How does opioid potency compare to morphine. What factors affect opioid conversion calculations. Why is accurate opioid conversion essential for pain management. How can healthcare providers ensure safe opioid switching practices.

Understanding Opioid Potency and Conversion

Opioid medications play a crucial role in pain management, particularly for cancer patients and those with chronic pain conditions. However, not all opioids are created equal. Their potency can vary significantly, which necessitates careful calculation when switching between different opioids or adjusting dosages. This process, known as opioid conversion, requires a thorough understanding of relative potency and morphine equivalents.

The World Health Organization (WHO) provides guidelines for opioid conversion, emphasizing the importance of accurate calculations to ensure patient safety and effective pain control. These guidelines include a table of approximate potency ratios for various opioids relative to morphine, which serves as the standard reference point.

Key Factors in Opioid Conversion

• Relative potency to morphine
• Route of administration (oral, intravenous, transdermal)
• Patient-specific factors (age, renal function, pain severity)
• Drug-specific characteristics (half-life, receptor affinity)

Healthcare providers must consider these factors when performing opioid conversions to ensure safe and effective pain management for their patients.

Morphine Equivalents: The Standard for Comparison

Morphine serves as the benchmark for comparing the potency of other opioids. By establishing a common reference point, healthcare providers can more easily calculate equivalent doses when switching between different opioid medications. This standardization is crucial for maintaining consistent pain control and minimizing the risk of adverse effects.

To calculate morphine equivalents, multiply the dose of the current opioid by its relative potency to morphine. Conversely, to determine the equivalent dose of another opioid from a morphine dose, divide the morphine dose by the relative potency of the desired opioid.

Example Calculation

If a patient is taking 20mg of oxycodone and needs to switch to morphine:

1. Oxycodone relative potency to morphine: 1.5
2. Calculation: 20mg oxycodone × 1.5 = 30mg morphine equivalent

This calculation provides a starting point for the new morphine dose, which may require further adjustment based on individual patient response.

Opioid Potency Chart: A Valuable Clinical Tool

The WHO guidelines include a comprehensive opioid potency chart that provides relative potency ratios for various opioids compared to morphine. This chart is an invaluable resource for healthcare providers when performing opioid conversions.

Notable Potency Ratios

• Codeine: 0.1 (less potent than morphine)
• Oxycodone: 1.5 (more potent than morphine)
• Hydromorphone: 5 (significantly more potent than morphine)
• Fentanyl: 100 (extremely potent compared to morphine)

These ratios highlight the substantial differences in potency among opioids, underscoring the importance of accurate conversion calculations.

Special Considerations for Methadone Conversion

Methadone presents unique challenges in opioid conversion due to its complex pharmacokinetics and pharmacodynamics. While a single 5mg dose of methadone is equivalent to 7.5mg of morphine, its long plasma half-life and broad-spectrum receptor affinity result in a much higher relative potency when administered regularly.

The WHO guidelines specifically note that methadone conversions can be highly variable and often result in a much higher relative potency than expected. As a result, they recommend seeking guidance from a specialist when converting to regularly administered methadone.

Factors Complicating Methadone Conversion

• Variable long plasma half-life
• Broad-spectrum receptor affinity
• Potential for drug interactions
• Individual patient variability in metabolism

Given these complexities, healthcare providers should exercise extreme caution and closely monitor patients when initiating or adjusting methadone therapy.

Patient-Specific Factors Affecting Opioid Conversion

While opioid potency charts provide a valuable starting point for conversions, it’s crucial to consider individual patient factors that can influence opioid response and metabolism. These factors can significantly impact the accuracy of conversion calculations and the effectiveness of pain management strategies.

Key Patient Factors to Consider

• Age: Elderly patients may be more sensitive to opioids
• Renal function: Impaired kidney function can affect opioid clearance
• Liver function: Hepatic impairment may alter opioid metabolism
• Pain severity: Higher pain levels may require dose adjustments
• Opioid tolerance: Long-term opioid use can affect dosing requirements
• Concurrent medications: Potential drug interactions can impact opioid effectiveness

Healthcare providers must carefully assess these factors and adjust conversion calculations accordingly to ensure safe and effective pain management for each patient.

Best Practices for Safe Opioid Switching

Switching between opioids requires careful planning and monitoring to minimize risks and maintain effective pain control. Healthcare providers should follow established best practices to ensure patient safety during opioid conversions.

