Download Analgesic Products Comparison Chart

MUSC Opioid Analgesic Comparison Chart
Approved by the Pharmacy and Therapeutics Committee
(February 2006, November 2009, March 2010, December 2011)
Prepared by the MUSC Department of Pharmacy Services and the Pain Management Service
Available online at http://academicdepartments.musc.edu/pharmacy_services/medusepol/pdf/OpioidAnalgesicConversionChart.pdf.
Disclaimer: This document is a guideline, and not a policy statement. This conversion chart is designed to facilitate the rational conversion of one opioid
regimen to an approximately equianalgesic dose of another opioid. The authors have strived to ensure that the information included in the chart reflects the
current level of knowledge regarding opioid conversions. As a result, it is the user’s responsibility to examine all available information on opioid
conversions and to integrate with knowledge about the patient. Always use clinical judgment when making decisions for an individual patient.
COMMONLY USED OPIOID ANALGESICS
†Equi-analgesic
Route
Onset of
Action
Duration of
Action
Usual Dosing
Interval
Appropriate
for PCA
Concentration
for PCA
IV
immediate
30 to 60 min
1 to 2 hr
Yes
50 micrograms/mL
SC**
15 min
30 min to 2 hr
3 to 6 hr
N/A
N/A
TM
TD
5 to 15 min
12 to 24 hr
highly variable
72 hr per patch
See page 4
72 hr
N/A
N/A
N/A
N/A
100 micrograms IV
(0.1 mg IV)
100 micrograms SC
(0.1 mg SC)
See page 4
See page 4
PO
15 to 30 min
4 to 6 hr
3 to 6 hr
N/A
N/A
7.5 mg PO
IV/SC
15 min
4 to 6 hr
3 to 6 hr
Yes
1 mg/mL
1.5 mg IV
PO
30 to 60 min
> 8 hr
(chronic use)
8 to 12 hr
(chronic use)
N/A
N/A
See page 5
PO
30 to 60 min
3 to 6 hr
3 to 6 hr
N/A
N/A
30 mg PO
IV
5 to 10 min
3 to 6 hr
3 to 6 hr
Yes
SC
15 to 30 min
3 to 6 hr
3 to 6 hr
MorphINE
extended release
(MS Contin®, various)
PO
30 to 90 min
8 to 12 hr
MorphINE
extended release
(Kadian®, Avniza®)^
PO
30 to 90 min
PO
PO
Medication
Fentanyl
(Sublimaze®,
Duragesic®, Actiq®,
Fentora®)
HYDROmorphONE
(Dilaudid®)
Methadone
(Dolophine®, various)
MorphINE
immediate release
(MSIR®, Roxanol®,
various)
OxyCODdone
immediate release
(Roxicodone™, OxyIR®,
various)
OxyCODone
controlled release
(OxyContin®, various)
Dosing
Notes
See page 4 for details
See page 4 for details
See page 4 for details
See page 4 for details
HYDROmorphONE is not
equivalent to morphINE
**See page 5 for details**
Equianalgesic dosing is variable
with chronic dosing
morphINE is not equivalent to
HYDROmorphONE
Yes
1 mg/mL
5 mg/mL
N/A
10 mg IM/SC
8 to 12 hr
N/A
N/A
30 mg PO
morphINE is not equivalent to
HYDROmorphONE
Do not crush, chew, or break.
12 to 24 hr
12 to 24 hr (Kadian®)
24 hr (Avniza®)
N/A
N/A
30 mg PO
morphINE is not equivalent to
HYDROmorphONE
Do not crush, chew, or break.
10 to 15 min
4 to 6 hr
4 to 6 hr
N/A
N/A
20 mg PO
oxyCODone is not equivalent to
OxyMORphone
1 hr
12 hr
12 hr
N/A
N/A
20 mg PO
oxyCODone is not equivalent to
OxyMORphone
Do not crush, chew, or break.
