Opioid rotation and dose equivalence

Health Professional Resources Hunter Integrated Pain Service March 2013

1. Opioid rotation
i. ii. Individual opioids have different structures and act via different receptor mechanisms. Therefore cross-tolerance is incomplete and adverse effects vary. Opioid rotation can be used to treat tolerance or adverse effects. At least for a time improved analgesia and fewer adverse effects may be achieved with a new opioid at a lower equivalent dose. Opioid rotation can also be used as a means of facilitating dose reduction and progression toward cessation. There are many methods of opioid rotation; two are outlined here. Firstly and mostly simply the 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 a short acting opioid for several days. A second more complex method can be used if the patient 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 opioid is tapered and ceased over the week while simultaneously the new agent is commenced at low dose and built up to a target level that is typically 50% lower in dose equivalent terms. Oral clonidine (50-150 mcg 2-3 times daily) can be used to cover the process of opioid rotation to reduce sympathetically mediated withdrawal effects. This is particularly helpful if the opioid dose is very high (>300mg daily oral morphine equivalent) or if > 50% dose equivalent reduction is undertaken.

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2. Dose equivalence
i. 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 unless otherwise specified) are considered equivalent for the purpose of calculating opioid rotation targets when the initial maintenance opioid dose is 100mg of morphine. Table 2 shows the oral and transdermal opioids currently available in Australia. These can all be considered as options for rotation. Buprenorphine dose in mcg/hr is approximately equal to the same twice daily dose of long acting morphine in mg: 5 mcg/hr = approximately MS Contin 5mg bd 10 mcg/hr = approximately MS Contin 10mg bd 20 mcg/hr = approximately MS Contin 20mg bd Methadone conversion ratios vary according to dose. Morphine to methadone conversion ratios of up to 10:1 may be appropriate at high opioid dose levels.

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

Table 1. Opioid conversion ratios

Opioids
morphine : oxycodone morphine : methadone oxycodone : methadone morphine : hydromorphone morphine : tramadol morphine : codeine morphine : fentanyl transdermal morphine : buprenorphine transdermal

Conversion ratio
1.5 : 1 3:1 2:1 5:1 1:5 1:6 150 : 1 75 : 1

Examples
morphine 30mg = oxycodone 20mg morphine 30mg = methadone 10mg oxycodone 20mg = methadone 10mg morphine 20mg = hydromorphone 4mg morphine 10mg = tramadol 50mg morphine 10mg = codeine 60mg fentanyl 25 mcg/hr = morphine 90mg daily buprenorphine 10 mcg/hr = morphine 18mg daily

Table 2. Oral and transdermal opioids available in Australia

Generic name
Morphine

Long acting agents

MS Contin tabs 5,10,15,30,60,100,200mg MS Mono caps 30,60,90,120mg Kapanol caps 10,20,50,100mg Oxycontin tabs 5,10,15, 20, 30, 40, 80mg Targin tabs (oxycodone/naloxone) 5/2.5, 10/5, 20/10, 40/20mg Physeptone tabs 10mg Jurnista 4, 8, 16, 32, 64mg Durogesic patch 12, 25,50,75,100mcg/hr Norspan patch 5, 10, 20mcg/hr Tramal SR tabs 100, 150, 200mg Durotram XR 100, 200, 300mg

Short acting agents

Ordine liquid 1,2,5,10 mg/ml Sevredol tabs 10,20 mg Anamorph tabs 30 mg Endone tabs 5 mg Oxynorm caps 5,10,20 mg and liquid 1,10 mg/ml Proladone suppositories 30 mg Dilaudid tabs 2,4,8 mg and liquid 1 mg/ml Temgesic sublingual tabs 200 mcg Tramal caps 50 mg

Oxycodone

Methadone Hydromorphone Fentanyl Buprenorphine Tramadol