Guidelines for Safe Opioid Switching

1. Document all conversion calculations in the patient’s medical record
2. Use conservative initial dosing when switching to a new opioid
3. Provide patients with clear instructions for the new medication regimen
4. Monitor patients closely for signs of under- or over-medication
5. Be prepared to adjust doses based on individual patient response
6. Consider consulting with pain management specialists for complex cases

By adhering to these best practices, healthcare providers can minimize the risks associated with opioid switching and optimize pain management outcomes for their patients.

The Role of Technology in Opioid Conversion Calculations

As healthcare continues to embrace digital solutions, various technological tools have emerged to assist with opioid conversion calculations. These tools can help streamline the conversion process and reduce the risk of human error.

Digital Opioid Conversion Tools

• Mobile apps for quick reference and calculations
• Electronic health record (EHR) integrated calculators
• Online conversion calculators with up-to-date potency data
• Clinical decision support systems for complex conversions

While these tools can be valuable aids, it’s important to note that they should not replace clinical judgment. Healthcare providers must still consider individual patient factors and use their expertise to make final dosing decisions.

Educating Patients on Opioid Conversion and Safety

Patient education is a crucial component of safe and effective opioid use, particularly when switching between medications or adjusting doses. Healthcare providers should take the time to explain the conversion process and provide clear instructions to patients and their caregivers.

Key Points for Patient Education

• Reasons for opioid switching or dose adjustments
• Expected changes in pain control and potential side effects
• Proper use of the new medication, including dosing schedule
• Signs of opioid toxicity or inadequate pain control to watch for
• Importance of follow-up appointments and communication with healthcare providers
• Safe storage and disposal of opioid medications

By empowering patients with knowledge about their pain management regimen, healthcare providers can improve adherence, safety, and overall treatment outcomes.

Understanding opioid potency and conversion is essential for healthcare providers managing patients with chronic pain or cancer-related pain. The WHO guidelines and opioid potency chart provide valuable resources for performing these calculations, but it’s crucial to remember that individual patient factors play a significant role in determining appropriate dosing. By combining clinical expertise with careful consideration of patient-specific variables and adherence to best practices, healthcare providers can ensure safe and effective opioid switching to optimize pain management for their patients.

Table A6.2, Approximate potency of opioids relative to morphine; PO and immediate-release formulations unless stated otherwisea – WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva: World Health Organization; 2018.

WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents.

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Table A6.2Approximate potency of opioids relative to morphine; PO and immediate-release formulations unless stated otherwise

^a

Source: Adapted with permission from Twycross et al. 2017:371 (Table 4) (3).

a

Multiply dose of opioid in the first column by relative potency in the second column to determine the equivalent dose of morphine sulfate/hydrochloride; conversely, divide morphine dose by the relative potency to determine the equivalent dose of another opioid.

b

Dependent in part on severity of pain and on dose; often longer-lasting in very elderly and those with renal impairment.

c

The numbers in parenthesis are the manufacturers’ preferred relative potencies.

d

A single 5 mg dose of methadone is equivalent to morphine 7.5 mg, but a variable long plasma half-life and broad-spectrum receptor affinity result in a much higher-than-expected relative potency when administered regularly – sometimes much higher than the range given above. Therefore, guidance from a specialist is recommended for conversions to regularly administered methadone.

From: ANNEX 6, Pharmacological Profiles and Opioid Conversion Tables

© World Health Organization 2018.

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3201-Opioid Conversion Calculator | eviQ

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• All calculations must be confirmed before use. Significant inter/intra patient variability exists in the response to different opioid drugs and the dose of these agents. After changing an opioid drug or its dose, patients should be closely assessed and the dose or drug altered as necessary.
• Calculations used for opioid switching should be documented in the patients record.
• All conversions are made by first calculating the daily oral morphine equivalent of the opioid being converted from, and then calculating the specific dose of the opioid being converted to. For conversion factors used in the calculator select here.
• It is the responsibility of the user to round up or down calculated results if required, to align with preparations available at individual workplaces.
• The eviQ opioid conversion calculator is only to be used for patients greater than 12 years old. For this reason the Date of Birth field is mandatory. For patients under this age consult with a pain or palliative care specialist

• Combination products: There is no conclusive evidence that combination analgesics containing lower doses of codeine with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone.
• Buprenorphine transdermal patches: Calculator will only allow conversion FROM a buprenorphine patch and not TO a patch as there is limited evidence about, and experience of it’s use compared to other opioids.
• Methadone: Dose conversion to: from other opioids and methadone is complex; consultation with pain management specialists familiar with methadone use is recommended
• Fentanyl Lozenges: There is no dose equivalence between fentanyl lozenges and other opioid formulations. The optimal dose cannot be predicted by the dose of regular opioid or pervious breakthrough opioid. It should be individually titrated by starting at the lowest dose (200 micrograms)

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Disclaimer: The Cancer Institute NSW does not warrant or represent that the information is free from errors or omission. Furthermore, changes in circumstances after the time of publication of the information may impact on the accuracy of the information. The user agrees not to hold the Cancer Institute NSW or any of its officers, employees or contractors liable in any way for use and/or outcomes brought about through the use of any information obtained from the opioid calculator. The doses are calculated as a guideline only, based on currently published conversion factors and may differ from those used in your institution. Clinical application of any information obtained from the opioid calculator is the sole responsibility of the user.