10 mg IV
OxyMORphone
immediate release
PO
N/A
N/A
10 mg
(Opana®, various)^
OxyMORphone
extended release
PO
N/A
N/A
10 mg
(Opana ER®, various)^
† Equi-analgesic dosing is based on morphine 10 mg administered parenterally (ie, IV/SC). Calculation example on page 3. ^ Nonformulary status
** Subcutaneous use of fentanyl has not been well-studied; data presented are from a small pharmacokinetic study and a review of a subcutaneous infusion of fentanyl
IV = intravenous; SC = subcutaneous; TM = transmucosal; TD = transdermal; PO = oral
COMMONLY USED COMBINATION OPIOID ANALGESICS
OxyMORphone is not
equivalent to oxyCODone
OxyMORphone is not
equivalent to oxyCODone
Do not crush, chew, or break.
1
Medication
Route
Onset of
Action
Duration of
Action
Usual Dosing
Interval
†Equi-analgesic
Notes
Dosing
HydroCODONE combinations
PO
30 to 60 min
4 to 6 hr
4 to 6 hr
30 mg PO
(see below)
Oxycodone combinations
PO
10 to 15 min
4 to 6 hr
4 to 6 hr
20 mg PO
(see below)
Codeine combinations
PO
30 to 60 min
4 to 6 hr
4 to 6 hr
200 mg PO
(see below)
† Equi-analgesic dosing is based on morphine 10 mg administered parenterally (ie, IV/SC). Calculation example on page 3.
Maximum dose of
hydrocodone is 40 mg/day
Doses should not exceed
120 mg/day in opiate naïve patients
** The FDA does not recommend combination products with an acetaminophen content > 325 mg.
These products will be phased out and may not be available after 2011**
Opioid
Hydrocodone
Oxycodone
Codeine
Acetaminophen
Content
167 mg (elixir)
300 mg
325 mg
400 mg**
500 mg**
650 mg**
660 mg**
750 mg**
Aspirin
Content
Ibuprofen
Comments
--
--
Maximum dose of
acetaminophen is 4 g/day
2.5 mg
5 mg
7.5 mg
10 mg
--
--
200 mg
2.5 mg
5 mg
7.5 mg
10 mg
300 mg
325 mg
400 mg**
500 mg**
650 mg**
--
--
4.5 mg
--
325 mg
5 mg
12 mg
15 mg
30 mg
60 mg
15 mg
30 mg
60 mg
--
--
400 mg
120 mg
300 mg
650 mg**
--
--
Brand Names
Opioid Content
Lortab®
Lorcet®
Maxidone®*
Norco®*
Vicodin®
Xodol®*
Zydone®*
2.5 mg
5 mg
7.5 mg
10 mg
Ibudone®
Reprexain®
Vicoprofen®
Percocet®
Roxicet®*
Roxilox®*
Tylox®*
Percodan®*
Roxiprin®*
Combunox Capsules®*
Tylenol® with Codeine Elixir
Tylenol® with Codeine No. 2
Tylenol® with Codeine No. 3
Tylenol® with Codeine No. 4
Aspirin with Codeine
Empirin with Codeine No. 3
Empirin with Codeine No. 4
Maximum dose of
acetaminophen is 4 g/day
Maximum dose of
acetaminophen is 4 g/day
325 mg
This chart is not considered all-inclusive. All orders/prescriptions must specify dose based on opioid content and acetaminophen, aspirin or ibuprofen content. * Nonformulary status
HIGH-RISK, NON-PREFERRED OPIOID PRODUCTS
2
Medication
Route
Onset of
Action
Duration of
Action
Usual Dosing
Interval
Appropriate
for PCA
Concentration
for PCA
†Equi-analgesic
Codeine phosphate
(various)
PO
30 to 60 min
4 to 6 hr
4 to 6 hr
N/A
N/A
200 mg PO
IV
10 to 30 min
4 to 6 hr
4 to 6 hr
N/A
N/A
120 mg IV
PO
30 to 60 min
4 to 6 hr
4 to 6 hr
N/A
N/A
200 mg PO
PO
10 to 15 min
2 to 4 hr
3 to 4 hr
N/A
N/A
300 mg PO
IV
1 to 5 min
2 to 4 hr
3 to 4 hr
NO
N/A
75 – 100 mg IV
IV
2 to 3 min
3 to 6 hr
3 to 6 hr
N/A
N/A
--
SC/IM
< 15 min
3 to 6 hr
3 to 6 hr
N/A
N/A
--
Codeine sulfate
(various)
Meperidine
(Demerol®)
Nalbuphine
(Nubain®)
Dosing
Notes
Doses should not exceed
120 mg/day in opiate naïve
patients
See meperidine use guidelines
on the MUSC Formulary and
Drug Information Resources
Web page
† Equi-analgesic dosing is based on morphine 10 mg administered parenterally (ie, IV/SC). IV = intravenous; SC = subcutaneous; PO = oral
EQUIANALGESIC CONVERSION EQUATION
Current opioid (single conversion dose & route)
Total 24° dose of current opioid
=
New opioid (single conversion dose & route)
Total 24° dose of new opioid
Equianalagesic conversions should not be considered a simple straightforward calculation.
