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PL Detail-Document #280801

This PL Detail-Document gives subscribers


additional insight related to the Recommendations published in
PHARMACISTS LETTER / PRESCRIBERS LETTER
August 2012

Opioid Conversion Algorithm


Equianalgesic doses are approximate, and should be used only as a guideline. Dosing must be
titrated to individual response. Response may vary depending on tolerance, age, renal and hepatic
function, other conditions, drug interactions, and genetics. Also consider pain control at time of switch.
Below is a stepwise guide for estimating opioid dose conversions.1-4

Add up current total daily opioid dose (scheduled and as-needed doses).

Conversion involves a Both opioid products involved in conversion are one of the
noninjectable fentanyl following: morphine, oxycodone, oxymorphone,
product hydromorphone (not extended-release), fentanyl (not
(e.g., transdermal, transdermal, oral transmucosal, buccal, sublingual, nasal).
transmucosal, etc),
methadone, extended-
release hydromorphone Use equianalgesic dosing chart
(Exalgo, Jurnista to calculate equivalent total
[Canada]), tramadol daily dose of new opioid.
(e.g., Ultram, Ralivia
[Canada]) or tapentadol
(e.g., Nucynta).
Reduce dose by 50% to
help offset incomplete
Do not use cross-tolerance.
equianalgesic dosing
chart. See our PL
Detail-Document, Reduce dose further if appropriate based on age, liver function, renal function,
Equianalgesic Dosing drug interactions, baseline pain control, etc.
of Opioids for Pain
Management, for
more information. Divide daily dose based on drug/dosage form.

For long-acting products, prescribe short-acting product


for breakthrough pain (10% to 15% of total daily dose
every 1 to 2 h as needed).

Instruct patient/caregiver:
1. Follow instructions exactly. Do not increase dose without calling prescriber.
2. Do not use alcohol or take sedatives unless approved by prescriber.
3. Hold dose and seek medical help in the event of confusion, respiratory depression, or excessive
sedation.
**Pharmacist will dispense MedGuide (U.S.) with long-acting products, methadone, and fentanyl patch
and oral transmucosal, buccal, sublingual, and nasal products.**
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(PL Detail-Document #280801: Page 2 of 4)

Example 1

M.K. is a 78-year-old female with severe rheumatoid arthritis and renal insufficiency (CrCl
20 mL/min). She has been taking OxyContin 120 mg twice daily for the past six months,
methotrexate, and carbamazepine. Her new insurance plan will not cover OxyContin, but it will
cover MS Contin. To how much MS Contin should she be switched?

1. Calculate total oxycodone dose: 120 mg x 2 = 240 mg daily.


2. Convert oxycodone to morphine using equianalgesic chart:

morphine 30 mg = morphine X mg
oxycodone 20 mg* oxycodone 240 mg

X = 360 mg morphine

3. Reduce dose by 50%: 360 mg/2 = 180 mg total daily morphine dose.
The 50% dose reduction helps account for incomplete cross tolerance, and in M.K.s case,
also renal insufficiency (morphine has a renally eliminated metabolite), age, and
carbamazepine use (carbamazepine reduces oxycodone levels, but not morphine levels).

4. Divide dose as appropriate based on drug/dosage form: 90 mg every 12 hours.

5. Monitor M.K.s response. Provide immediate-release product for breakthrough pain.


Advise patient to hold dose and seek medical help in the event of sedation or confusion,
and to seek emergency help in the event of respiratory depression.

*NOTE: a conversion factor of 30 mg oxycodone=30 mg morphine could be used to arrive


at an even more conservative estimate.

New proposed alternative method (Webster LR, Fine PG. Overdose deaths demand a new
paradigm for opioid rotation. Pain Med 2012;13:571-4.):

1. Reduce current opioid by 10% to 30%: Oxycodone 120 mg twice daily reduced by 10% to
30% = 84 to 108 mg twice daily (practically, based on available table strengths, 80 to
100 mg twice daily).
2. Start new opioid at initial dose for opioid-nave patient or at lowest available dose: MS
Contin 15 mg twice daily.
3. Patient will be on MS Contin 15 mg twice daily AND OxyContin 80 or 100 mg twice daily.
4. Reduce dose of original opioid (i.e., OxyContin) by about 10% to 25% each week, while
increasing dose of new opioid (i.e., MS Contin) by about 10% to 20%, per
efficacy/tolerability. Switch can be completed in 3 to 4 weeks.
5. Provide immediate-release dosage form for breakthrough pain.

