How does an opioid conversion calculator work. What are the key factors in calculating morphine equivalents. Why is understanding opioid potency crucial for pain management. How can healthcare providers ensure safe opioid dosing across different medications.

Understanding Opioid Potency and Conversion

Opioid medications play a crucial role in pain management, but their varying potencies make accurate dosing challenging. An opioid conversion calculator is an essential tool for healthcare providers to safely and effectively switch between different opioid medications or adjust dosages. These calculators use established conversion ratios to determine equivalent doses across various opioids, with oral morphine typically serving as the standard reference point.

The World Health Organization (WHO) provides guidelines for opioid conversion, emphasizing the importance of patient safety and individualized care. These conversions are not exact due to factors like individual patient variability, pain severity, and medication-specific characteristics. Therefore, healthcare providers must use conversion calculators as a starting point, closely monitor patients, and adjust dosages as needed.

Key Principles of Opioid Conversion

• Calculate the total daily dose of the current opioid
• Convert to oral morphine equivalents using established ratios
• Determine the equivalent dose of the new opioid
• Reduce the calculated dose by 25-50% to account for incomplete cross-tolerance
• Closely monitor the patient and adjust as necessary

Morphine Equivalence: The Standard for Comparison

Morphine serves as the reference point for opioid potency comparisons due to its well-established pharmacological profile and long history of clinical use. The concept of morphine equivalence allows healthcare providers to standardize dosing across different opioid medications. This standardization is crucial for several reasons:

1. It facilitates safer opioid rotation when changing medications
2. It helps prevent overdosing or underdosing when switching between opioids
3. It provides a common language for discussing opioid dosages across healthcare settings
4. It aids in research and epidemiological studies on opioid use and effectiveness

When using morphine equivalence, it’s important to remember that these are approximate conversions. Factors such as individual patient characteristics, route of administration, and specific opioid properties can all influence the actual clinical effect.

Relative Potency of Common Opioids

Understanding the relative potency of different opioids is crucial for accurate conversions. The WHO guidelines provide a table of approximate potencies relative to oral morphine for various opioids. Here are some examples:

• Codeine: 0.1 (10 mg codeine ≈ 1 mg morphine)
• Tramadol: 0.1-0.2
• Hydrocodone: 1
• Oxycodone: 1.5
• Hydromorphone: 5
• Fentanyl: 100 (transdermal)

These ratios help clinicians estimate equivalent doses when switching between opioids. However, it’s crucial to note that these are general guidelines and may not account for individual patient factors or specific medication formulations.

Factors Influencing Opioid Conversion Accuracy

While opioid conversion calculators provide valuable guidance, several factors can affect the accuracy of these conversions in clinical practice:

1. Individual Patient Variability

Patients may respond differently to opioids due to genetic factors, age, gender, and overall health status. This variability can lead to unexpected responses when switching between medications.

2. Pain Severity and Chronicity

The intensity and duration of pain can influence opioid effectiveness and the required dosage. Chronic pain patients may develop tolerance, necessitating higher doses for adequate pain control.

3. Route of Administration

Oral, transdermal, intravenous, and other routes of administration can affect drug absorption, bioavailability, and potency. Conversion calculators must account for these differences.

4. Drug Interactions

Other medications, particularly those affecting the cytochrome P450 enzyme system, can alter opioid metabolism and effectiveness. Healthcare providers must consider potential drug interactions when converting opioids.

5. Incomplete Cross-Tolerance

When switching between opioids, patients may not have complete cross-tolerance, potentially leading to increased sensitivity to the new medication. This is why guidelines often recommend reducing the calculated equivalent dose by 25-50% when rotating opioids.

