Morphine Equivalent Dose (MED) - Opioid Conversions
Morphine Milligram Equivalents
(MME)
Link to the 2022 CDC Update
The Morphine Equivalent Dose (MED) conversions calculator allows a clinician to generate an equivalent dose
of morphine for a patient taking one or more common opioids. This
tool also provides precise control over methadone conversions as well.
Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring.
Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of
opioids.
The amount of residual drug in the patient's system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new
opioid.
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Converting From:
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Codeine (PO) |
(Daily dose in mg) |
Fentanyl (Transdermal) |
(mcg/hr) |
Hydrocodone (PO) |
(Daily dose in mg) |
Hydromorphone (PO) |
(Daily dose in mg) |
METHadone (PO) [ ? ]Additional options available near the bottom of the page.
|
(Daily dose in mg) |
MORPHine (PO) |
(Daily dose in mg) |
Oxycodone (PO) |
(Daily dose in mg) |
Oxymorphone (PO) |
(Daily dose in mg) |
Tapentadol (PO) |
(Daily dose in mg) |
Tramadol (PO) |
(Daily dose in mg) |
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Please review these important
points:
- Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring.
- Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of
opioids.
- The amount of residual drug in the patient's system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new
opioid.
- Review the concept of incomplete
cross-tolerance:
D. McAuley: "Incomplete cross-tolerance relates to
tolerance to a currently administered opiate that does not
extend completely to other opioids. This will tend to lower the
required dose of the second opioid. This incomplete
cross-tolerance exists between all of the opioids and the
estimated difference between any two opiates could vary widely.
This points out the inherent dangers of using an equianalgesic
table and the importance of viewing the tabulated data as
approximations. Many experts recommend - depending on age and
prior side effects - reducing the dose of the new opiate by 33
to 50 percent to account for this incomplete cross-tolerance.
(Example: a patient is receiving 200mg of oral morphine daily
(chronic dosing), however, because of side effects a switch is
made to oral hydromorphone 25 - 35mg daily - (this represents a
33 to 50 percent reduction in dose compared to the calculated
50mg conversion dose produced via the equianalgesic calculator).
This new regimen can then be re-titrated to patient response. In
all cases, repeated comprehensive assessments of pain are
necessary in order to successfully control the pain while
minimizing side-effects."
- The use of high but ineffective doses of a previous opioid may result in overestimation of the converted opioid.
The authors
make no claims of the accuracy of the information contained
herein; and these suggested doses and/or guidelines are not a
substitute for clinical judgment. PLEASE
READ THE
DISCLAIMER CAREFULLY BEFORE
ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE
TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. |
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Advanced options
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Review only if converting FROM chronic oral
methadone
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Converting FROM
chronic Methadone:
1 - 20 mg/day:
21 - 40 mg/day:
41 - 60 mg/day:
> 60 mg/day:
Highly variable - extreme caution
required. Lowering this value will lower the
estimated dose of morphine. Consider lowering this number for larger
previous doses of methadone. The residual
affects of methadone can last several days after discontinuation depending on
the previous dose (long half-life).
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Background:
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Equianalgesic
dosage table |
Buprenorphine
(IM/IV):
0.4
Butorphanol (IM/IV): 2.0
Codeine (IM/IV): 120
Codeine (PO): 200
Fentanyl (IM/IV): 0.1
Fentanyl (Transdermal): 0.2
Hydrocodone (PO): 30
Hydromorphone (IV/IM/SC): 1.5
Hydromorphone (PO): 7.5
Levorphanol (acute PO): 4.0
Levorphanol (chronic PO): 1.0
Meperidine (IV/IM/SC): 75 |
Meperidine (PO): 300
Methadone (acute IV): 5.0
Methadone (acute PO): 10
Methadone (chronic PO): See below.
Morphine (IV/IM/SC): 10
Morphine (acute PO): 60
Morphine (chronic PO): 30
Nalbuphine (IV/IM/SC): 10
Oxycodone (PO): 20
Oxymorphone (IV/IM/SC): 1.0
Oxymorphone (PO): 10
Tapentadol (PO): 75-100 |
Additional conversion data |
References |
- American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025.
