amendments are within the written text.
Printing: It is highly recommended this guide is printed in colour, to aid ease of use. The access point for the current electronic version of the guide is at Eastern Metropolitan Region Palliative Care Consortiumor Centre for Palliative Care DISCLAIMER
The information in this document is to be used as a guide to practice only. It is the responsibility of the user to ensure information contained in this document is
used correctly. This guide reflects current palliative care practice in the Eastern Metropolitan Region and published evidence at the time of the review. The current
electronic version of the document is available and should always be referred to.
Before converting and administering, all medication doses derived from this guide to practice, should be checked and prescribed by a medical doctor or nurse
practitioner with appropriate experience in opioid prescribing.
Opioids may be given via different routes as part of clinical practice to reflect clinical needs. These routes (i.e. intranasal & buccal) may not have a place in
conversion guides.
Medication doses should be modified in response to the patient/client's clinical situation and status, including previous exposure to opioids and concurrent
medications. All patients should be monitored closely until stable when commencing, adjusting dosage and/or switching opioid medications.
Adhere to all legislation and professional requirements including organisational policies and procedures regarding opioid medications and their administration.
GENERAL NOTES (1, 2, 3)
The conversions are applicable in pain for palliative care patients It is recommended that opioids be converted to the equianalgesic oral morphine as the first step Calculate the equianalgesic starting dose of the new opioid using the guidelines Apply a dose reduction of 25% to 50% to the equianalgesic starting dose to allow for cross-tolerance  A dose reduction closer to 50% is appropriate if the patient is elderly or medically frail  Also consider o dose and duration of previous opioid treatment o current pain severity o patient's ethnicity, for example, oxycodone may be metabolised differently by Caucasian, Asian and North African groups due to genetic polymorphism o renal and hepatic function o occurrence of adverse effects o direction of switch of opioid  Provide supplemental opioid analgesia (breakthrough medication) during the titration process of 1/10th to 1/6th of the total daily opioid dose  Frequently monitor for patient response and individual dose titration Eastern Metropolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2013. Page 2 of 12

TABLE OF CONTENTS

Instructions for use 2
Disclaimer 2
General Notes 2
Oral morphine to other oral opioids 4
Oral opioids to parental opioids 4
Parenteral morphine to other parental opioids 5
Transdermal buprenorphine to oral morphine 5
Transdermal fentanyl to morphine 6
Parenteral fentanyl to transdermal fentanyl 6
Transdermal and intranasal fentanyl 7
Methadone 8
References 9
Acknowledgements 10
Appendix: Summary Chart 11- 12
r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 3 of 12

ORAL MORPHINE TO OTHER ORAL OPIOIDS
Conversion
Oral to Oral
Comments
Reference
Oral Morphine 10mg = Oral Tramadol 100mg Morphine to Tramadol Tramadol has a limited role in managing moderate-severe pain in palliative care Morphine to Codeine Oral Morphine 6mg = Oral Codeine 60mg CONSULTANT REQUIRED. Morphine to Methadone See methadone conversion on p8 for more information. Oral Morphine 15mg = Oral Oxycodone 10mg Morphine to Oxycodone The oxycodone component of Targin® should be considered in conversions Morphine to Hydromorphone Oral Morphine 5mg = Oral Hydromorphone 1mg ORAL OPIOIDS TO PARENTERAL OPIOIDS– same drug to same drug
Conversion
Parenteral
Calculation
Comments
Reference
Oral Morphine 30mg = Subcutaneous Morphine 10 to 15mg Oral Oxycodone 10mg = Subcutaneous Oxycodone 5mg Oral Hydromorphone 15mg = Subcutaneous Hydromorphone 5mg Consultation with a palliative care Oral Methadone 20mg = Subcutaneous Methadone10 mg service or pain clinic advised Tramadol has a limited role in Oral Tramadol 120mg = Parenteral Tramadol 100mg managing moderate to severe pain in palliative care r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 4 of 12

