August 16, 2015 Equianalgesia Opioid Calculator: JHH Applications Suzanne A Nesbit, PharmD, CPE Clinical Pharmacy Specialist, Pain Management Department of Pharmacy The Johns Hopkins Hospital

Patient Case 35 yo comes into the clinic complaining of persistent back pain. He has been taking Percocet (7.5mg oxycodone /324mg APAP) 2 tablets every 2-4 hours for his pain. He currently rates his pain 7/10. –Would you recommend any changes to his regimen? Long acting opioid + short acting for breakthrough pain

Opioid Prescribing Skills Mrs. A is hospitalized and receiving adequate analgesia with meperidine 120 mg IM q3h. She is now able to take food and meds by mouth. What dose and schedule of oral hydromorphone would you prescribe to provide her with an approximately equal amount of analgesia? Hydromorphone ___ mg every __ hours __ I do not know how to answer this question

Equianalgesia Different dose of two opioids that approximately provide the same pain relief convert route and drug morphine 10mg parenterally standard decrease dose by up to 50% in tolerant patient

Equianalgesic Conversion usually convert to morphine equivalents patient taking 18 Percocet (7.5mg/325mg) per day 18 X 7.5mg = 135 mg oxycodone 135 = 20 X = mg oral morphine decrease dose for incomplete cross tolerance 30 X

Opioid Rotation Unresponsiveness Unmanageable adverse effects Route of administration Potency Cost

Equianalgesic Chart Drug Parenteral (mg)Oral (mg) Duration (hours) Morphine1030 2424 Hydromorphone 424 Oxycodone20 2424 Fentanyl0.1 2424 Methadone510 6868 Meperidine 75  424 Oxymorphone1107-9

Current Equianalgesia Tables Single dose studies Broad guidelines Calculated dose reduced due to incomplete cross tolerance Clinical status of the patient considered Titrate and reassess

Equianalgesia Studies Single Dose –Usually acute pain ; opioid naïve patients Retrospective –Chart review of patients with opioid rotation Cross-over –Stable patients on an opioid; switched to another to determine dose and analgesic effect

Dose Reduction Large interpatient variability in potencies to opioids Clinical status of patient: age, organ function, comorbidities, pain control Relative potencies for chronic dosing unknown Cross-tolerance: incomplete –start with 50%–75% of published equianalgesic dose –more if pain, less if adverse effects Methadone –start with 10%–25% of published equianalgesic dose

Challenging Conversions Fentanyl Methadone Oxycodone Hydromorphone

Johns Hopkins Opioid Conversion Software and Applications Floppy disc 1989 PDAs 2002 –Tungsten Palm Version –Windows CE Version Hopkins Opioid Program –Web-based version /16/201512

iPhone Application /16/201515

Main Conversion Screen 8/16/201516

Drug and Dose Entry 8/16/201517

Final Output Screen 8/16/201518