Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2018 Oct 29:11:2587-2601.
doi: 10.2147/JPR.S170269. eCollection 2018.

Practical management of opioid rotation and equianalgesia

Erwan Treillet  1 , Sophie Laurent  2 , Yacine Hadjiat  3
Affiliations
Review

Practical management of opioid rotation and equianalgesia

Erwan Treillet et al. J Pain Res. .

Abstract

Purpose: To review the recent literature on opioid rotation (ie, switching from one opioid drug to another or changing an opioid's administration route) in cancer patients experiencing severe pain and to develop a novel equianalgesia table for use in routine clinical practice.

Methods: The MEDLINE database was searched with terms "cancer pain," "opioid rotation," "opioid switching," "opioid ratio," "opioid conversion ratio," and "opioid equianalgesia" for the major opioids (morphine, oxycodone, fentanyl, and hydromorphone) and the intravenous, subcutaneous, oral, and transdermal administration routes. Selected articles were assessed for the calculated or cited opioid dose ratio, bidirectionality, and use of the oral morphine equivalent daily dose or a direct drug-to-drug ratio.

Results: Twenty publications met our selection criteria and were analyzed in detail. We did not find any large-scale, prospective, double-blind randomized controlled trial with robust design, and most of the studies assessed relatively small numbers of patients. Bidirectionality was investigated in seven studies only.

Conclusion: The updated equianalgesic table presented here incorporates the latest data and provides information on bidirectionality. Despite the daily use of equianalgesic tables, they are not based on high-level scientific evidence. More clinical research is needed on this topic.

Keywords: equianalgesic dose; fentanyl; hydromorphone; morphine; opioid rotation; opioid switching; oxycodone.

PubMed Disclaimer

Conflict of interest statement

Disclosure Yacine Hadjiat is an employee of Mundipharma and reports no other conflicts of interest in this work. Erwan Treillet and Sophie Laurent report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flow diagram for the selection of studies.
Figure 2
Figure 2
Conversion ratios of morphine to and from other opioids. Abbreviations: iv, intravenous; po, oral; sc, subcutaneous; su, suppository; td, transdermal.
Figure 3
Figure 3
Conversion ratios of fentanyl to and from other opioids. Abbreviations: iv, intravenous; po, oral; sc, subcutaneous; td, transdermal.
Figure 4
Figure 4
Conversion ratios of oxycodone to and from other opioids. Abbreviations: iv, intravenous; im, intramuscular; po, oral; sc, subcutaneous; td, transdermal.
Figure 5
Figure 5
Conversion ratios of hydromorphone to and from other opioids. Abbreviations: po, oral; sc, subcutaneous.
See this image and copyright information in PMC

References

    1. Mercadante S, Bruera E. Opioid switching in cancer pain: From the beginning to nowadays. Crit Rev Oncol Hematol. 2016;99:241–248. - PubMed
    1. Lawlor PG, Bruera E. Side-effects of opioids in chronic pain treatment. Curr Opin Anaesthesiol. 1998;11(5):539–545. - PubMed
    1. Walters JB, Montagnini M. Current concepts in the management of opioid-induced constipation. J Opioid Manag. 2010;6(6):435–444. - PubMed
    1. Reimer K, Hopp M, Zenz M, et al. Meeting the challenges of opioid-induced constipation in chronic pain management - a novel approach. Pharmacology. 2009;83(1):10–17. - PubMed
    1. Mccann S, Yaksh TL, von Gunten CF. Correlation between myoclonus and the 3-glucuronide metabolites in patients treated with morphine or hydromorphone: A pilot study. J Opioid Manag. 2010;6(2):87–94. - PubMed