PARENTERAL MORPHINE TO OTHER PARENTERAL OPIOIDS
Conversion
Parenteral
Parenteral
Calculation
Comments
Reference
Morphine 10,000micrograms (10mg) = Fentanyl 100 micrograms Morphine 10mg = Hydromorphone 2mg Tramadol has a limited role in managing moderate to Morphine 10mg = Tramadol 100mg severe pain in palliative care Morphine 10mg = Oxycodone 10mg TRANSDERMAL BUPRENORPHINE TO ORAL MORPHINE
Patch Strength
Delivery Rate
Oral Morphine Dose
Reference
Buprenorphine 5 mg/7 days 5 micrograms/hour 9 to 12 mg/24 hours Conversion ratio 1:75 (6) and 1:100 (3) 120 micrograms/24 hours Buprenorphine10 mg/7 days 10 micrograms/hour 18 to 24 mg/24 hours Conversion ratio 1:75 (6) and 1:100 (3) 240 micrograms/24 hours Buprenorphine 20 mg/7 days 20 micrograms/hour 36 to 48 mg/24 hours Conversion ratio 1:75 (6) and 1:100 (3) 480 micrograms/24 hours CONVERSION CALCULATION – TRANSDERMAL BUPRENORPHINE TO ORAL MORPHINE
5 mg patch = 5 micrograms buprenorphine per hour 5 mcg x 24 = 120 micrograms over 24 hours 120mcg buprenorphine x 75 (conversion) = 9000mcg or 9mg oral morphine 120mcg buprenorphine x 100 (conversion) = 12000mcg or 12mg oral morphine Comment - Breakthrough pain is treated with immediate release morphine or oxycodone. After removal of the buprenorphine patch, a short acting opioid should be prescribed for the initial 24 hours and a long acting opioid commenced after 24hours4 r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 5 of 12

TRANSDERMAL FENTANYL TO MORPHINE
Oral Morphine equivalent
Parenteral Morphine
Breakthrough immediate release Oral
Patch Strength
Reference
(mg/24 hours)
equivalent (mg/24 hours)
Morphine (mg) – 1/6th of daily dose
Fentanyl Patch 12 Fentanyl Patch 25 Fentanyl Patch 50 1200mcg/24 hours Fentanyl Patch 75 1800 mcg/24 hours Fentanyl Patch 100 2400 mcg/24 hours CONVERSION CALCULATION – TRANSDERMAL FENTANYL TO ORAL MORPHINE
25 micrograms/hour fentanyl patch 600mcg x 100 (conversion) = 60000 micrograms morphine = 60 mg oral morphine CONVERTING TO TRANSDERMAL FENTANYL (3,11)
To Transdermal Fentanyl*
4 hour immediate release (IR) oral opioid Give regular doses IR oral opioid for the first 12 hours after applying patch 12 hour controlled release (CR) long acting oral opioid Apply the patch at the same time as administering the final 12 hour (CR) dose 24 hour controlled release (CR) long acting oral opioid Apply the patch twelve hours after administering the final 24 hour (CR) dose Continuous subcutaneous infusion morphine (syringe driver) Continue the syringe driver unchanged for 8 to 12 hours after applying the patch, then cease Continue the syringe driver at the same rate for 3 hours after applying the patch, then decrease the dose in Continuous subcutaneous infusion fentanyl (syringe driver) the syringe driver by 50% for 3 hours, then cease *Effective systemic analgesic concentrations are generally reached in less than 12 hours for fentanyl r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 6 of 12

PARENTAL FENTANYL TO TRANSDERMAL FENTANYL - same drug to same drug
Conversion
Calculation
Reference
Parenteral Fentanyl Transdermal Fentanyl Fentanyl 600 micrograms / 24 hours = Fentanyl patch 25 micrograms/hour TRANSMUCOSAL FENTANYL
Fentanyl transmucosal (Actiq®) offers a faster onset of relief than oral morphine in breakthrough pain. Transmucosal fentanyl should only be used in patients who are already receiving opioids, and are opioid tolerant. A patient should be receiving at least 60mg of oral morphine equivalents per day, or 50 micrograms transdermal fentanyl per hour, if transmucosal fentanyl is to be considered for breakthrough pain. There is no direct conversion ratio between morphine and transmucosal fentanyl. Refer to Product Information for further information. INTRANASAL FENTANYL
Intranasal Fentanyl solutions are being administered in some clinical settings to provide rapid management of breakthrough pain. Use is not confined to palliative care. Fentanyl is well absorbed into the nasal mucosa with approximately 70% bioavailability. Administration is with an atomisation device. Further information is available in Therapeutic Guidelines (eTG complete) fentanyl analogues section. It is strongly recommended that intranasal therapy be initiated by a pain or palliative care practitioner in an inpatient setting to allow monitoring for efficacy and toxicities. r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 7 of 12

METHADONE

Conversion to methadone from other opioids is complex, and should not be attempted without consultation with a specialist experienced in the use of
methadone. Consultation is of particular importance for the higher doses shaded in red below. It is strongly recommended that Methadone therapy be initiated in
the inpatient setting where patients can be closely monitored for signs of cumulative toxicity (commonly sedation or confusion).

Methadone is lipophilic - care must be taken to avoid toxicity as it may take several days to reach steady-state plasma concentrations. Elimination half-life is lengthy and
highly variable between individuals.
Conversion methods used by palliative care physicians vary considerably and there is no clear-cut evidence to support one method over another.
Conversions should be based on current daily oral morphine equivalent dosage.

