Palliative Care Guidelines - NHS Lanarkshire

© NHS Lothian Issue date: January 2009 Review date: March 2012A guide to dose conversions FROM morphine TO second line opioid analgesics used for moderate to severe pain• Use this chart as a guide. The doses are approximate and not exact equivalent doses.• Opioid bioavailability (particularly for oral morphine) and response are highly variable.• Always prescribe an appropriate drug and dose for breakthrough pain: 1/6 th of the 24hour regular opioid dose.• Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail or elderly and re-titrate.• Reduce the dose by up to 30% when converting from a second line opioid back to morphine and re-titrate.• Check the information about individual drugs if the patient has renal or liver impairment.• Particular care is needed when changing between opioids at higher doses or when the dose of the first opioid has been rapidly increased asthese patients are at greater risk of adverse effects.• Morphine and oxycodone doses can be measured accurately in 1mg dose increments. Decimal places are not recommended.• Fentanyl: dose conversions from oral morphine are usually given as a range for each patch dose. The minimum dose of oral morphine when itwould be safe to convert to fentanyl is shown in this table. Check fentanyl guideline.Monitor the patient carefully If in doubt – seek adviceA guide to dose conversions FROM morphine TO second line opioid analgesics used for moderate to severe pain4-hrdoseOral morphine12-hrMR dose24-hrtotal doseSubcutaneousmorphine4-hrdose24-hr totaldoseSubcutaneousdiamorphine4-hrdose24-hr totaldose4-hrdoseOral oxycodone12-hrMR dose24-hr totaldoseSubcutaneousoxycodone4-hrdose24-hrtotal doseFentanyltransdermalPatch strength(micrograms)2 or 3mg 5mg 15mg 1mg 7 or 8mg 1mg 5mg 1 or 2mg - 7 or 8mg 1mg 5mg Do not use5mg 15mg 30mg 2 or 3mg 15mg 2mg 10mg 2 or 3mg 5mg 15mg 1mg 7 or 8mg 1210mg 30mg 60mg 5mg 30mg 2.5mg 20mg 5mg 15mg 30mg 2 or 3mg 15mg 2515mg 45mg 90mg 7 or 8mg 45mg 5mg 30mg 7 or 8mg 20mg 45mg 3mg 20mg 3720mg 60mg 120mg 10mg 60mg 7.5mg 40mg 10mg 30mg 60mg 5mg 30mg 5030mg 90mg 180mg 15mg 90mg 10mg 60mg 15mg 45mg 90mg 7 or 8mg 45mg 6240mg 120mg 240mg 20mg 120mg 10mg 80mg 20mg 60mg 120mg 10mg∗ 60mg 7550mg 150mg 300mg 25mg 150mg 15mg 100mg 25mg 75mg 150mg ∗ 75mg 8760mg 180mg 360mg 30mg∗ 180mg 20mg 120mg 30mg 90mg 180mg ∗ 90mg 100MR = modified release (long acting)∗ Morphine injection is available in a maximum concentration of 30mg/ml. Oxycodone injection is only available as 10mg/ml.Another SC opioid will be needed for breakthrough pain if patient needs a dose that is in an injection volume above 1ml – Seek advicePalliative Care Guidelines: Choosing and Changing Opioids3