Safe Practices in Opioid Conversion

Ensuring patient safety during opioid conversion requires careful consideration and adherence to best practices. Healthcare providers should follow these guidelines:

• Document all calculations and rationale for opioid conversions in the patient’s medical record
• Use conservative initial dosing when switching to a new opioid, typically 25-50% less than the calculated equianalgesic dose
• Provide appropriate breakthrough pain medication during the transition period
• Educate patients and caregivers about the signs of opioid toxicity and underdosing
• Schedule frequent follow-ups to assess pain control and adjust dosages as needed
• Consider consulting with pain management specialists for complex cases or high-dose conversions

By following these practices, healthcare providers can minimize the risks associated with opioid conversion while ensuring effective pain management for their patients.

Special Considerations for Methadone Conversion

Methadone presents unique challenges in opioid conversion due to its complex pharmacokinetics and pharmacodynamics. The WHO guidelines specifically note that methadone conversions require special attention:

“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.”

This complexity arises from several factors:

• Methadone has a long and variable half-life, ranging from 8 to 59 hours
• It exhibits non-linear pharmacokinetics, especially at higher doses
• Methadone has additional mechanisms of action beyond mu-opioid receptor activation
• There’s a risk of QT interval prolongation, which can lead to serious cardiac arrhythmias

Due to these factors, methadone conversion and initiation should ideally be overseen by clinicians with specific expertise in its use. The conversion process often involves more gradual titration and closer monitoring than with other opioids.

Interpreting and Applying WHO Guidelines

The World Health Organization’s guidelines for opioid conversion provide a valuable framework for healthcare providers. However, it’s essential to understand how to interpret and apply these guidelines effectively:

1. Recognizing Limitations

The WHO table of approximate potencies is a helpful starting point, but it’s crucial to recognize its limitations. The guidelines state that these are approximate values and may not account for all clinical scenarios.

2. Considering Formulations

The WHO guidelines primarily focus on oral and immediate-release formulations unless otherwise stated. When dealing with extended-release or alternative formulations, additional considerations may be necessary.

3. Adapting to Clinical Context

While the guidelines provide general conversion ratios, clinicians must adapt these to individual patient needs. Factors such as pain severity, opioid tolerance, and comorbidities should inform the conversion process.

4. Utilizing Additional Resources

The WHO guidelines should be used in conjunction with other clinical resources, local protocols, and specialist input when necessary. This comprehensive approach ensures the safest and most effective opioid conversion practices.

By carefully interpreting and applying these guidelines, healthcare providers can optimize pain management while minimizing risks associated with opioid use and conversion.

The Role of Technology in Opioid Conversion

As healthcare continues to evolve, technology plays an increasingly important role in opioid conversion and pain management. Digital tools and software applications offer several advantages in this complex field:

1. Automated Calculations

Digital opioid conversion calculators can quickly perform complex calculations, reducing the risk of human error. These tools often incorporate the latest conversion ratios and can account for multiple variables simultaneously.

2. Integration with Electronic Health Records (EHRs)

Advanced systems can integrate opioid conversion tools directly into EHRs. This integration allows for automatic consideration of patient-specific factors, medication history, and potential drug interactions.

3. Clinical Decision Support

Some digital platforms offer clinical decision support, providing recommendations based on patient data and evidence-based guidelines. These systems can alert healthcare providers to potential risks or suggest alternative pain management strategies.

4. Monitoring and Analytics

Technology enables better tracking of opioid prescribing patterns and patient outcomes. This data can inform institutional policies, identify areas for improvement, and contribute to research on opioid use and effectiveness.

5. Patient Education and Engagement

Digital tools can provide patients with accessible information about their pain management plan, including dosing instructions and potential side effects. Some applications even allow patients to track their pain levels and medication use, facilitating more informed discussions with their healthcare providers.

While these technological advancements offer significant benefits, it’s crucial to remember that they are tools to support clinical decision-making, not replace it. Healthcare providers must still apply their clinical judgment and consider individual patient factors when using these digital resources.

As technology continues to advance, we can expect even more sophisticated tools to emerge, potentially incorporating artificial intelligence and machine learning to further refine opioid conversion and pain management strategies. However, the fundamental principles of patient safety, individualized care, and careful monitoring will remain central to effective opioid use in pain management.

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

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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.