Opioid rotation and conversion ratios used by palliative physicians and pharmacists in Japan

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Methods A cross-sectional survey was conducted between March 7th to 20th, 2024, targeting palliative care physicians and pharmacists in the following three societies: Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer. The primary endpoint was to determine the CRs and ORRs used by participants, which were measured in the survey. Results 433 responses (68.1% physicians and 31.9% pharmacists) were received. 30.3% conducted > 30 opioid rotations in the past 6 months. For most CRs and ORRs obtained from all the participants, values for the median, first quartile, third quartile, and mode were consistent. Among groups of professions and number of opioid rotations frequency, there were no differences in the median opioid ratios involving morphine, hydromorphone and oxycodone. However, there were significant differences in the ORRs involving intravenous (IV) fentanyl, specifically in the rotation ratios between IV fentanyl and IV morphine. Conclusion There was great consistency in the CRs and ORRs used by physicians and pharmacists in palliative care in Japan. This would suggest that education on the ratios is well established for medical professionals in Japan. Opioid opioid conversion opioid rotation opioid conversion ratio opioid rotation ratio opioid switching Figures Figure 1 Introduction Pain is one of the most common symptoms experienced by palliative care patients [1]. Opioids are the preferred drugs to treat pain in these patients [2]. When pain that remains uncontrolled despite opioid dose increase, a new strategy may be required, such as conversion from oral to intravenous (IV) route or rotation to another opioid [3]. Opioid rotation from one opioid to another can also be necessary when accumulation of opioid metabolites, leading to adverse effects such as excessive drowsiness, confusion, myoclonus and hallucinations [4]. Opioid rotation has been recognized as an important tool in pain management. To perform opioid rotation effectively and minimize adverse effects such as uncontrolled pain and accidental opioid overdose, it is crucial to use established opioid rotation ratios. However, there are several versions of equianalgesic tables using various opioid conversion ratios (CRs) and opioid rotation ratios (ORRs) and being used all around the world [5]. The use of several different CRs and ORRs for the opioid rotation may increase the risk for adverse effects [2]. Palliative care Emphasis program on symptom management and Assessment for Continuous medical Education (PEACE), a basic palliative care training program for medical professionals, was established in Japan in 2008. In accordance with the basic plan to promote cancer control programs in Japan, all cancer treatment cooperation centers designated by Ministry of Health, Labour and Welfare are required to hold standardized education programs as basic palliative care training for all medical professionals involved in cancer treatment [6]. These programs were developed by Japanese Society for Palliative Medicine and consists of seven lectures and group work, including a module on the assessment and treatment of cancer pain. By March 2025, this training program had been held 9,943 times nationwide, completed by 199,563 doctors and numerous other medical professionals such as nurses and pharmacists [7]. The educational materials on cancer pain used in these basic palliative care training introduce standardized CRs and ORRs. However, there has never been a nationwide survey on the ratios actually used in clinical practice. This study was conducted a cross-sectional survey to confirm the actual ratios in clinical practice in Japan. Materials and Methods This study is a non-mandatory questionnaire survey targeting healthcare professionals to obtain their voluntary answers regarding the actual CRs and ORRs used in clinical practice. The study was approved by the Institutional Review Board of the National Cancer Center, Japan (6000-085). Formal approval of the study protocol by an ethics committee was not required according to the Japanese national policies. All procedures were performed in accordance with the Declaration of Helsinki. Palliative care physicians and pharmacists willing to complete the survey clicked on the survey link, which displayed the questionnaire statement. Participants indicated their willingness to participate in the survey by completing and submitting the survey. Survey The survey was composed of 31 questions and was developed by the study team who have expertise in opioid conversions and rotations, referencing the previous study [5] ( Online Resource 1 ). The survey took approximately 5–10 minutes to complete. We conducted a cross-sectional survey among palliative care physicians and pharmacists in Japan between March 7th to 20th, 2024. An email with an embedded link was sent to members of the following three societies: Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer. At the time of survey