Significant 'inter/intra' patient variability exists depending on the selected opiate, dose, and
expected response. See information regarding cross- tolerance.
Example: Patient is receiving morphine, with a 24-hr-dose total of 180 mg PO.
What is the equivalent 24-hr dose of hydromorphone?
Equianalgesic Dose
Total 24-hr dose
morphine 30 mg PO
morphine 180 mg PO
hydromorphone 7.5 mg PO
hydromorphone X mg
X = hydromorphone 45 mg PO/24 hrs.
Accounting for cross tolerance of 50% = hydromorphone 22.5 mg PO/24 hrs
OPIOID CROSS-TOLERANCE
Incomplete cross-tolerance relates to tolerance to a
currently administered opiate that does not extend
completely to other opioids.
− This will tend to lower the required dose of the
second opioid.
− It is importance to view the calculated data as
approximations.
− A 50% reduction in calculated dose is
recommended.
− Dose should be re-titrated to patient response.
− In all cases, repeated comprehensive assessments of
pain are necessary in order to successfully control the
pain while minimizing adverse effects.
− This dose not include conversions for methadone (see
page 5) or transdermal fentanyl (reduction is built into
the conversion – see page 4).
Recommended dose = hydromorphone 2 – 4 mg PO every 3 hrs
(2 mg for moderate pain; 4 mg for severe pain)
RECOMMENDATIONS FOR FENTANYL USE
3
Fentanyl to Fentanyl Conversion: 1:1 conversion
Conversion between Fentanyl Transdermal System and Morphine
To convert therapy to fentanyl transdermal system (Duragesic®), calculate
the 24-hr ORAL morphine dose and select the appropriate transdermal system
strength using the following chart:
Oral 24-hr morphine
(mg/day)
< 60
60 to 134
135 to 224
225 to 314
315 to 404
405 to 494
495 to 584
585 to 674
675 to 764
765 to 854
855 to 944
945 to 1034
1035 to 1124
*12.5-microgram patch is nonformulary
Fentanyl transdermal system
(Duragesic®)
(micrograms/hr)
12.5*
25
50
75
100
125
150
175
200
225
250
275
300
Conversion for Transmucosal Fentanyl
Actiq® (lozenge on a stick)
− 800 micrograms = 10 mg IV morphine
Fentora® (buccal tablet - nonformulary)
− 200 micrograms = 10 mg IV morphine
Transmucosal Conversions
Current Lozenge Dose
Initial Buccal Dose
(Actiq®)
(Fentora®)
200 micrograms
100 micrograms
400 micrograms
100 micrograms
600 micrograms
200 micrograms
800 micrograms
200 micrograms
1200 micrograms
400 micrograms
1600 micrograms
400 micrograms
Clinical Practice Points for Fentanyl Use
 Transdermal fentanyl should not be used in opioid naïve patients

Re-consider analgesic option when transition from ICU to floor, especially with fentanyl

Buccal tablet: Place above rear molar between the upper check and gum. Tablet should not be split, sucked, chewed, or
swallowed. Disintegration usually takes up to 25 minutes. After 30 minutes, if remnants from the tablet remain, they may be
swallowed with a glass of water.