Method: (12,13)
1. Stop original opioid when commencing methadone. 2. Days 1 and 2 - give calculated daily dose (see table below) plus 25 to 50% extra (as loading, to saturate tissues), give in 4 divided doses (6 hourly). Omit loading dose in frail, elderly or in those on long-acting sedatives. 3. Days 3 and 4 – give calculated daily dose (without the loading) in 3 divided doses (8 hourly). 4. Day 5 onwards – give calculated daily dose in 2 divided doses (12 hourly). 5. Use short-acting opioids for breakthrough pain (e.g. oxycodone, morphine) Royal Perth Methadone Conversion Protocol (12)
METHADONE CONVERSION RATIO
Conversion
Daily oral morphine equivalent dose
Daily oral methadone dose
I.e. 3 mg morphine: 1 mg methadone Less than 100 mg 0 to 30 mg methadone 101 mg to 300 mg 20 mg to 60 mg methadone 301 mg to 600 mg 30 mg to 60 mg methadone 601 mg to 800 mg 50 mg to 65 mg methadone 801 mg to 1000 mg 50 mg to 65 mg methadone More than 1000 mg
The EMRPCC gratefully acknowledges the following palliative care physicians for their contribution to the methadone section in the 2008 guidelines (14) :
Shirley Bush; Kate Jackson; Brian Le; Peter Martin; Greg Mewett and Peter Poon.
r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 8 of 12 REFERENCES 2013
Fine PG, Portenoy RK. Establishing best practices for opioid rotation; conclusions of an expert panel. J Pain Symptom Manage 2009;38:426-439 Periera J, Lawlor P, Vigano A, Dorgan M, Breura E. Equianalgesic dose ratios for opioids: a critical review and proposals for long – term dosing. J Pain Symptom Manage 2001;22:672-87 Twycross R, Wilcock A. Palliative Care Formulary. 4th ed. Nottingham. Palliativedrugs.com Ltd; 2011 Palliative Care Expert Group, Therapeutic Guidelines: Palliative Care.2010 Version 3. Therapeutic Guidelines Limited: Melbourne Knotlova H, Fine P, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage 2009;38:26-439 Mercadante S, Caraceni A. Conversion ratios for opioid switching in the treatment of cancer pain: a systematic review. Palliat Med 2011;25:504-515 McPherson MM. Demystifying opioid conversions: a guide for effective dosing. Bethesda.ASHP;2010 Wallace M, Rauck RL, Moulin D, Thipphawong, J, Khanna S & Tudor IC. Conversion from standard opioid therapy to once – daily oral extended- release hydromorphone in patients with Chronic Cancer Pain. J Int Med Res 2008;36:343-352. Durogesic® Transdermal System Product Informationaccessed August 2013 10. Vissers KCP, Besse K, Hang G, Devulder J, Morlion B. Opioid rotation in the management of chronic pain: where is the evidence? Pain Prac 2010;10:85-93 11. Prommer E. The role of fentanyl in cancer – related pain. J Palliat Med 2009;12:947-54 12. Palliativedrugs.comaccessed July 2013 13. Ayonrinde OT, Bridge DT. The rediscovery of methadone for cancer pain management. Med J Aust 2000;173: 536-40. 14. Eastern Metropolitan Region Palliative Care Consortium Opioid Working Party, 2008. Opioid Conversion Ratios- guide to practice Oct 2008 r opolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2014. Page 9 of 12 EMRPCC Opioid Conversion Guide Review 2013
Project officer: Ms S Scholes, BPharm Grad Cert Heath (Palliative Care) MSHP AACPA
EMRPCC Clinical Group representatives (2013)
Eastern Health: Director of Palliative Care, Clinical Nurse Consultant, Social Worker
Eastern Palliative Care Assoc. Inc: Palliative Care Physician, Clinical Nurse Consultant, Family Support Consultant
St Vincent's Hospital – Melbourne: Palliative Care Clinical Nurse Consultant, Occupational Therapist
Royal District Nursing Service: Clinical Nurse Specialist (Palliative Care)
EMRPCC: Consortium Manager
Special Acknowledgments:
J McCarthy Eastern Health (Wantirna Health) Palliative Care Pharmacist
Acknowledgment is also extended to the original 2008 EMRPCC clinical group and all contributors to the initial EMRPCC Opioid Conversion Ratios – Guide to Practice
(October2008) and the 2011 EMRPCC clinical group who revised the document EMRPCC Opioid Conversion Ratios- Guide to Practice (December 2010)