administration, there were 1428-, 7405-, and 3052-members comprising physicians and pharmacists, respectively. The primary endpoint was to determine the CRs and ORRs used by palliative care physicians and pharmacists practicing in Japan, which were measured by Question 10 in the survey. CRs were estimated by Question 10.a to Question 10.d (between same opioids but different routes: from intravenous to oral). ORRs were estimated by Question 10.e to Question 10.n (between different opioids). The secondary endpoint was to determine if CRs and ORRs differ significantly according to demographics such as profession and practice type. Statistical method Survey results were summarized using standard descriptive statistics and frequency tabulation. The CRs and ORRs were presented as median, interquartile range, and mode, overall and by groups. The differences in CRs and ORRs between or among groups were assessed using the Wilcoxon rank-sum test. The Smirnov-Grubbs test was applied as necessary. The collected data were analyzed using EZR (Saitama Medical Center, Jichi Medical University, Japan), a graphical user interface for R [8]. Results A total of 433 responses were received. Table 1 describes the participant characteristics, work setting, and opioid availability. Among the participants, 295 (68.1%) were physicians and 138 (31.9%) were pharmacists, and 30.3% conducted > 30 opioid rotations in the past 6 months. The median age of participants were 48 years (range 26–74), and the median years of clinical experience was 22 years (range 2–47), with 77.6% having more than 15 years. In Japan, tapentadol production was discontinued in 2024, and the number of medical institutions where it was available gradually decreased during this survey period. Table 2 gives the median and mode of the opioid ratios obtained from all the participants. For most CRs and ORRs, values for the median, first quartile, third quartile, and mode were consistent. Table 1 Participant characteristics and opioid availability (n = 433) Variable Levels n % Age (years old) median 48 (26–74) Discipline Physician 295 68.1 Pharmacist 138 31.9 Years of clinical experience median 22 (2–47) > 15 336 77.6 ≤ 15 98 22.6 Work setting a Inpatient 346 79.9 Outpatient 243 56.1 Hospice /palliative care unit 137 31.6 Home visits 109 25.2 Academic 173 40.0 Urban 111 25.6 Rural 120 27.7 Number of opioid rotations performed in the past 6 months > 30 131 30.3 10ཞ30 170 39.3 < 10 133 30.7 Opioid availability a Oral morphine 417 96.3 Intravenous morphine 425 98.2 Fentanyl transdermal 433 100.0 Intravenous fentanyl 403 93.1 Oral oxycodone 429 99.1 Intravenous oxycodone 403 93.1 Oral hydromorphone 409 94.5 Intravenous hydromorphone 359 82.9 Oral methadone 304 70.2 Oral tapentadol 260 60.0 a More than one response allowed for this question. Table 2 Opioid conversion and rotation ratios Conversion or rotation type n Median (IQR) Mode CR from IV to oral morphine 419 2 (2, 2) 2 CR from IV to oral hydromorphone 373 5 (5, 5) 5 CR from IV to oral oxycodone 410 1.33 (1.33, 1.33) 1.33 ORR from IV hydromorphone to oral morphine 371 25 (25, 25) 25 ORR from IV oxycodone to oral morphine 409 2 (2, 2) 2 ORR from oral hydromorphone to oral morphine 394 5 (5, 5) 5 ORR from oral oxycodone to oral morphine 421 1.5 (1.5, 1.5) 1.5 ORR from transdermal fentanyl 25 mcg/hour to MEDD (mg) 414 60 (60, 60) 60 ORR from MEDD 100mg to transdermal fentanyl mcg/hour 411 41.6 (41.6, 41.6) 41.6 ORR from IV morphine (mg) to IV fentanyl (mcg) 373 20 (20, 30) 20 ORR from IV fentanyl 30 mcg to IV morphine (mg) 385 1.5 (1.5, 1.5) 1.5 ORR from oral tapentadol 5mg to oral oxycodone 328 1 (1, 1) 1 CR, concersion ratio for changing the route of opioid administration; ORR, opioid rotation ratio for rotation from one opioid to another; IV, intravenous; MEDD, morphine equivalent daily dose; IQR, interquartile range; mcg, micrograms; mg, milligrams. There were no differences in the median opioid ratios involving morphine, hydromorphone and oxycodone among groups of professions and number of opioid rotations in the past 6 months, as given in Table 3 to Table 4 . In this CRs and ORRs, almost all values for the median, first quartile, third quartile and mode were also consistent. CRs and ORRs were distributed with little variation as shown in Fig. 1 and Online Resource 2 . There were significant differences in the ORRs involving IV fentanyl, as given in Table 5 . Although the medians were the same for all groups regarding profession, opioid rotation frequency, years of clinical experience and specialty, significance differences were observed in the two rotation ratios from IV morphine to IV fentanyl and from IV fentanyl to IV morphine. Table 3 Opioid conversion ratios Level Sub level n Median (IQR) Mode p-value CR from IV to oral morphine Profession Physician 285 2 (2, 2) 2 0.426 Pharmacist 133 2 (2, 2) 2 Number of opioid rotations performed in the past 6 months > 30 127 2 (2, 2) 2 0.721 ≤ 30 291 2 (2, 2) 2 CR from IV to oral hydromorphone Profession Physician 251 5 (5, 5) 5 0.684 Pharmacist 121 5 (5, 5) 5 Number of opioid rotations performed in