Lozenge: Place between cheek and lower gum, moving from one side to the other using the handle. Patient should suck, not
chew, the lozenge. Lozenge should be consumed over 15 minutes.
4
RECOMMENDATIONS FOR METHADONE USE
NOTE: HIGHLY recommended that practitioners NOT FAMILIAR with prescribing or monitoring methadone call either
pain management or pharmacy services for recommendations and guidelines for initiation, dose escalation and follow-up.
Methadone conversion ratio: When switching from an opioid to methadone, the equianalgesic dose ration of methadone depends on
the ORAL morphine-equivalent daily dose (MEDD) of the preceding opioid.
Oral MEDD
(mg/day)
0 to 99
100 to 299
300 to 499
500 to 999
> 1000
Methadone Dose
Conversion Ratio
4:1
8:1
12:1
16:1
20:1
Steps for conversion of opioid to methadone:
1. Convert to ORAL morphine equivalent (24 hr total dose)
2. Divide by ratio above
3. Divide by 50% to account for incomplete cross-tolerance
4. Divide by 3 for frequency (every 8 hr dosing)
5. Round down to the nearest tablet size – 2.5-mg intervals
Example: Patient receiving 860 mg morphine PO equivalent.
860 mg
16
53.75
53.75
2
26.87
26.87
3
8.9
Recommended starting dose: methadone 7.5 mg every 8 hours (dose rounded down based on available tables)
Clinical Practice Points for Methadone Use
 ANY prescriber that can prescribe a C-II medication can prescribe methadone for PAIN
 Half-life can be as long as 130 hours; therefore, steady-state concentrations are reached in 4 – 7 days. Dose adjustments for pain
management should not happen more frequently than every 4 – 7 days.
Of note: Considerable inter-individual variability in elimination half-life; generally reported as 8–59 hours, but values have ranged from 9–87 hours in
postoperative patients, from 8.5–75 hours in opiate-dependent patients, and up to 120 hours in outpatients receiving therapy for chronic malignant pain




Once daily methadone is reserved for maintenance therapy in patients with opioid addiction and should not be used for treatment
of pain.
If naloxone is required, multiple intermittent doses or a continuous infusion may be required.
US Boxed Warning for patients at risk for QT prolongation, with medications known to prolong the QT interval (eg,
haloperidol), or for patients with a history of conduction abnormalities.
− QT interval prolongation and torsade de pointe may be associated with doses > 200 mg/day, but have been associated with
lower doses.
− Correct potassium and magnesium abnormalities prior to initiation.
Methadone is a substrate for the cytochrome P450 enzyme system; therefore, plasma concentrations may be inhibited or induced
by certain concomitant medications. The dose may need to be adjusted based on any potential interaction.
− For questions regarding drug interactions, contact pharmacy or pain management service.
GENERAL CLINICAL PRACTICE POINTS FOR OPIOID USE
5

The equianalgesic opioid doses are for severe pain in patients that are opioid naïve. When converting from one opioid to another,
the calculated equianalgesic dose is an estimate, not the usual starting dose. Individualize and titrate the dose according to crosstolerance, patient age, condition, history (eg, chronic pain), response, and the clinical situation. Reduce dose by 25 to 50% in the
elderly; by 25% in hepatic or renal dysfunction.

Re-consider analgesic option when transition from ICU to floor, especially with fentanyl

Cross allergenicity between opioids varies greatly between patients. Alternative analgesics such as acetaminophen, aspirin, and
non-steroidal anti-inflammatory medications (eg, ibuprofen, naproxen) should be considered in a patient who has experienced a
life-threatening reaction.