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(PL Detail-Document #280801: Page 3 of 4)

What if M.K.s prescriber had opted to switch her to Hydromorph Contin (Canada)?

1. Calculate total oxycodone dose: 120 mg x 2 times daily = 240 mg.


2. Convert oxycodone to hydromorphone CR using equianalgesic chart:

hydromorphone 7.5 mg = hydromorphone X mg


oxycodone 20 mg* oxycodone 240 mg

X = 90 mg hydromorphone

3. Reduce dose by 50% = 45 mg hydromorphone.


4. Divide dose as appropriate based on drug/dosage form = 24 mg q 12 hrs.

*NOTE: a conversion factor of 30 mg oxycodone=7.5 mg hydromorphone CR could be


used to arrive at an even more conservative estimate.

Example 2

J.J. is a 43-year-old male who has just been admitted to the rehab hospital after being released from
an acute care facility for treatment of two broken legs and a broken pelvis after a motorcycle
accident. He has been prescribed oxycodone 5 mg/acetaminophen 325 mg, two tablets every four
hours as needed. He has been taking the maximum dose. The admitting physician is concerned
about J.J.s acetaminophen use because of his long history of alcohol abuse. Plus, the physician
would like to be able to give J.J. an extra dose of pain medication before and/or after physical
therapy if needed. He cant escalate the dose of the acetaminophen combination product due to the
risk of acetaminophen toxicity. Therefore, he would like to switch J.J. to immediate-release
hydromorphone. How much hydromorphone should be prescribed for J.J.?

1. Calculate total oxycodone dose: 5 mg x 2 tablets x 6 times daily = 60 mg daily.


2. Convert oxycodone to hydromorphone using equianalgesic chart:

hydromorphone 7.5 to 8 mg = hydromorphone X mg


oxycodone 20 mg* oxycodone 60 mg

X = 22.5 to 24 mg hydromorphone

3. Reduce dose by 50%: 12 mg.


The 50% dose reduction helps account for incomplete cross tolerance.

4. Divide dose as appropriate based on drug/dosage form: 2 mg every 4 hours as needed.

5. Monitor J.J.s response. Advise nurse to hold dose and call prescriber/on-call physician
in the event of confusion, respiratory depression, or excessive sedation.

*NOTE: a conversion factor of 30 mg oxycodone=7.5 to 8 mg hydromorphone IR could be


used to arrive at an even more conservative estimate.

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(PL Detail-Document #280801: Page 4 of 4)

Users of this PL Detail-Document are cautioned to use 2. FDA. Introduction for the FDA blueprint for
their own professional judgment and consult any other prescriber education for extended-release and
necessary or appropriate sources prior to making long-acting opioid analgesics.
clinical judgments based on the content of this http://www.fda.gov/downloads/Drugs/DrugSafety/In
formationbyDrugClass/UCM277916.pdf.
document. Our editors have researched the (Accessed July 14, 2012).
information with input from experts, government 3. Agency for Healthcare Research and Quality.
agencies, and national organizations. Information and Morbidity & mortality rounds on the web. Case &
internet links in this article were current as of the date commentary. Strassels SA. Miscalculated risk.
of publication. Hospital medicine. August 2006.
http://webmm.ahrq.gov/case.aspx?caseID=132#ta
Project Leader in preparation of this PL Detail- ble1. (Accessed July 13, 2012).
4. American Academy of Hospice and Palliative
Document: Melanie Cupp, Pharm.D., BCPS Medicine. Guidelines for prescribing opioids for
hospice and palliative care patients.
References http://www.aahpm.org/pdf/guidelinesforopioids.pdf.
1. American College of Physicians. ACP Internist (Accessed July 16, 2012).
Extra. Chronic pain management: an appropriate
use of opioid analgesics.
http://www.acpinternist.org/archives/2008/01/extra/
pain.pdf. (Accessed July 15, 2012).

Cite this document as follows: PL Detail-Document, Opioid Conversion Algorithm. Pharmacists


Letter/Prescribers Letter. August 2012.