the past 6 months > 30 124 5 (4, 5) 5 0.867 ≤ 30 249 5 (5, 5) 5 CR from IV to oral oxycodone Profession Physician 278 1.33 (1.33, 1.33) 1.33 0.263 Pharmacist 131 1.33 (1.33, 1.33) 1.33 Number of opioid rotations performed in the past 6 months > 30 128 1.33 (1.33, 1.33) 1.33 0.866 ≤ 30 281 1.33 (1.33, 1.33) 1.33 Table 4 Opioid rotation ratios involving oxycodone and hydromorphone Level Sub level n Median (IQR) Mode p-value ORR from oral oxycodone to oral morphine Profession Physician 286 1.5 (1.5, 1.5) 1.5 0.299 Pharmacist 134 1.5 (1.5, 1.5) 1.5 Number of opioid rotations performed in the past 6 months > 30 128 1.5 (1.5, 1.5) 1.5 0.484 ≤ 30 292 1.5 (1.5, 1.5) 1.5 ORR from IV oxycodone to oral morphine Profession Physician 277 2 (2, 2) 2 0.835 Pharmacist 131 2 (2, 2) 2 Number of opioid rotations performed in the past 6 months > 30 128 2 (2, 2) 2 0.54 ≤ 30 280 2 (2, 2) 2 ORR from oral tapentadol 5mg to oral oxycodone Profession Physician 218 1 (1, 1) 1 0.209 Pharmacist 109 1 (1, 1) 1 Number of opioid rotations performed in the past 6 months > 30 109 1 (1, 1) 1 0.261 ≤ 30 218 1 (1, 1) 1 ORR from IV hydromorphone to oral morphine Profession Physician 251 25 (20, 25) 25 0.276 Pharmacist 119 25 (25, 25) 25 Number of opioid rotations performed in the past 6 months > 30 123 25 (20, 25) 25 0.971 ≤ 30 248 25 (25, 25) 25 ORR from oral hydromorphone to oral morphine Profession Physician 268 5 (5, 5) 5 0.803 Pharmacist 125 5 (5, 5) 5 Number of opioid rotations performed in the past 6 months > 30 127 5 (5, 5) 5 0.236 ≤ 30 267 5 (5, 5) 5 Table 5 Opioid rotation ratios involving transdermal and intravenous fentanyl Level Sublevel n Median (IQR) Mode p-value ORR from transdermal fentanyl 25 mcg/hr to MEDD (mg) Profession Physician 283 60 (60, 60) 60 0.742 Pharmacist 130 60 (60, 60) 60 Number of opioid rotations performed in the past 6 months > 30 129 60 (60, 60) 60 0.729 ≤ 30 285 60 (60, 60) 60 ORR from MEDD 100mg to transdermal fentanyl (mcg/hr) Profession Physician 283 41.6 (41.6, 41.6) 41.6 0.433 Pharmacist 127 41.6 (41.6, 41.6) 41.6 Number of opioid rotations performed in the past 6 months > 30 127 41.6 (41.6, 41.6) 41.6 0.396 ≤ 30 285 41.6 (41.6, 41.6) 41.6 ORR from IV morphine (mg) to IV fentanyl (mcg) (n = 350) a Profession Physician 242 20 (20, 25) 20 0.045 Pharmacist 108 20 (20, 40.6) 20 Number of opioid rotations performed in the past 6 months > 30 111 20 (20, 30) 20 0.639 ≤ 30 239 20 (20, 27.5) 20 Years of clinical experience > 15 273 20 (20, 30) 20 0.030 ≤ 15 77 20 (20, 20) 20 Specialty Palliative care 317 20 (20, 30) 20 0.395 Others 33 20 (20, 30) 20 ORR form IV fentanyl 30 mcg to IV morphine (mg) (n = 375) a Profession Physician 258 1.5 (1.5, 1.5) 1.5 0.026 Pharmacist 117 1.5 (1.5, 2.0) 1.5 Number of opioid rotations performed in the past 6 months > 30 117 1.5 (1.5, 1.5) 1.5 0.004 ≤ 30 258 1.5 (1.5, 1.5) 1.5 Years of clinical experience > 15 295 1.5 (1.5, 1.5) 1.5 < 0.001 ≤ 15 80 1.5 (1.5, 1.5) 1.5 Specialty Palliative care 336 1.5 (1.5, 1.5) 1.5 0.004 Others 39 1.5 (1.5, 1.5) 1.5 a Outliers were removed using the Smirnov-Grubbs test. Discussion This study is the first nationwide survey targeting physicians and pharmacists regarding CRs and ORRs in Japan. The CRs and ORRs used by Japanese physicians and pharmacists involved in palliative care were consistent for most kinds of opioids. However, variations were observed for IV fentanyl, which differed according to profession, opioid rotation frequency, years of clinical experience and specialty. Most CRs and ORRs in this survey were consistent, with median, interquartile range, and mode having the same values. Meanwhile, international guidelines indicated that the only agreed CR was oxycodone, revealing inconsistencies internationally [9]. There were no agreed CRs or ORRs for fentanyl. In Japan, the PEACE project, a basic palliative care training program for all doctors involved in cancer treatment, was began in 2008. By March 2025, over 190,000 doctors had completed the program. The CRs and ORRs provided in its educational materials ( Online Resource 3 ) have become widely adopted throughout Japan. Therefore, the CRs and ORRs have stabilized at consistent tendencies. The ORRs of IV fentanyl were considered to be more prone for miscalculations than other opioids and analyzed excluding outliers in this study. Nevertheless, there were significant difference between groups accoding to profession and opioid rotation frequency in ORRs of IV fentanyl. Furthermore, additional groups based on years of clinical experience and specialty were included, and there were also significant differences in most groups. The groups of clinical experience were divided into two based on 2008, the year the PEACE project training program began. Thus, participation in the palliative care education program would influence the variation in ORRs of IV fentanyl. The CRs and ORRs used in Japan were partially similar to those used abroad such as ORR from oral morphine to oral oxycodone and ORR from oral morphine to oral hydromorphone, but partially different. In the international CR consencus, CR from oral oxycodone