Structural Class
Phenanthrenes
Morphine
Hydromorphone*
Oxymorphone*
Codeine
Hydrocodone
Oxycodone*
Piperidine/phenylpiperadine
Diphenylheptanes
Fentanyl*
Meperidine
Methadone*
Propoxyphene
− For patients with Type I hypersensitivity reactions, all opioids must be used with caution. Selecting
an opioid in a different structural class may result in the lowest chance of cross-sensitivity.
− For patients with non-allergic histamine-mediated adverse reactions, selecting an agent with lower
potential for histamine release (denoted by *) may reduce symptoms.
− Tramadol (Ultram®) is contraindicated in patients who have a true opioid allergy.
USE OF NALOXONE FOR REVERSAL OF APNEA/HYPOVENTILATION (POLICY C-154)
Clinical Practice Points:
− Can be administered IV, IM, SC, or intratracheally (ETT), with the most rapid onset of action achieved following IV
administration
− Can reverse some of the symptoms of opioid overdose which include respiratory depression, sedation, and hypotension. It is
important to note that the analgesic effect of the opioid will also be reversed
− See page 7 for dosing and administration.
6
Dosing and Administration of Naloxone for Reversal of Opioid Sedation (Policy C-154)
Mix naloxone (0.4 mg/mL) with 9 mL of 0.9% sodium chloride for a total volume of 10 mL (unless otherwise stated).
Dilution concentration will be 0.04 mg/mL.
Patients with IV Access
Patients without IV Access (IM, SC, ETT)
Patients in the Neonatal ICU
Patients ≤ 20 kg
Patients ≤ 20 kg
Patients ≤ 2 kg
Dilute and give 0.02 mg (0.5 mL) IV every Give undiluted (0.4 mg/mL) naloxone
Dilute and give 0.01 mg/kg IV/SC every
3 minutes until desired respiratory rate is
0.01 mg/kg SC/IM/ETT every 2 minutes until 3 minutes until desired respiratory rate is
established NOT until return of desired
desired respiratory rate is established
established NOT until return of desired
sensorium.
NOT until return of desired sensorium.
sensorium.
Patients > 20 kg
Dilute and give 0.08 mg (2 mL) IV every
3 minutes until desired respiratory rate is
established NOT until return of desired
sensorium.
Patients > 20 kg
Give undiluted (0.4 mg/mL) naloxone at
0.2 mg (0.5 mL) SC/IM/ETT every 2 minutes
until desired respiratory rate is established
NOT until return of desired sensorium.
Patients > 2 kg
Give undiluted (0.4 mg/mL) naloxone
0.01 mg/kg IV/SC every 3 minutes until
desired respiratory rate is established NOT
until return of desired sensorium.
Naloxone – Continuous Infusion
− To initiate a continuous intravenous Naloxone drip, a separate physician order is required.
− Recommended only after initial IV or IM administration for prolonged respiratory depression, when the patient has been subject to
sustained release or long acting opioid (eg, Oxycontin®, MS Contin®, Oramorph®, methadone) or has epidural opioid.
− Pharmacy will prepare the infusion. Start infusion at a rate of 2.5 micrograms/kg/hr. Titrate as needed to maintain analgesia and
adequate respiratory drive.
Cautions with naloxone administration
− Return to full alertness is often accompanied by withdrawal and return of pain.
− Giving a full undiluted ampule (1 mL = 0.4 mg/mL) of naloxone in a patient who has received opioids but is not in respiratory arrest
may cause ischemia, heart attack, hypertension, stroke, heart failure, and/or pulmonary edema.
− Do not assume compatibility with any other medications.
− DO NOT use to reverse hypotension, nausea or vomiting from opioids.
− DO NOT use to reverse seizures from meperidine (Demerol®).
− When naloxone is given, there is a risk of acute withdrawal syndrome in habituated patients and infants of opioid-habituated mothers.
− Use cautiously in patients with known renal insufficiency as it may have a prolonged effect.
7