The EMRPCC Clinical Group welcomes feedback regarding the planned formal review process in 2016. Please send comments to: Consortia Manager, Eastern Metropolitan Region Palliative Care Consortium PO Box 2110 Rangeview VIC 3132 Australia or Email Eastern Metropolitan Region Palliative Care Consortium (Victoria) Opioid Conversion Ratios - Guide to Practice 2013 v2 www.emrpcc.org.au 2013. Page 10 of 12 Opioid Conversion Ratios - Guide to Practice 2013
Summary Chart (V2)
The entire document must be viewed at
ORAL MORPHINE TO OTHER ORAL OPIOIDS
Conversion
Oral to Oral
Morphine to Tramadol Oral Morphine 10mg = Oral Tramadol 100mg Morphine to Codeine Oral Morphine 6mg = Oral Codeine 60mg Morphine to Methadone CONSULTANT REQUIRED Morphine to Oxycodone Oral Morphine 15mg = Oral Oxycodone 10mg Morphine to Hydromorphone Oral Morphine 5mg = Oral Hydromorphone 1mg ORAL TO PARENTERAL – same drug to same drug
Conversion
Parenteral
Oral Hydromorphone 60mg = Subcutaneous Hydromorphone Hydromorphone Hydromorphone Oral Morphine 30mg = Subcutaneous Morphine 10 to 15mg Oral Methadone 20mg = Subcutaneous Methadone 10mg Oral Oxycodone 20mg = Subcutaneous Oxycodone 10mg PARENTERAL MORPHINE TO OTHER PARENTERAL OPIOIDS
Parenteral
Conversion Ratio
Morphine to Fentanyl Morphine 10mg = Fentanyl 100mcg Morphine to Hydromorphone Morphine 10mg = Hydromorphone 2mg Morphine to Tramadol Morphine 10 mg = Tramadol 100 mg Morphine to Oxycodone Morphine 10 mg = Oxycodone 10 mg Eastern Metropolitan Region Palliative Care Consortium (Victoria) - Clinical Group Opioid Conversion Ratios – Guide to Practice 2013 v 2 (November 2014) www.emrpcc.org.au TRANSDERMAL BUPRENORPHINE TO ORAL MORPHINE
Patch Strength
Delivery Rate
Oral Morphine Dose
Buprenorphine 5 mg / 7 days
5 micrograms/hour 9 to 12 mg/24 hours 120 micrograms/24 hours Buprenorphine 10 mg / 7 days
10 micrograms/hour 18 to 24 mg/24 hours 240 micrograms/24 hours Buprenorphine 20 mg / 7days
20 micrograms/hour 36 to 48 mg/24 hours 480 micrograms/24 hours CONVERSION CALCULATION – TRANSDERMAL BUPRENORPHINE TO ORAL MORPHINE
5 mg patch = 5 micrograms buprenorphine per hour 5 mcg x 24 = 120 micrograms over 24 hours 120mcg buprenorphine x 75 (conversion) = 9000mcg or 9mg oral morphine 120mcg buprenorphine x 100 (conversion) = 12000mcg or 12mg morphine TRANSDERMAL FENTANYL TO MORPHINE
Oral Morphine
Parenteral Morphine
Breakthrough immediate release
Patch Strength
equivalent
equivalent
Oral Morphine (mg) 1/6th daily
(mg/24 hours)
(mg/24 hours)
Fentanyl Patch 12
Fentanyl Patch 25
Fentanyl Patch 50
Fentanyl Patch 75
Fentanyl Patch 100
CONVERSION CALCULATION – TRANSDERMAL FENTANYL TO ORAL MORPHINE
25micrograms per hour fentanyl patch 25mcg/hour x 24 = 600mcg/24 hours 600mcg x 100 (conversion) = 60000 micrograms morphine = 60mg oral morphine

DISCLAIMER:
The information contained in this summary is to be read in conjunction with the entire document. This summary reflects current Eastern
Metropolitan Region palliative care practice and available literature at the time of the release.
All medication doses should be checked and prescribed by a medical doctor or nurse practitioner with appropriate experience in opioid
prescribing before administering. Medication doses should be modified in response to the patient/client's clinical situation and status,
including previous exposure to opioids and concurrent medications. All patients should be monitored closely until stable when
commencing, adjusting dosage and/or switching opioid medications.
Adhere to all legislative and professional requirements including organisational policies and procedures regarding opioid medications
and their administration.

Eastern Metropolitan Region Palliative Care Consortium (Victoria) - Clinical Group Opioid Conversion Ratios – Guide to Practice 2013 v 2 (November 2014) www.emrpcc.org.au

Source: http://www.bswrpc.org.au/wp-content/uploads/2014/11/EMRPCC-Opioid-Conversion-2013-V2-November-2014.pdf