to IV oxycodone was 2:1 (88% of agreement), while 4:3 was used in Japan, as shown in the results of this study [10, 11]. Additionally, the following two CRs did not reached consensus internationally: CR from oral morphine to IV morphine was 2.5:1 (55.2% of agreement) and CR from oral hydromorphone to IV hydromorphone was 2.5:1 (63.8% of agreement) [9, 12, 13]. In Japan, the CRs were generally used 2:1 and 5:1, respectively [14, 15]. In most Western countries, the ratio used from IV to oral hydromorphone is 2:1, whereas the ratios of 5:1 and 4:1 are more likely to use in Japan and Australia [16]. Similar to IV fentanyl, where ratios differ between 10 and 20 when rotating to IV morphine [17]. These would be due to racial differences, such as physiques and metabolic enzymes [18]. In actual clinical practice, CRs and ORRs are merely guidelines, and it is recommended to prescribe opioids considering the condition and background of each patient. The ratios in this survey were not based on the condition of patients [9]. Further research on CRs and ORRs under patients‘ different conditions could provide additional insights into trends and characteristics. This study had several limitations. As this was a web-based survey, there were possibilities that other disciplines other than physicians and pharmacist taking the survey and participants taking the survey more than once. It was difficult to verify the accuracy of participants‘ profession and opioid rotation frequency. Furthermore, the results may not fully reflect the overall population due to the low percent of responses to the survey. Conclusion There was greater consistency in the CRs and ORRs used by physicians and pharmacists in palliative care in Japan compared to other countries. This would suggest that education on the ratios is well established for medical professionals in Japan. Declarations Acknowledgments We, authors would like to thank members of Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer, for their cooperation in the questionnaire survey. Funding This work was supported by Health Labor Sciences Research Grant (Grant numbers [22EA1004]). Competing Interests Financial interests: Author RN, HI, DT, AO, NK, MY, KI, MA, TT, SY, EK, HH, HM, HM, AR and ES declare they have no financial interests. Dr. YM received honoraria from Daiichi-Sankyo, Takeda Pharmaceutical, Shionogi, Kyowa Kirin, Teikoku Seiyaku, Terumo, and Hisamitsu Pharmaceutical. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Rumi Nishimura and Eriko Satomi. The first draft of the manuscript was written by Rumi Nishimura and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This is a non-mandatory questionnaire survey targeting healthcare professionals. The study was approved by the Institutional Review Board of the National Cancer Center, Japan (6000-085). Formal approval of the study protocol by an ethics committee was not required according to the Japanese national policies. Consent to participate Informed consent was obtained from all individual participants included in the study. 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East","correspondingAuthor":false,"prefix":"","firstName":"Emi","middleName":"","lastName":"Kubo","suffix":""},{"id":585800870,"identity":"42a62f61-a1a0-44b0-be5c-2e63fc5867db","order_by":11,"name":"Hideaki Hasuo","email":"","orcid":"","institution":"Kansai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hideaki","middleName":"","lastName":"Hasuo","suffix":""},{"id":585800871,"identity":"e8c0ef1d-9437-4e22-8b68-3e9187b3ef77","order_by":12,"name":"Hiromichi Matsuoka","email":"","orcid":"","institution":"National Cancer Center Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hiromichi","middleName":"","lastName":"Matsuoka","suffix":""},{"id":585800872,"identity":"618e804f-c2ea-4ae9-b09f-bac882fafcca","order_by":13,"name":"Hironori Mawatari","email":"","orcid":"","institution":"Yokohama Minami Kyosai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hironori","middleName":"","lastName":"Mawatari","suffix":""},{"id":585800873,"identity":"57d16090-3071-4ae6-927f-d08f442cb05c","order_by":14,"name":"Yoshihisa Matsumoto","email":"","orcid":"","institution":"The Cancer Institute Hospital of Japanese Foundation for Cancer Research","correspondingAuthor":false,"prefix":"","firstName":"Yoshihisa","middleName":"","lastName":"Matsumoto","suffix":""},{"id":585800874,"identity":"28221e6f-1e4b-4163-8a6e-2dae655969b8","order_by":15,"name":"Akhila Reddy","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Akhila","middleName":"","lastName":"Reddy","suffix":""},{"id":585800875,"identity":"cf04a7a2-b4b2-4cef-8184-6bf785ea6c7b","order_by":16,"name":"Eriko Satomi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYPACCTkYi5kY5YwNQC3GJGthSGwg2kX8/IefP/iYY5G+nf3wA8YvFQzs5oS0SM5IM2ycuU0id2dPmgGzzBkGZktC9hncYDBs5gVq2XCDh4FZso2B2eAAAS32549/BGlJNyBaiwFDDtiWBJAWxo/EaJG4kVM4E+gXww1n0gwOM5yRIOwX/v7jGz583FYnb3D88MOHPypskgmGGAo4zMMgkWxAkhbGHwwMdqRpGQWjYBSMgpEAAOanPAS+76pBAAAAAElFTkSuQmCC","orcid":"","institution":"National Cancer Center