Equianalgesia Opioid Calculator JHH Applications Suzanne A Nesbit

Equianalgesia Opioid Calculator: JHH Applications Suzanne A Nesbit, Pharm. D, CPE Clinical Pharmacy Specialist, Pain Management Department of Pharmacy The Johns Hopkins Hospital 29 October 2020

Patient Case • 35 yo comes into the clinic complaining of persistent back pain. He has been taking Percocet (7. 5 mg oxycodone /324 mg 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

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

Equianalgesic Conversion • usually convert to morphine equivalents • patient taking 18 Percocet (7. 5 mg/325 mg) per day • 18 X 7. 5 mg = 135 mg oxycodone • X 30 • 135 = 20 X = 202. 5 mg oral morphine • decrease dose for incomplete cross tolerance

Opioid Rotation • • • Unresponsiveness Unmanageable adverse effects Route of administration Potency Cost

Equianalgesic Chart Parenteral (mg) Oral (mg) Duration (hours) Morphine 10 30 2 4 Hydromorphone 1. 5 7. 5 2 4 20 2 4 Drug Oxycodone Fentanyl 0. 1 2 4 Methadone 5 10 6 8 Meperidine 75 100 300 2 4 1 10 7 -9 Oxymorphone

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 2005 • www. hopweb. org • www. hopontheweb. org 10/29/2020 12

i. Phone Application 2012 10/29/2020 15

Main Conversion Screen 10/29/2020 16

Drug and Dose Entry 10/29/2020 17

Final Output Screen 10/29/2020 18