The following Opioid Use Guidelines have been prepared by
Palliative Care Clinicians Special Interest Group as part
of their 'Best Practices Project'.
Note: This information was produced as a guide ONLY. All doses and
recommendations should be checked and verified by an experienced
provider prior to use. The authors assume no responsibility for its
Table 1: Equianalgesic Dosing
Peds dose: (IR)
initial / kg
PO MS : Drug
Drug PO :
3 : 1
1 : 1
1 : 1
1, 2 or
4 : 1
1 : 4
1 : 1.5
or 10 mg
10 : 1
1 : 3
2 : 1
Transdermal Fentanyl (TDF) @ = SC/IV. Equianalgesic dosing:
see over OR 1:300 to PO MS. TDF for chronic stable
pain; absorption has slow onset + is erratic with cachexia
or fever. Buccal/SL fentanyl for B/T pain NOT
proportionate. Start low. Opioid tolerant patients only.
Patients on codeine and hydrocodone can be treated as opioid
Oxymorphone levels increase @ 50% when taken with food and
erratically with alcohol use.
Steps to Rotate or Change Opioids
1. Calculate 24 hr dose of current drug.
2. Translate that to equianalgesic 24 hr dose of oral morphine.
3. Calculate 24 hr equianalgesic dose of new drug and reduce
dose to 50-75% of calculated dose if pain is
well controlled; use 100% otherwise.
4. Divide to attain appropriate interval and dose for new drug.
5. Always have breakthrough dosing available while making changes.
release (IR) / short acting meds only) 50-150% of IV basal dose q15
minutes OR 10-20% of 24 hr oral dose q1hr.
(due to inadequate baseline pain control)
Increase rate by 50-100% of IV basal rate q15 minutes.
Give a breakthrough dose each time basal rate is increased.
= uncontrollable pain with appropriate increases
in dose OR side effects such as neuroexcitation, myoclonus, or
protracted central effects.
a) Rotate to another opioid as above.
b) Dose reduce opioid by 25-50% with addition of other treatment
c) Treat side effect +/- dose reduce.
Reversal with Naloxone:
overdose in rare cases:
Mix 0.4 mg amp with saline to make 10cc + administer 0.5 -1 ml
(0.02-0.04 mg) IV/SC q2-5 minutes until response; naloxone effect
shorter in duration than long acting opioids and close monitoring
+/- repeat doses sometimes necessary.
Table 2: MS : Me
Rotation from PO Morphine ( MS) to PO Methadone (Me)
1 for up to 100mg MS
15 : 1
for 501 - 1000 mg MS
1 for 101 - 300 mg MS
20 : 1
for > 1000 mg MS
1 for 301 - 500 mg MS
Rotation to Methadone
Day 1: Calculate dose (above). Give @ 33% methadone dose +
@ 66% of present drug.
Day 2: Give @ 66% methadone dose + @ 33% present drug.
Day 3: Give 100% methadone dose.
Rotation from Methadone
Ratios above do not necessarily apply –
consult an expert.
Use only with experience or training in pain mgt.
- Dosing interval is titrated for analgesic effect q4-12h;
start with q8h.
- Delayed side effects @ Day 4 after initiation: highly lipid
soluble with potential delayed and prolonged side effects
that outlast analgesic efficacy.
- Prolonged QT
esp at high dose > 200 mg/day; interactions at CYP450 (esp 2D6,
- Some common drugs that increase methadone effect: SSRI’s (fluoxetine),
TCA’s (amitriptyline), macrolides, metronidazole, antifungals,
methadone effect: many HIV drugs, carbamazepine, rifampin, phenytoin.
and from Transdermal Fentanyl (TDF)
Transdermal Fentanyl (mcg/hr) X 2 = approx 24 hr dose of MS PO
From TDF: Start new drug @ 50% dose for 6-24 hrs after removal
To TDF: Continue old drug @ 50% dose for 6-24 hrs after starting
All patients on opioids should be on a stepped BOWEL REGIMEN:
1. → Senna + docusate (Senokot S) 1-2 tabs twice daily or
→ MOM 30-60 cc twice to three times daily or
→ Lactulose 30-60 cc twice to three times daily or
→ PEG solution (Miralax) 1-4 T daily
dose or high dose stimulant + osmotic
Methylnatrexone (Relistor) for unresponsive opioid bowel while
continuing conventional bowel management preparations (this is
normally a short-term intervention).
Methylnatrexone is a Mu opioid antagonist that does NOT cross BBB
8 mg (81-135lb); 12 mg (> 135 lb) or 0.15 mg/kg sc every other day
or as needed not to exceed q24hr
impaction with enemas/suppositories
This card was produced as a guide ONLY. All doses
and recommendations should be checked and verified by an
experienced provider prior to use. The authors assume no
responsibility for its use. References available upon request or at
www.nhhpco.org/opioid.htm. © NHHPCO 2006 (rev. 2010)
Repetitive research (see references
below) shows that equianalgesic ratios between methadone and
morphine are dose dependent and vary depending on dose. Studies
show relationships that vary considerably with the most conservative
ratio listed above in Table 2 (Ms : Me). Intuitively the
variation in ratio occurs gradually, not at sudden intervals.
A regression equation can be
derived that estimates the relationship based on gradual change in
ratio. Below is one regression equation derived from slightly more
aggressive ratios than in table 2.
Special thanks to Louis
Gallerani for deriving the equation and plotting the graph.
Quigley C. Opioid Switching to improve pain relief and drug
tolerability. Cochrane Review, 2004, Issue 3, pg1-34 (everyone
should have this comprehensive review and use it to access primary
Pereira J et al. Equianalgesic
Dose ratios for Opioids: a critical review and proposals for long
term dosing. J of Pain and Symp Mgt, 22(2), August 2001, pg
Benitez-Rosario MA et al. Opioid
switching from transdermal fentanyl to oral methadone in patients
with cancer pain. Cancer, 2004, Dec 15;101(12):2866-72
Kornick CA et al. A safe and
effective method for converting cancer patients from IV to TD
fentanyl. Cancer, 2001, Dec 15; 92(12):3056-61
Equianalgesic cards and tables:
ADJUVANT THERAPIES FOR PAIN
NSAIDS, steroids, calcitonin, bisphosphonates
- ibuprofen 600 mg every 6 hours
(no NSAID has been proven any more effective than any other in large
studies though individual responses vary)
- if one NSAID does not work, try another in a different class
gabapentin, TCA’s, topical anesthetics
- gabapentin 100 mg po tid rapidly escalating to up to 4800 mg/d
- desipramine 10-25 mg po qhs up to 100 mg po qhs
- transdermal lidocaine 5% applied as needed
- compounded mixes (ie ketamine 5-10%; amitriptylline 2-5%;
ketoprofen 10-20%; baclofen 2-10%)
- baclofen 5-20 mg 2-4 times per day up to 60 mg/day
- tizanidine 2-8 mg tid up to 36 mg/day
50-100 mg tid
Cognitive Behavioral Therapy
Physical treatments (heat, cold, splinting)
Sensual Therapy (art, music, touch, aromatherapy)
Spiritual assessment and treatment
This information is available on plastic laminated Pocket Cards
directly from the
Hospice and Palliative Care Organization.
Information and ORDER FORM available HERE.
Please Note: The foregoing information was produced as a guide ONLY.
All doses and recommendations should be checked and verified by an
experienced provider prior to use. The authors assume no
responsibility for its use.