Opioid Conversions in Acute Care

  title={Opioid Conversions in Acute Care},
  author={Asad E. Patanwala and Jeremiah J. Duby and Dustin Waters and Brian L. Erstad},
  journal={Annals of Pharmacotherapy},
  pages={255 - 267}
Objective: To discuss the historical basis and limitations of opioid conversion tables, review the relevant literature, and establish an evidence-based equianalgesic dose ratio (EDR) table for performing conversions in the acute care setting. Data Sources: Articles were identified through searches of MEDLINE (1966–January 2007) using the key words opioid, tolerance, conversion, dose, equianalgesic, equipotent, acute care, morphine, hydromorphone, fentanyl, methadone, and oxycodone. Additional… 
Intravenous Opioids for Severe Acute Pain in the Emergency Department
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Practical management of opioid rotation and equianalgesia
The updated equianalgesic table presented here incorporates the latest data and provides information on bidirectionality, and is developed for use in routine clinical practice.
Review and critique of opioid rotation practices and associated risks of toxicity.
Most of the fatal outcomes occurring during opioid rotation are preventable, and the current process being used for opioid rotation has important flaws that must be corrected.
Morphine to Methadone Conversion: An Interpretation of Published Data
There is a lack of consensus for an appropriate method for converting morphine (and by extension, other opioids) to methadone, so a case report illustrating a popular method for high-dose conversion is included.
Inconsistencies in Opioid Equianalgesic Ratios: Clinical and Research Implications
Large variability in opioid conversions is demonstrated based on the use of common equianalgesic ratios for transdermal fentanyl, long-acting oxycodone, and methadone, which supports the need for well-designed, rigorous studies to evaluate opioid conversions.
Opioid conversions and patient-controlled analgesia parameters in opioid-dependent patients
  • N. Eipe, J. Penning
  • Medicine
    Canadian journal of anaesthesia = Journal canadien d'anesthesie
  • 2010
The Dual Ratio Opioid Conversion Chart, developed to manage acute pain in opioid dependent patients, provides a conservative estimate for a new opioid dose, and depending on the direction of conversion, they provide a 25% or 33% reduction when compared with the conventional threefold ratio.
A review of common methods to convert morphine to methadone
  • Eric Wong, K. Walker
  • Medicine
    Journal of community hospital internal medicine perspectives
  • 2012
This article will focus on the dosing dilemma that exists after the patient is deemed an appropriate candidate for methadone and a conversion is necessary from another opioid.
Safe Methadone Induction and Stabilization: Report of an Expert Panel
Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.
Quality Assessment of the Methods Used in Published Opioid Conversion Reviews
Recommendations to improve methodological quality would include performing the data selection and extraction in duplicate, listing or showing the flowchart of studies that were included and excluded along with the reasons, including the main studies data illustrating tables, and including an assessment of the quality of the primary included studies.
Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients
Implementation of an MMA guideline significantly reduced opioid use in trauma patients at a Level 1 trauma center and the use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.


Clinical Application of Opioid Equianalgesic Data
A 5-step process as a guide for clinicians faced with the need to change a patient's opioid regimen is presented to help to build a comfort level when dealing with the clinical challenges of converting from one opioid to another.
Equianalgesic dose/ratio between methadone and other opioid agonists in cancer pain: comparison of two clinical experiences.
The fact that methadone ratio is different according to the opioid dose used previously should be taken into careful consideration by the clinician in order to avoid severe toxicity or death during switchover.
The conversion challenge: From intrathecal to oral morphine
A case report describes the experience of converting a patient’s IT morphine to oral morphine and discusses the scarcity of published data to validate suggested equianalgesic intraspinal morphine recommendations.
Rapid switching between transdermal fentanyl and methadone in cancer patients.
A rapid switching using an initial fixed ratio of fentanyl to methadone of 1:20 is an effective method to improve the balance between analgesia and adverse effects in cancer patients with poor response to the previous opioid.
Methadone use in cancer patients with pain: a review.
Future research should address the use of methadone as a first-line agent in the management of cancer pain, its use in patients with neuropathic pain, and in those who develop rapid tolerance to other opioids.
Methadone versus morphine as a first-line strong opioid for cancer pain: a randomized, double-blind study.
  • E. Bruera, J. Palmer, M. Fisch
  • Medicine, Psychology
    Journal of clinical oncology : official journal of the American Society of Clinical Oncology
  • 2004
Methadone did not produce superior analgesic efficiency or overall tolerability at 4 weeks compared with morphine as a first-line strong opioid for the treatment of cancer pain.