Evidence and Recommendations You Can Trust


3120 West March Lane, P.O. Box 8190, Stockton, CA 95208 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249
Copyright 2012 by Therapeutic Research Center

Subscribers to the Letter can get PL Detail-Documents, like this one,


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PL Detail-Document #310711
This PL Detail-Document accompanies the related article published in
PHARMACISTS LETTER / PRESCRIBERS LETTER
July 2015

Equianalgesic Dosing of Opioids for Pain Management


Equianalgesic doses contained in this chart are approximate, and should be used only as a guideline. Dosing must be titrated to individual response.
There is often incomplete cross-tolerance among these drugs. It is, therefore, recommended to begin with a 50% lower dose than the equianalgesic
dose when changing drugs and then titrate to a safe/effective response.1,3,4,34 Dosing adjustments for renal or hepatic insufficiency, cytochrome
P450 drug interactions, genetics, and other conditions or medications that affect drug metabolism, kinetics, or response may also be
necessary.2,34,48,53 Also consider pain control at time of switch.4,5 In general, use cautious dosing for elderly or debilitated patients, and patients with
renal or hepatic impairment.48 Some products have specific dosing recommendations for these populations (see footnotes). See our Opioid
Conversion Algorithm for instructions on converting from one opioid to another.
A website with an equianalgesic dose calculator is available at http://www.hopweb.org
NA = not available. Continue to the next section for dosing of atypical opioids (e.g., tramadol, etc).
Drug Equianalgesic Doses Approximate Usual Starting Dose (Opioid-Naive
(mg)1,3,4 Equianalgesic 24 hr Dose Adults)
(Assumes Around-the- (Doses NOT Equianalgesic)
Clock Dosing)g
Parenteral Oral Parenteral Oral Parenteral Oral
Morphine (immediate-release tablets, oral 10 30 3-4 mg 10 mg q 4 h 2.5 mg 10 mg q 4 h (acute or
solution, injection) q4h q 4 h50 chronic pain)41,51, j

2-10 mg q 4 h (hospice)5
Controlled-release morphine NA 30 NA 30 mg q 12 h NA MS Contin (U.S.):
(e.g., MS Contin, Kadian) (Kadian may 15 mg q 12 h29, j
be given as MS Contin (Canada):
60 mg 30 mg q 12 h57, j
q 24 h)6,21
Other products not for
initial dosing.6,21,h, j
Extended-release morphine (Avinza [U.S.], NA 30 NA 60 mg q 24 h NA Avinza: 30 mg q 24 h7, j
Embeda [with naltrexone, U.S.]) (Embeda Embeda:
may be 20 mg q 24 h12, j
given as
30 mg
q 12 h)12
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(PL Detail-Document #310711: Page 2 of 8)

Drug Equianalgesic Doses Approximate Usual Starting Dose (Opioid-Naive


(mg)1,3,4 Equianalgesic 24 hr Dose Adults)
(Assumes Around-the- (Doses NOT Equianalgesic)
Clock Dosing)g
Parenteral Oral Parenteral Oral Parenteral Oral
Hydromorphone (Dilaudid) 1.5-2 7.5-8 0.5-0.8 mg 2-4 mg q 4 h See footnotes See footnote a.
q4h a,d.

Controlled-release hydromorphone NA 7.5 NA 6 mg q 12 h NA 3 mg q 12 h30, j


(Hydromorph Contin [Canada])

Extended-release hydromorphone (Exalgo, NA See NA See footnote NA See footnotes e, h, and j.


Jurnista [Canada]) footnote b.
b.

Oxycodone (e.g., Roxicodone [U.S.], NA 20-30 NA 5-10 mg NA 5-15 mg q 4-6 h


Oxy IR [Canada], also in Percocet, others) q4h (acute or chronic
pain)42,43 (Product labeling)
5-10 mg q 8-12 h14 or
5 mg q 4-6 h41 (chronic
noncancer pain)
(Guidelines)

Controlled-release oxycodone (OxyContin NA 20-30 NA 20-30 mg NA 10 mg q 12 h9, j


[U.S.], OxyNeo [Canada]) q 12 h

Extended-release oxycodone and Indicated for acute pain only. Not interchangeable with other products due to differing
acetaminophen (Xartemis XR [U.S.]) pharmacokinetics. Dose is two tablets every 12 hours. Each tablet contains oxycodone 7.5 mg
and acetaminophen 325 mg. The second dose may be taken as early as eight hours after the
first dose if needed, but subsequent doses should be taken every 12 hours.59

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(PL Detail-Document #310711: Page 3 of 8)