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how to achieve the desired and lasting result

• Date: June 12, 2021

• Author: Yuliana Borisovna Ivashchenko

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9000 4 According to the latest statistics, 3% of the people on earth, which is approximately 200 million people, are drug addicts. With the advent of the Internet in our lives, the number of cases of distribution of drugs through the worldwide network has increased, about 600 sites that sell drugs have been recorded. The mass distribution of drugs and, accordingly, their use destroys not only moral and ethical principles, but also endangers the lives and health of countless people.

This situation and the results of research make the issue of prevention, which will be aimed at the younger generation, as well as the treatment of drug addicts, relevant.

You need to start with medication support – that’s where any drug addiction treatment begins.

Effective drug addiction treatment is a comprehensive approach using different types of methods, including: the use of medications, various rehabilitation centers and drug treatment dispensaries (labor centers, centers operating under the 12 step program, spiritual and Orthodox centers, the community of anonymous drug addicts , monasteries and church churches), coding, substitution therapy (replacement of a drug familiar to the patient with another drug – methadone, bublemorphine, methadol). It is also believed that Effective drug addiction treatment can be achieved with strict therapy in several stages. The first stage is the relief of acute withdrawal disorders. As part of this stage, detoxification agents are used that are aimed at relieving pain, autonomic disorders, somatic disorders (clophelin, cholecystokinin or pancreozymin). A similar effect of drugs was revealed – tacus-decapeptide and deltoran-peptide, which also normalize the level of dopamine.

The results of studies have shown that the problem of vegetative disorders copes with the inhibitor – aprotinin, which largely removes such disorders. In general, this type of treatment is successful, as it normalizes the psychological state of the patient, eliminates metabolic disorders, and normalizes sleep. To stop the craving for drugs, it is preferable to use antipsychotics and anticonvulsants, after which antidepressants (melipramine, lyudiomil and amitriptyline) are prescribed in case of apathetic and anxious mood of the patient. Also in therapeutic practice, to normalize the functioning of the central nervous system and form long-term remissions, nootropic drugs (phenibut, picamilon, pantogam) are used. An important drug in the treatment of dependence on psychostimulants is the dopamine agonist bromocriptine.

Medical treatment is only a stage. Psychological help is also important!

But an important condition for getting rid of drug addiction is not only drug treatment, but also the stage of anti-relapse therapy, which is the patient’s work with psychologists and psychotherapists in combination with psychotherapy and supportive pharmacotherapy (drug therapy). During this period, an antagonist, naltrexone, is used to prevent relapse in drug addicts. The stage is aimed at correcting the psychological state of the patient and is an indicator of whether effective drug addiction treatment during rehabilitation. A prerequisite for therapy is the resocialization of patients, during which the skills of preventing breakdowns are mastered, the process of transition to a society where there is no place for drug addiction.

Unfortunately, drug has not yet been created to cure this disease in a matter of minutes. Drug addiction treatment is a complex and multi-stage process that requires a full course of treatment, including the stage of resocialization. The formation of a patient’s motivation for recovery is an important task for a possible long-term remission. For a drug-free society, not only the treatment of drug addiction is important, but also its prevention is the work of all members of society.

Diagram of addiction to drugs

Author: Ivashchenko Yuliana Borisovna

Specialist in working with addictions

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How the “diagram of life” works ? An excerpt from the book of psychotherapist Irina Gibermann “I live as I want”

An excerpt from the book of psychotherapist Irina Gibermann “I live as I want”.

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I live as I want. Accept the past and find yourself in the present, Irina Gibermann

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The Life Chart is a very powerful tool for exploring the psyche. I love giving this exercise to my patients in both personal and group work. Its goal is to understand what patterns certain life scenarios repeat. You can often see how decisions are made not logically, but unconsciously, based on the “old” method laid down in the psyche, and then, like a stencil, are superimposed on seemingly new phases of life.