-
Ayonrinde OT, Bridge DT. The rediscovery of methadone for cancer pain management. Med J Aust 2000; 173(10): 536-540.
Daily oral morphine dose equivalents
|
Conversion ratio of oral morphine to
oral methadone |
<100 mg |
3:1 |
101-300 mg |
5:1 |
301-600 mg |
10:1 |
601-800 mg |
12:1 |
801-1000 mg |
15:1 |
>1000 mg |
20:1 |
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- Breitbart W, Chandler S, Eagel B, et al. An alternative
algorithm for dosing transdermal fentanyl for
cancer-related pain. Oncology. 2000;14:695-705.
- Donner B, et al. Direct conversion from oral
morphine to transdermal fentanyl. Pain. 1996;
64:527-534.
- Duragesic® Package Insert:
Accessed: October 2010.
- Fisch MJ, Cleeland CS: Managing cancer pain. In: Skeel RT, ed.: Handbook of Cancer Chemotherapy. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2003, pp 663.
- Friedman LL, Rodgers PE. Pain management in
palliative care. Clin Fam Prac. 2004;6:371-393.
- Fudin J, Marcoux MD, Fudin JA. Mathematical
Model For Methadone Conversion Examined. Practical
Pain Management. 2012(Sep):46-51.
-
Gazelle G, Fine PG. Fast Facts Documents #075 -
Methadone for the Treatment of Pain, 2nd ed 2009. End
of Life/ Palliative Education Resource Center. Link:
https://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_075.htm(Revisited April 2013).
"Due to incomplete cross-tolerance, it is recommended that the
initial dose is 50-75% of the equianalgesic dose" -
Based on the Ayonrinde method above.
Daily oral morphine dose equivalents
|
Conversion ratio of oral morphine to
oral methadone using 25% reduction (75% of
equianalgesic dose) |
<100 mg |
4:1 |
101-300 mg |
6.7:1 |
301-600 mg |
13.3:1 |
601-800 mg |
15.4:1 |
801-1000 mg |
20:1 |
>1000 mg |
26.7:1 |
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-
Methadone PI (package insert). Dolophine hydrochloride, 5 mg, 10mg tablets.
July 2012.
Oral Morphine to
Oral Methadone Conversion for Chronic Administration
(Package Insert versus GlobalRPh default factors) |
Daily Baseline Oral
Morphine Dose |
Estimated Daily Oral Methadone
Requirement as % of Daily Morphine Dose
|
< 100 mg |
20% to 30%
[Globalrph 25% (4:1)] |
100 to 300 mg |
10% to 20%
[Globalrph 12.5% (8:1)] |
300 to 600 mg |
8% to 12%
[Globalrph (300-499) 8.3%
(12:1)] |
600 mg to 1000 mg |
5% to 10%
[Globalrph (500-999) 6.66%
(15:1)] |
> 1000 mg |
< 5 %
[Globalrph (>1000) 5%
(20:1) ] |
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- McPherson ML. Demystifying opioid conversion
calculations. A guide for effective dosing. Bethesda:
American Society of Health System Pharmacists;2010.
-
Mercadante S, Casuccio A, Fulfaro F, et al.
Switching from morphine to methadone to improve
analgesia and tolerability in cancer patients: A
prospective study. J Clin Oncol. 2001;19:2898-2904.
30-90 mg |
4:1 |
90-300 mg |
8:1 |
> 300 mg |
12:1 |
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- Morley J, Makin M. The use of methadone in cancer
pain poorly responsive to other opiates. Pain Rev.1998;5:51-58.
- Ripamonti C, Groff L, Brunelli C, Polastri D, Stavrakis A, De Conno F. Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? J Clin Oncol. 1998;16(10):3216-3221.
- Rosenquist EW. Overview of the treatment of
chronic pain. In: UpToDate, Aronson MD (Ed), UpToDate,
Waltham, MA. (Accessed on January 15, 2015.)
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