Hospital","correspondingAuthor":true,"prefix":"","firstName":"Eriko","middleName":"","lastName":"Satomi","suffix":""}],"badges":[],"createdAt":"2025-11-27 01:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8216751/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8216751/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102210577,"identity":"57f2845f-04ee-472b-8d8e-72a97173db10","added_by":"auto","created_at":"2026-02-09 12:21:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":197719,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8216751/v1/0e6ccc81891fa9ad881d6e17.png"},{"id":103508024,"identity":"daf27870-37e1-4283-af8b-94da428ce656","added_by":"auto","created_at":"2026-02-26 13:46:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1032143,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8216751/v1/650a3137-39e7-441b-82d4-99dc2daa1ed0.pdf"},{"id":102210568,"identity":"07067e3c-8a87-4726-a8dc-1b2a14820d6b","added_by":"auto","created_at":"2026-02-09 12:21:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29205,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryinformation20251127.docx","url":"https://assets-eu.researchsquare.com/files/rs-8216751/v1/533e8a447f25340d459b1d56.docx"},{"id":102210595,"identity":"d7599c7c-a167-4055-beae-b1a7958dd64b","added_by":"auto","created_at":"2026-02-09 12:21:28","extension":"pptx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":60274,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryinformation20251127.pptx","url":"https://assets-eu.researchsquare.com/files/rs-8216751/v1/5edef7d1e1916d7801a7bf50.pptx"}],"financialInterests":"Competing interest reported. Dr. Yoshihisa Matsumoto received honoraria from Daiichi-Sankyo, Takeda Pharmaceutical, Shionogi, Kyowa Kirin, Teikoku Seiyaku, Terumo, and Hisamitsu Pharmaceutical.","formattedTitle":"\u003cp\u003eOpioid rotation and conversion ratios used by palliative physicians and pharmacists in Japan\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePain is one of the most common symptoms experienced by palliative care patients [1]. Opioids are the preferred drugs to treat pain in these patients [2]. When pain that remains uncontrolled despite opioid dose increase, a new strategy may be required, such as conversion from oral to intravenous (IV) route or rotation to another opioid [3]. Opioid rotation from one opioid to another can also be necessary when accumulation of opioid metabolites, leading to adverse effects such as excessive drowsiness, confusion, myoclonus and hallucinations [4]. Opioid rotation has been recognized as an important tool in pain management. To perform opioid rotation effectively and minimize adverse effects such as uncontrolled pain and accidental opioid overdose, it is crucial to use established opioid rotation ratios. However, there are several versions of equianalgesic tables using various opioid conversion ratios (CRs) and opioid rotation ratios (ORRs) and being used all around the world [5]. The use of several different CRs and ORRs for the opioid rotation may increase the risk for adverse effects [2].\u003c/p\u003e \u003cp\u003ePalliative care Emphasis program on symptom management and Assessment for Continuous medical Education (PEACE), a basic palliative care training program for medical professionals, was established in Japan in 2008. In accordance with the basic plan to promote cancer control programs in Japan, all cancer treatment cooperation centers designated by Ministry of Health, Labour and Welfare are required to hold standardized education programs as basic palliative care training for all medical professionals involved in cancer treatment [6]. These programs were developed by Japanese Society for Palliative Medicine and consists of seven lectures and group work, including a module on the assessment and treatment of cancer pain. By March 2025, this training program had been held 9,943 times nationwide, completed by 199,563 doctors and numerous other medical professionals such as nurses and pharmacists [7]. The educational materials on cancer pain used in these basic palliative care training introduce standardized CRs and ORRs. However, there has never been a nationwide survey on the ratios actually used in clinical practice. This study was conducted a cross-sectional survey to confirm the actual ratios in clinical practice in Japan.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study is a non-mandatory questionnaire survey targeting healthcare professionals to obtain their voluntary answers regarding the actual CRs and ORRs used in clinical practice. The study was approved by the Institutional Review Board of the National Cancer Center, Japan (6000-085). Formal approval of the study protocol by an ethics committee was not required according to the Japanese national policies. All procedures were performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003ePalliative care physicians and pharmacists willing to complete the survey clicked on the survey link, which displayed the questionnaire statement. Participants indicated their willingness to participate in the survey by completing and submitting the survey.