I do not know the author of this exercise. It was taught to me in a clinic where I worked for over ten years, and it has been passed down by word of mouth for decades. Each therapist made his own adjustments, integrated his ideas and set his own trajectories for the movement of thought, but it was carried out by all patients undergoing treatment.

And this is the strength of the concept: for the same task in each case, an absolutely individual interpretation. Over the years, I have collected a huge number of questions that I like and that I pay attention to when my patients draw their life chart.

These questions, in my experience, play the role of important landmarks in self-exploration. You can make notes for yourself and later transfer them to a separate sheet.

1. Do you know your biological parents?
2. Are you a desirable child? What and who told you about it and how old were you then?
3. What family situation have you come to? How many family members live with you under the same roof?
4. What is the atmosphere like at home? Did important events in family history take place before your birth: funeral of relatives, war, emigration, loss of all property during persecution, persecution, fire?
5. Mom and dad together or not?
6. Were there any abortions, miscarriages, missed pregnancies, children who died at an early age before or after your birth that you know about? When did you find out about this? Who told you about this? How did you find the information?
7. What are the relationships within the family with other generations: mother with father’s parents, father with mother’s parents, you with grandparents?
8. What is your relationship with older brothers or sisters?
9. What is your relationship with the children after you? How did you know that mom was pregnant, and how old were you? How did you react to the appearance of the baby? What important events took place during that period?
10. Divorce of parents. At what age and how were you informed about it? What was your involvement in making the decision? On which side were you emotionally, who were you worried about? With whom did you stay after the divorce, with whom did the other children stay? Do you know the true reason for divorce (infidelity, betrayal, alcohol, drugs, conflicts, violence, etc.) and how do you live with it?
11. The appearance of other family members after the parents divorce: mom, dad, new children from one of the parents, patchwork-family (the so-called patchwork family, with children from different marriages), your place in this system.
12. What was your childhood like before kindergarten? Did you go to nursery? Who was there as a resource? Did you have friends?
13. What was the time like in kindergarten? What were you into? Did you have a hobby?
14. What was the mood like before school? Did you want to go there? Were your relatives or family members at this school? Were there connections with teachers, did your parents work there?
15. What were your expectations for your future profession? When did you form your idea of ​​it?
16. Highlights during high school: studying abroad on exchange, moving, losing friends, changing schools, bullying (you bullied others or experienced bullying), first experience with boundary testing: sex, leaving home, rebellious behavior, showdown with police or prison, etc.
17. First experience with alcohol or drugs. Each of them has its own color. In what situations did you repeat this experience? Were there any pauses? Or perhaps one drug replaced another? When it was not possible to consume, what did you compensate for (work, sports, food, etc.), what relapses happened, how many times did you try to be cured, who taught you to use, what is happening with these people now, when a frank conversation with the family took place, there are Are there family members with whom you can openly do this?
18. Transition from school to new system. Where did you go after school? Why? What were the motives?
19. When did you leave your parents’ house? Where and with whom did you move? How did you leave or how were you kicked out? How did you communicate with your parents after leaving?
20. Did you create your own family? How many times? How did you choose your partners?
21. Do your parents know your partners? Do they know about your sexual orientation?
22. Do you have any history of abortions, miscarriages, loss of children (if you are a man: did your girlfriend have abortions, did she blackmail you with this, did you deliberately get pregnant for the sake of your genes, and not for the sake of relationships)?
23. When did your grandparents die? Are your parents still alive? When were important family members buried? Were you able to say goodbye and survive the grief?
24. What were the basic career or job decisions you made? Where were they cowardly? Where did you take on too much?
25. What losses affected you? How did you live grief?
26. Your most important successes. How did you celebrate them? How were you awarded? Were you able to appropriate your own victories?
27. Your failures. Have you forgiven yourself for them? Do you still feel guilty? Shame? To sweep?

Next, take a sheet of paper and transfer your notes and answers to it. This is a very important point that requires attention and concentration.

Draw two lines: X and Y. The scale goes up to +100, down to -100. This is the emotional scale. The life line starts from 0 right at the intersection of X and Y. This is the base: what kind of family did you come to, whether you wanted a child, were there abortions and deaths before and after your birth, what happened to your parents and mother during pregnancy, artificial or natural was the conception.

Then draw the stages of life on the line: 0-3, 3-6, 6-12, 12-21, 21-30, 30-40, 40-55, 55-65, 65-75 years. For each phase of life, we prescribe two important points.

1. What were the important events in your life and family that changed you?
2. What happened to your emotions, what did you feel and experience?

With all the individuality of the life of each of us, I love this exercise very much.