Drug Equianalgesic Doses Approximate Usual Starting Dose (Opioid-Naive


(mg)1,3,4 Equianalgesic 24 hr Dose Adults)
(Assumes Around-the- (Doses NOT Equianalgesic)
Clock Dosing)g
Parenteral Oral Parenteral Oral Parenteral Oral
Oxymorphone 1 10 0.3-0.4 mg 5 mg q 6 h 0.5 mg 10-20 mg q 4-6 h (acute
(Opana [U.S.]) q4h q 4-6 h10 pain)44,i
5-10 mg q 4-12 h
(chronic noncancer
pain)14,41
Extended-release oxymorphone NA 10 NA 10 mg NA 5 mg q 12 h11, j
(Opana ER [U.S.])c,k q 12 h

Extended-release hydrocodone NA See NA See footnote NA Zohydro ER: 10 mg


(Zohydro ER [U.S.], Hysingla ER [U.S.]) footnote f. q 12 h (chronic pain)58, j
f.
Hysingla ER: 20 mg
q 24 h (chronic pain)62
Hydrocodone (in Norco [U.S.], others) NA 30-45 NA 10-15 mg NA 5-10 mg q 4-6 h
q4h (moderate to moderately
severe pain)45
5-10 mg q 4-12 h
14,41
(Chronic noncancer pain)

Codeinen 100-130 200 30-50 mg 60 mg q 4 h 10 mg 15-60 mg q 4 h (mild to


q4h q 3-4 h52 moderately severe
pain)46

15-30 mg q 4-12 h
(chronic noncancer
pain)14,41

Controlled-release codeine (Codeine Contin NA 200 NA 180 mg NA 50 mg q 12 h49


[Canada])m,n q 12 h

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(PL Detail-Document #310711: Page 4 of 8)

Drug Equianalgesic Doses Approximate Equianalgesic Usual Starting Dose (Opioid-


(mg)1,3,4 24 hr Dose (Assumes Around- Naive Adults)
the-Clock Dosing)g (Doses NOT Equianalgesic)
Parenteral Oral Parenteral Oral Parenteral Oral
Methadone (Dolophine [U.S.], Metadol Variable Variable For opioid-tolerant patients only.14 The conversion ratio of methadone
[Canada])o is highly variable depending on factors such as patient tolerance,
morphine dose, and length of dosing (short-term versus chronic
dosing). Because the analgesic duration of action is shorter than the
half-life, toxicity due to drug accumulation can occur with just a few
doses.35 For conversion methods, see
http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthPr
ofessional/page3. Some experts recommend that only those with
substantial experience with its use should prescribe methadone.39,55

Meperidine (Demerol) 75 300 Should be used for acute dosing only (short duration of action [2.5 to
3.5 hours] and neurotoxic metabolite, normeperidine).1 Avoid in renal
insufficiency and use caution in hepatic impairment and in the elderly
(potential for toxicity due to accumulation of normeperidine).1,16-18,55
Seizures, myoclonus, tremor, confusion, and delirium may occur.1

Fentanyl 0.1 NA All noninjectable fentanyl products are for opioid-tolerant patients
only (i.e., taking 60 mg or more of morphine or its equivalent daily for
(See footnote l) at least 1 week). Do not convert mcg for mcg among fentanyl
products (i.e., patch, transmucosal lozenge [Actiq (U.S.)], buccal tablet
[Fentora], nasal spray [Lazanda (U.S.)], sublingual tablet [Abstral]).
See specific product labeling (U.S.: Drugs@FDA; Canada: Health
Canada Drug Product Database) for dosing. Patch product labeling
recommendations (e.g., switch patients from oral morphine 60 to
134 mg daily or its equivalent to fentanyl 25 mcg/hr patch) are
conservative.63,64 Therefore, the use of this conversion from the patch
to another opioid can lead to overdose, and should not be done.63,64
Some experts use a conversion factor of oral morphine 60 mg =
fentanyl patch 25 mcg/hr in patients with chronic cancer pain, round
up or down based on patient factors, and available patch sizes, and
clinical judgement.56 In the U.S. intermediate patch strengths not
Continued studied in clinical trials (37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr) are
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(PL Detail-Document #310711: Page 5 of 8)

Fentanyl, available for use during conversion or titration for patients who would
continued normally be converted/stepped up to the 50 mcg/hr, 75 mcg/hr, or
100 mcg/hr patch, but for whom these doses might be too high.65 The
intermediate-dose patches may be more expensive than using generic
versions of two standard strength patches (e.g., 12.5 mcg/hr patch plus
25 mcg/hr patch), but using a single patch is preferred to reduce the
risk of medication errors.66

