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1. Avoid morphine in patients with renal failure or insufficiency. Morphine’s toxic
metabolites are renally cleared, thus this is a bad option for these patients. Fentanyl
is the best option, followed by dilauid. (People tend to not know what it looks like
when people have elevated levels of toxic opioid metabolities. What you will see
firs tis confusion, followed by muscular tics, then seizure/comas.)
Fentanyl Patch – Absorbed via fat. Watch for placement location. Also patient’s who
are cachectic may not absorb the medication at all.
Will give a bolus depending on pt’s temperature (Watch in patient’s
who may have fevers)
Takes about 12-24 hours to have an effect on patients
The only side-effect of opioids to which patients do not build a tolerance is
constipation. Remember to start your patients on a bowel regimen when starting

2. Simple conversions
1mg IV Hydromorphone = 20 mg PO morphine
1mg IV Hydromorphone = 5 mg PO hydromorphone
30mg PO Morphine = 1.5mg IV Hydromorphone
*****
Please refer to a more formal chart for further conversion. I will be sticking to
commonly used medications here.

3. 1) Tally 24 hour use of all opioids (PO and IV)
2) Convert opioid amounts to equivocal doses of PO medication
3) Evaluate need for cross-tolerance reduction (10-30% reduction in total
dose)*see note bellow
4) If capable of using MS Contin divide total dose of PO morphine by 2 to
determine BID dose, or if only able to do shorter acting opioids (IE Oxy IR,
Morphine Elixir, or PO dilaudid) divide by 6 for q4h dosing
5) Provide PRN’s for breakthrough pain that can total 50-100% of patient’s
total dose in a 24 hours period.
6) Remember to start a bowel regimen
*Cross tolerance – patient’s who are on one opioid will respond stronger to another
if switched (even with equivocal dosing). For example, if someone is taking 1
mg of IV dilaudid, 20 mg of PO morphine would have a stronger response in

4. Pt taking 8.8mg IV Dilaudid-> convert to PO morphine -> (20:1 ratio) equivalent to
176 mg po morphine
As this pain is due to cancer, which will be a chronic pain for this patient, I will want
to convert the patient to a long acting medication. I will use MS CONTIN.
As I am switching from Dilaudid to morphine I will reduce dose for cross tolerance
(15% reduction = ~25mg morphine) -> Thus will require ~ 150mg po morphine daily
As MS CONTIN is a BID medication, 75mg MS Contin BID would be ideal dosing for
this patient.
Breakthrough dosing would be at least 75mg of morphine per day (50% of total day’s
dose). Will divide by 6 to do q 4 hour dosing.
75/6 = 12.5 mg per dose – This can be written for as morphine elixir.
Or as 15mg of Immediate Release Morphine