AAHPM Publications to adopt updated, evidence-based Opioid Equianalgesic Table

Written by: Kristina Newport, MD HMDC FAAHPM

“Evidence-based opioid rotation ratios are not optional; they are essential for safe and effective pain management. Ignoring these proven ratios risks uncontrolled pain, overdose, or toxicity. Until robust randomized trials prove otherwise, our duty is to apply the best available data to protect patients and ensure adequate analgesia.” – Akhila Reddy, MD FAAHPM

The equianalgesic table is a critical tool of hospice & palliative care(HPC) practice,  often one of the first things HPC clinicians memorize early in their training. For those of us who trained in the 1990s and early 2000s, the data informing relative opioid potencies were limited to short term, single-dose studies often in acute postoperative pain or patients with cancer pain on low-dose opioids, resulting in wide variations and tables dating as far back as 1960. *

Since that time, additional studies have informed our available knowledge.  AAHPM member and fellow of the Academy Akhila Reddy, MD (Reddy et al., 2023) has led this work through the research she has done as a Professor at The University of Texas MD Anderson Cancer Center. She has systematically  worked to provide real-world, translatable evidence to inform the process of opioid switching.  With this evidence in hand, AAHPM took part in the convening of an expert panel along with ASCO and MASCC (MASCC/ASCO/AAHPM Expert Panel, 2023) who published a joint guideline for opioid conversions in adults with cancer based on the Delphi technique. The resulting paper outlines the areas of consensus on opioid conversions and highlights  the need for personalized titration and very frequent follow-up during the first week of an opioid rotation for all opioids, to prevent severe toxicity or uncontrolled pain and encourage additional well-designed trials.  Their recommendations aligned with a previous expert panel who recommended the creation of a new equianalgesic table and similarly personalized calculations that account for patient characteristics and goals. *

AAHPM Board member and phenomenal translator of all things pharmacological Mary Lynn McPherson (McPherson, 2022), PharmD, PHD, FAAHPM,BCPS was a participant in the expert panel as well as a scoping review that helps us all to understand what they found from a deep dive into the opioid conversion literature, including Dr. Reddy’s work. As she always does,  McPherson, PharmMD then expertly translates all of this into tools that all of us can use in her book, Demstifying Opioid Conversations, 2nd Ed, where she not only published an “Selected Equianalgesic Opioid Dosing” by ML McPherson, Copyright © 2022 American Society of Health-System Pharmacists, Inc., used under CC BY-NC-ND 4.0. She also guides us on the process needed to safely and effectively make opioid conversions using her table.

“Opioid Conversion Ratio tables are a useful tool for practitioners working with patients experiencing pain. It is critically important that we use the strongest evidence available, and use good clinical judgement throughout the process.” – Mary Lynn McPherson, PharmD PhD FAAHPM

As a result of evidence-based updates and our assessment of the best possible tools available, starting with our 2026 publications, AAHPM will adopt the table below as recommended conversion tool in our publications. This will include future editions of  The Essentials Book Set and the Primer of Palliative Care and follows similar adoption by the Center to Advance Palliative Care and Palliative Fast Facts. 

“What do I do now? I can’t possibly unlearn the ‘old’ table!”

Never fear, we are here for you. In addition to the AAHPM publications that will include and guide the use of the updated table, we plan additional opportunities for you to learn from the creator of the table herself including:

• September 18^th on Maximizing Pharmacocompetence in Pain and Symptom Management lead by Mary Lynn McPherson (McPherson, 2022), PharmD PhD FAAHPM and Alexandra McPherson, PharmD MPH.
• Annual Assembly 2-hour session Opioid Conversion Calculations and Breakthrough Pain led by faculty experts Mellar P. Davis, MD, FCCP, FAAHPM, Mary Lynn McPherson, PharmD, PhD, FAAHPM, Kathleen Broglio, DNP ANP-BC ACHPN FAAHPM and Marcin Chwistek, MD, FAAHPM
• Annual Assembly full-day Pre-Conference Workshop March 4th, 2026 on What Every Expert Should Know: Advanced Pharmacologic Approaches in Hospice and Palliative Care presented by Mary Lynn McPherson, PharmD, PhD, FAAHPM, Alexandra L. McPherson, PharmD MPH, Eric Widera, MD, Jeremy Hirsch, MD and Max Stevenson, PharmD MA BCPS 

You will also be hearing about this in an upcoming quarterly electronic newsletter and we will be distributing pocket versions of the table for those who attend the Annual Assembly in San Diego in March.  And, we encourage you to share your experiences and challenges with the table on the Connect forum, so we can all learn together.  

I am certain this will not be the last time you hear from AAHPM on updates in opioid management: when high-quality evidence leads to the need for more changes, we will share that with you.  And when personalized medicine allows us to fine tune opioid dosing for each individual patient,  we’ll do our best to help you understand that process too.  Because we know that the best serious illness care is evidence-based and patient-centered. 

References

*Houde, R. W., Wallenstein, S. L., & Rogers, A. (1960). Clinical pharmacology of analgesics. 1. A method of assaying analgesic effect. Clinical Pharmacology & Therapeutics, 1(2), 163–174. https://doi.org/10.1002/cpt196012163

*Wen, R. Y., Atayee, R. S., & Edmonds, K. P. (2022). A comparison of institutional opioid equianalgesia tools: A national study. Journal of Palliative Medicine, 25(11), 1686–1691. https://doi.org/10.1089/jpm.2021.0678

*Reddy, A., Sinclair, C., Crawford, G. B., et al. (2022). Opioid rotation and conversion ratios used by palliative care professionals: An international survey. Journal of Palliative Medicine, 25(12), 1557–1562. https://doi.org/10.1089/jpm.2022.0045

*Reddy, A., Yennurajalingam, S., Desai, H., Reddy, S., de la Cruz, M., Wu, J., Liu, D., Rodriguez, E. M., Waletich, J., Shin, S. H., Gayle, V., Patel, P., Dalal, S., Vidal, M., Tanco, K., Arthur, J., Tallie, K., Williams, J., Silvestre, J., & Bruera, E. (2014). The opioid rotation ratio of hydrocodone to strong opioids in cancer patients. The Oncologist, 19(11), 1186–1193. https://doi.org/10.1634/theoncologist.2014-0130

*Reddy, A., Vidal, M., Stephen, S., Baumgartner, K., Dost, S., Nguyen, A., Heung, Y., Kwan, S., Wong, A., Pangemanan, I., Azhar, A., Tayjasanant, S., Rodriguez, E., Waletich, J., Lim, K. H., Wu, J., Liu, D., Williams, J., Yennurajalingam, S., & Bruera, E. (2017). The conversion ratio from intravenous hydromorphone to oral opioids in cancer patients. Journal of Pain and Symptom Management, 54(3), 280–288. https://doi.org/10.1016/j.jpainsymman.2017.07.001

*Reddy, A., Tayjasanant, S., Haider, A., Heung, Y., Wu, J., Liu, D., Yennurajalingam, S., Reddy, S., de la Cruz, M., Rodriguez, E. M., Waletich, J., Vidal, M., Arthur, J., Holmes, C., Tallie, K., Wong, A., Dev, R., Williams, J., & Bruera, E. (2016). The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients. Cancer, 122(1), 149–156. https://doi.org/10.1002/cncr.29688

*Davis, M. P., Davies, A., McPherson, M. L., et al. (2025). Opioid conversion in adults with cancer: MASCC-ASCO-AAHPM-HPNA-NICSO guideline. Supportive Care in Cancer, 33(3), 243. https://doi.org/10.1007/s00520-025-09286-z