\u003c/p\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003cp\u003eThe survey was composed of 31 questions and was developed by the study team who have expertise in opioid conversions and rotations, referencing the previous study [5] (\u003cb\u003eOnline Resource 1\u003c/b\u003e). The survey took approximately 5\u0026ndash;10 minutes to complete.\u003c/p\u003e \u003cp\u003e We conducted a cross-sectional survey among palliative care physicians and pharmacists in Japan between March 7th to 20th, 2024. An email with an embedded link was sent to members of the following three societies: Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer. At the time of survey administration, there were 1428-, 7405-, and 3052-members comprising physicians and pharmacists, respectively.\u003c/p\u003e \u003cp\u003eThe primary endpoint was to determine the CRs and ORRs used by palliative care physicians and pharmacists practicing in Japan, which were measured by Question 10 in the survey. CRs were estimated by Question 10.a to Question 10.d (between same opioids but different routes: from intravenous to oral). ORRs were estimated by Question 10.e to Question 10.n (between different opioids). The secondary endpoint was to determine if CRs and ORRs differ significantly according to demographics such as profession and practice type.\u003c/p\u003e \u003cp\u003eStatistical method\u003c/p\u003e \u003cp\u003eSurvey results were summarized using standard descriptive statistics and frequency tabulation. The CRs and ORRs were presented as median, interquartile range, and mode, overall and by groups. The differences in CRs and ORRs between or among groups were assessed using the Wilcoxon rank-sum test. The Smirnov-Grubbs test was applied as necessary. The collected data were analyzed using EZR (Saitama Medical Center, Jichi Medical University, Japan), a graphical user interface for R [8].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 433 responses were received. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the participant characteristics, work setting, and opioid availability. Among the participants, 295 (68.1%) were physicians and 138 (31.9%) were pharmacists, and 30.3% conducted\u0026thinsp;\u0026gt;\u0026thinsp;30 opioid rotations in the past 6 months. The median age of participants were 48 years (range 26\u0026ndash;74), and the median years of clinical experience was 22 years (range 2\u0026ndash;47), with 77.6% having more than 15 years. In Japan, tapentadol production was discontinued in 2024, and the number of medical institutions where it was available gradually decreased during this survey period.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e gives the median and mode of the opioid ratios obtained from all the participants. For most CRs and ORRs, values for the median, first quartile, third quartile, and mode were consistent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics and opioid availability (n\u0026thinsp;=\u0026thinsp;433)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevels\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years old)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003emedian 48 (26\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiscipline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYears of clinical experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003emedian 22 (2\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eWork setting\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInpatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutpatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospice /palliative care unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10ཞ30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003eOpioid availability\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntravenous morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFentanyl transdermal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntravenous fentanyl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral oxycodone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntravenous oxycodone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral hydromorphone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntravenous hydromorphone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral methadone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral tapentadol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eMore than one response allowed for this question.