Atypical Opioids: analgesics with mixed receptor effects and dose ceilings
Buprenorphine: partial mu receptor The initial dose of transdermal buprenorphine (Butrans) for patients taking less than 30 mg of
agonist/kappa receptor antagonist40 oral morphine or equivalent per day is a 5 mcg/hr patch applied once weekly (Canada: start
with 5 mcg/hr patch in opioid-naive patients, and 5-10 mcg/hr patch in patients taking up to 80
mg oral morphine equivalents per day).47,60 U.S.: When converting from 30 to 80 mg of oral
morphine equivalents daily dose, first taper to 30 mg oral morphine equivalents per day, then
start with the 10 mcg/hr patch.60 The maximum dose is one 20 mcg/hr patch once weekly.47,60

Tapentadol: mu receptor Tapentadol controlled-release (Nucynta CR, Canada) and oxycodone controlled-release exhibit
agonist/norepinephrine reuptake inhibitor1 comparable pain relief in a dose ratio of 5:1 (tapentadol:oxycodone).31 The maximum dose of
tapentadol CR is 250 mg twice daily.31 No specific dose conversion is given for Nucynta (U.S.),
Nucynta IR (Canada), and Nucynta ER (U.S.).32,33 A conversion from immediate-release
tapentadol to immediate-release oxycodone has been suggested, as follows: tapentadol 50 mg
q 4-6 h to oxycodone 5 mg q 4-6 h; tapentadol 75 mg q 4-6 h to oxycodone 10 mg q 4-6 h;
tapentadol 100 mg q 4-6 h to oxycodone 15 mg q4-6 h.61 Not for use in severe renal or hepatic
dysfunction.31-33,38

Tramadol: partial mu receptor Tramadol (e.g., Ultram, Ralivia [Canada]), potency is about one-tenth that of morphine, similar
agonist/serotonin and norepinephrine to codeine.1 The maximum daily dose of tramadol is 300 mg to 400 mg, depending on the
reuptake inhibitor1,40 product.22-28,36,37 See product labeling for dosing in elderly, or in renal or hepatic dysfunction.

Mixed Agonist/Antagonists: mu receptor Parenteral morphine 10 mg is approximately equal to parenteral pentazocine 60 mg, oral
antagonist (or mu-neutral)/kappa receptor pentazocine 180 mg, parenteral butorphanol 2 mg, and parenteral nalbuphine 10 mg.49 The
agonist1,40 analgesic efficacy of these drugs is limited by a dose ceiling. Furthermore, they are
contraindicated for use in patients receiving an opioid agonist because they can precipitate
withdrawal and increase pain. They also pose a risk of psychotomimetic effects.1

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(PL Detail-Document #310711: Page 6 of 8)

