16.1 Practical and Makeshift Dose-Equivalence Guidelines
See also Frequently Asked Questions About Heroin, Morphine, and the Opiates - Heroin/Morphine FAQ
The effect of an opioid dose which avoids/lessens, the withdrawal-prevention opioid saturation. The withdrawal-prevention opioid saturation is especially relevant for comparing the effects and therefore for the equivalence details for opioid prescriptions. The flash and the perceptible flooding from short-term opioid preparations cannot be substituted by long-term effective opioids (see chapter 9.1 and picture 27).
Equivalence doses are, despite all uncertainties, the fundamentals of a practical necessity. They allow for as safe as possible dose. Practical details concerning the equivalence doses for opioids need to take the breathing depression effect and the euphoria in consideration. Time-dependent factors out of cumulation and tolerance need to be pragmatically introduced into the details.
Tab.27: Practical and Makeshift Equivalence Doses-Guidelines concerning the Withdrawal-inhibiting Opioid Saturation Effect |
|||
1 mg peroral Methadone per day equals |
1 |
MDQ |
|
1 mg injectable Methadone per day equals |
1 |
MDQ |
|
1 mg injectable Methadone per single consumption equals |
1 |
MQ |
|
100 mg Methadone per day equals |
100 |
MDQ |
|
100 mg Methadone per single consumption equals also |
100 |
MQ |
|
3 mg injectable Heroin per day equals |
1 |
MDQ |
|
1 mg injectable Heroin per single consumption equals |
1 |
MQ |
|
36 mg smokable Heroin per day equals |
1 |
MDQ |
|
12 mg smokable Heroin per single consumption equals |
1 |
MQ |
|
4,5 mg injectable Morphine per day equals |
1 |
MDQ |
|
1,5 mg injectable Morphine per single consumption equals |
1 |
MQ |
|
6 mg Morphine ret. tab. per day equals |
1 |
MDQ |
|
3 mg Morphine ret. tab. per single consumption equals |
1 |
MQ |
|
MQ = Methadon-Equivalent: is the dose of an opioid, which equals the effect of one milligramme of a single Methadone-intake. |
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It is assumed, that Morphine i.v. and Heroin is taken 3 times per day Morphine ret. is taken 2 times per day Methadone is taken times per day |
MDQ = Methadon-one-Day-Equivalent: is the dose of an opioid, which equals the effect of one milligramme of Methadone for a hole day. |
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Our details concerning the equivalence doses should only be understood as makeshift, practical guidelines for opioid-supported treatments. Our practical equivalence-dose guidelines in Tab.27 correspond to approximations out of partly bad insured, scientific details and experiences out of the 3 year Prove -trials. The equivalence details are a compromise out of different experiences and basics and should only be understood as practical makeshift values. Contradictions are to be expected, out of necessity, from the considerations presented and they cannot be solved. Our equivalence doses are approximate values concerning the comparable withdrawal-inhibiting opioid saturation from different opioids.
Methadone and it’s practical use is best-known by most doctors and is therefore taken as the reference value for equivalence doses.
We take the MDQ weighted total daily dose from the day before as a practical mass for the actual tolerance for dose calculations. The MDQ-Factor shows the conversion factor between two opioids (Tab.28).
As the different opioids are consumed at different frequencies, different equivalence doses need to be formulated for the single-consumption and the total daily dose: we therefore define the units as MQ (=Methadone-Equivalent) and MDQ (=Methadone-Daily-Equivalent).
The daily equivalence doses for diversified opioid-prescription can initially only then be formulated from the administration times. For the details concerning the daily equivalence doses, assumptions are made over the necessary regularity of consumption / -intervals of the different preparations and forms of consumption:
Heroin and methadone have about the same withdrawal-prevention opioid saturation effect when consumed once. Because heroin, for example, is usually consumed three times a day, the daily dose in mg is usually three times higher than that of methadone. The MDQ-factor for heroin to inject has therefore, for example, in the first approximation the value of 3.
For the details concerning MDQ-factors, it is presumed that heroin and morphine are consumed i.v. 3 times a day, morphine in retard form twice a day and methadone once a day. The daily equivalence doses far from dependent on the consumption regularity. MDQ and MDQ-factors can be used, unchanged even if, for example, heroin is consumed i.v. twice or four times daily.
Tab.28: Conversion Tables for the Daily Doses: Practical and makeshift equivalence factors for the equivalent withdrawal-preventing opioid saturation
MDQ-Faktor |
Heroin i.v. |
DAM-Cig. |
Methadon p.o. |
Methadone i.v. |
Morphine i.v. |
Mo ret. p.o. |
|
| He i.v. | 3 |
12 |
0.33 |
0.33 |
1.50 |
2 |
|
| DAM-Cig. | 36 |
0.08 |
0.03 |
0.03 |
0.125 |
0.16 |
|
| Me oral | 1 |
3 |
36 |
1 |
4.50 |
6 |
|
| Me i.v. | 1 |
3 |
36 |
1 |
4.50 |
6 |
|
| Mo i.v. | 4.50 |
0.66 |
8 |
0.22 |
0.22 |
1.33 |
|
| Mo ret. p.o. | 6 |
0.50 |
6 |
0.17 |
0.17 |
0.75 |
The Different Assumptions for Dose-Equivalence in Different Projects of the Prove-Trial (‘Swiss Heroin Trial’):
| MDQ-Faktors | KODA1 Bern |
Janus Basel |
ZokL2 Zürich |
| Methadon | 1 |
1 |
1 |
| Heroin i.v. | 3.6 |
5 |
3 |
| Morphine i.v. | 5.4 |
5 |
4.5 |
| Morphine in Retardform | - |
6-9 |
9 |
Heroin is usually consumed over three daily, intravenous doses. A few patients can make do with 2 daily heroin consumptions. In Basel in the Project Janus, they aimed at two, usually high-dosed heroin consumptions a day, with a sufficiently long ongoing effect (see Fig.26). When smoking heroin, the daily dose is usually divided over more than 3 smoking-sessions a day,, when smoking more than 10 cigarettes.
For the equivalence doses of morphine, one starts on 3 injections daily. In illegal circumstances, opioid addicts seem to prefer more frequent morphine injections. The histamine reaction can possibly be lessened this way. Two daily consumptions of morphine in retard form are enough. For a fast increase in dose, in the first few days, up to 4 consumptions a day does make sense. In pregnant women in their last trimenon, it is recommended that the dose be divided over three identical doses a day to prevent any fluctuations in dose
Methadone only needs to be consumed once a day.