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpioid conversion and rotation ratios\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion or rotation type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMode\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR from IV to oral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR from IV to oral hydromorphone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR from IV to oral oxycodone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.33 (1.33, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from IV hydromorphone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (25, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from IV oxycodone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from oral hydromorphone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from oral oxycodone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from transdermal fentanyl 25 mcg/hour to MEDD (mg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (60, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from MEDD 100mg to transdermal fentanyl mcg/hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.6 (41.6, 41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from IV morphine (mg) to IV fentanyl (mcg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (20, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from IV fentanyl 30 mcg to IV morphine (mg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eORR from oral tapentadol 5mg to oral oxycodone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCR, concersion ratio for changing the route of opioid administration; ORR, opioid rotation ratio for rotation from one opioid to another; IV, intravenous; MEDD, morphine equivalent daily dose; IQR, interquartile range; mcg, micrograms; mg, milligrams.\u003c/p\u003e \u003cp\u003eThere were no differences in the median opioid ratios involving morphine, hydromorphone and oxycodone among groups of professions and number of opioid rotations in the past 6 months, as given in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eto\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In this CRs and ORRs, almost all values for the median, first quartile, third quartile and mode were also consistent. CRs and ORRs were distributed with little variation as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cb\u003eOnline Resource 2\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThere were significant differences in the ORRs involving IV fentanyl, as given in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Although the medians were the same for all groups regarding profession, opioid rotation frequency, years of clinical experience and specialty, significance differences were observed in the two rotation ratios from IV morphine to IV fentanyl and from IV fentanyl to IV morphine.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpioid conversion ratios\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSub level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCR from IV to oral morphine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCR from IV to oral hydromorphone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (4, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCR from IV to oral oxycodone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33 (1.33, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33 (1.33, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33 (1.33, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.866\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33 (1.33, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpioid rotation ratios involving oxycodone and hydromorphone\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSub level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from oral oxycodone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from IV oxycodone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from oral tapentadol 5mg to oral oxycodone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from IV hydromorphone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (20, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (25, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (20, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (25, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from oral hydromorphone to oral morphine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOpioid rotation ratios involving transdermal and intravenous fentanyl\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSublevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from transdermal fentanyl 25 mcg/hr to MEDD (mg)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (60, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (60, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (60, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (60, 60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from MEDD 100mg to transdermal fentanyl (mcg/hr)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.6 (41.6, 41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.433\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.6 (41.6, 41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.6 (41.6, 41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.396\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.6 (41.6, 41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR from IV morphine (mg) to IV fentanyl (mcg) (n\u0026thinsp;=\u0026thinsp;350) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.639\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears of clinical experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.395\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (20, 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eORR form IV fentanyl 30 mcg to IV morphine (mg) (n\u0026thinsp;=\u0026thinsp;375) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of opioid rotations performed in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears of clinical experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5 (1.5, 1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eOutliers were removed using the Smirnov-Grubbs test.