a. Product labeling for hydromorphone recommends a starting dose of 0.2 mg to 1 mg IV every two to three hours (Canadian monograph: 2 mg IV every
four to six hours) as needed, or 2 mg to 4 mg orally every four to six hours as needed.8,15,20 An even lower oral starting dose (2 mg two or three times
daily) has been recommended for chronic pain in opioid-naive patients.14 Some institutions use even lower doses of parenteral hydromorphone (e.g., 0.2
mg to 0.5 mg every two hours as needed). One regimen starts opioid-naive patients at 0.2 mg IV every two hours as needed for mild or moderate pain,
with the option in moderate pain to give an extra 0.2 mg after 15 minutes if relief is inadequate after the first 0.2 mg dose. For severe pain, 0.5 mg IV
every two hours as needed is used initially. In adults <65 years of age, the 0.5 mg dose can be repeated in 15 minutes if relief is inadequate, for a
maximum of 1 mg in two hours.
b. Per the product labeling, convert to Exalgo 12 mg from oral codeine 200 mg, hydrocodone 30 mg, morphine 60 mg, oxycodone 30 mg, oxymorphone
20 mg, or transdermal fentanyl 25 mcg/hr. (These conversion doses should NOT be used when switching from Exalgo to another opioid.) After 50%
dose reduction for incomplete cross-tolerance, reduce dose again by 50% for moderate renal impairment, and by 75% for severe renal or moderate
hepatic impairment. Not for use in severe hepatic impairment.13 The Jurnista product monograph recommends a 5:1 oral morphine:oral
hydromorphone conversion ratio.19 When converting from immediate-release hydromorphone, the Jurnista dose should be rounded down.19
c. Per the product labeling, oral oxymorphone 10 mg ER is approximately equivalent to hydrocodone 20 mg or oxycodone 20 mg.11
d. Dilaudid Canadian monograph recommends parenteral starting dose of 2 mg.20 See footnote a for additional information and precautions.
e. No initial dose for Exalgo. For opioid-tolerant patients only.13 Initial Jurnista dose (opioid-naive or <40 mg daily oral morphine equivalents) is 4 to 8
mg q 24 h.19
f. Zohydro ER. Conversion factors for converting to Zohydro ER are 1 for hydrocodone or oxycodone; 2 for oxymorphone; 2.67 for hydromorphone;
0.67 for morphine; and 0.1 for codeine. Sum the current total daily dose of opioid, then multiply by the conversion factor to get the total daily Zohydro
ER dose. Round down. Divide q 12 h.58 (Conversion factors should NOT be used to switch from Zohydro ER to another opioid.)
Hysingla ER. Conversion factors for converting to Hysingla ER are 0.15 for codeine, 4 for hydromorphone, 1.5 for methadone, 0.5 for morphine, 1 for
oxycodone, 2 for oxymorphone, and 0.1 for tramadol. Reduce the calculated dose by 25% and give once daily. Patients taking hydrocodone can switch
to Hysingla ER at the same total daily dose taken once daily.62
g. Examples of doses seen in clinical practice, taking into account available dosage strengths.
h. Labeling for some products (Kadian, Jurnista [Canada]) recommends beginning treatment with an immediate-release formulation.6,19,21
i. Start with an oral dose of 5 mg q 4-6 h for opioid-naive elderly or opioid-naive patients with renal or liver impairment.44
j. Some experts do not recommend for chronic noncancer pain in opioid-naive patients.14
k. Opana ER has received a notice of compliance (June 2012) by Health Canada. At time of publication, it is not yet available on the Canadian market.
l. Relatively safe choice in renal or liver insufficiency.55 Clearance reduced by uremia.54 Do not start with patch in renal or liver failure.54 Watch for
delayed toxicity.54,55
m. Reduce dose by 25% when switching from oral codeine phosphate to account for phosphate content of tablet.49
n. Analgesic efficacy limited by a dose ceiling.46,49
o. Relatively safe choice in renal or liver insufficiency.54,55

Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making
clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and Internet links in this article were current as of the date of publication.

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(PL Detail-Document #310711: Page 7 of 8)

Project Leader in preparation of this PL Detail- 15. Product information for Dilaudid oral liquid and
Document: Melanie Cupp, Pharm.D., BCPS tablets. Purdue Pharma L.P. Stamford, CT 06901.
June 2013.
16. Product information for Demerol. Sanofi-Aventis
References U.S. Bridgewater, NJ 08807. July 2014.
1. National Cancer Institute Pain (PDQ). 17. Fulton CW. Limiting meperidine use in pain
Pharmacologic management. September 3, 2014. management. Hosp Pharm 2001;36:1214,1217-8.
http://www.cancer.gov/cancertopics/pdq/supportivec 18. PL Detail-Document, Potentially Harmful Drugs in the
are/pain/HealthProfessional/page3. (Accessed May Elderly: Beers List. Pharmacists Letter/Prescribers
1, 2015). Letter. June 2012.
2. Pergolizzi J, Boger RH, Budd K, et al. Opioids and 19. Product monograph for Jurnista. Janssen-Ortho Inc.
the management of chronic severe pain in the Toronto, ON M3C 1L9. March 2015.
elderly: consensus statement of an international 20. eCPS [Internet]. Ottawa (ON): Canadian
expert panel with focus on the six clinically most Pharmacists Association c2015. Dilaudid
often used World Health Organization step III opioids monograph (April 2012). http://www.e-
(buprenorphine, fentanyl, hydromorphone, therapeutics.ca. (Accessed May 1, 2015).
methadone, morphine, oxycodone). Pain Pract 21. Product monograph for Kadian. Abbott Labs.
2008;8:287-313. Vaughan, ON L4K 4T7. August 2014.
3. Agency for Healthcare Research and Quality. 22. Product information for Ultram. Janssen
Morbidity & mortality rounds on the web. Cases & Pharmaceuticals Inc. Titusville, NJ 08560. July
commentaries. Strassels SA. Miscalculated risk. 2014.
Hospital medicine. August 2006. 23. Product information for Ultracet. Janssen
http://www.webmm.ahrq.gov/case.aspx?caseID=132 Pharmaceuticals Inc. Titusville, NJ 08560. July
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Cite this document as follows: PL Detail-Document, Equianalgesic Dosing of Opioids for Pain Management.
Pharmacists Letter/Prescribers Letter. July 2015.

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