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first nationwide survey targeting physicians and pharmacists regarding CRs and ORRs in Japan. The CRs and ORRs used by Japanese physicians and pharmacists involved in palliative care were consistent for most kinds of opioids. However, variations were observed for IV fentanyl, which differed according to profession, opioid rotation frequency, years of clinical experience and specialty.\u003c/p\u003e \u003cp\u003eMost CRs and ORRs in this survey were consistent, with median, interquartile range, and mode having the same values. Meanwhile, international guidelines indicated that the only agreed CR was oxycodone, revealing inconsistencies internationally [9]. There were no agreed CRs or ORRs for fentanyl.\u003c/p\u003e \u003cp\u003eIn Japan, the PEACE project, a basic palliative care training program for all doctors involved in cancer treatment, was began in 2008. By March 2025, over 190,000 doctors had completed the program. The CRs and ORRs provided in its educational materials (\u003cb\u003eOnline Resource 3\u003c/b\u003e) have become widely adopted throughout Japan. Therefore, the CRs and ORRs have stabilized at consistent tendencies.\u003c/p\u003e \u003cp\u003eThe ORRs of IV fentanyl were considered to be more prone for miscalculations than other opioids and analyzed excluding outliers in this study. Nevertheless, there were significant difference between groups accoding to profession and opioid rotation frequency in ORRs of IV fentanyl. Furthermore, additional groups based on years of clinical experience and specialty were included, and there were also significant differences in most groups. The groups of clinical experience were divided into two based on 2008, the year the PEACE project training program began. Thus, participation in the palliative care education program would influence the variation in ORRs of IV fentanyl.\u003c/p\u003e \u003cp\u003eThe CRs and ORRs used in Japan were partially similar to those used abroad such as ORR from oral morphine to oral oxycodone and ORR from oral morphine to oral hydromorphone, but partially different. In the international CR consencus, CR from oral oxycodone to IV oxycodone was 2:1 (88% of agreement), while 4:3 was used in Japan, as shown in the results of this study [10, 11]. Additionally, the following two CRs did not reached consensus internationally: CR from oral morphine to IV morphine was 2.5:1 (55.2% of agreement) and CR from oral hydromorphone to IV hydromorphone was 2.5:1 (63.8% of agreement) [9, 12, 13]. In Japan, the CRs were generally used 2:1 and 5:1, respectively [14, 15]. In most Western countries, the ratio used from IV to oral hydromorphone is 2:1, whereas the ratios of 5:1 and 4:1 are more likely to use in Japan and Australia [16]. Similar to IV fentanyl, where ratios differ between 10 and 20 when rotating to IV morphine [17]. These would be due to racial differences, such as physiques and metabolic enzymes [18].\u003c/p\u003e \u003cp\u003e In actual clinical practice, CRs and ORRs are merely guidelines, and it is recommended to prescribe opioids considering the condition and background of each patient. The ratios in this survey were not based on the condition of patients [9]. Further research on CRs and ORRs under patients\u0026lsquo; different conditions could provide additional insights into trends and characteristics.\u003c/p\u003e \u003cp\u003eThis study had several limitations. As this was a web-based survey, there were possibilities that other disciplines other than physicians and pharmacist taking the survey and participants taking the survey more than once. It was difficult to verify the accuracy of participants\u0026lsquo; profession and opioid rotation frequency. Furthermore, the results may not fully reflect the overall population due to the low percent of responses to the survey.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere was greater consistency in the CRs and ORRs used by physicians and pharmacists in palliative care in Japan compared to other countries. This would suggest that education on the ratios is well established for medical professionals in Japan.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe, authors would like to thank members of Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer, for their cooperation in the questionnaire survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Health Labor Sciences Research Grant (Grant numbers [22EA1004]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial interests: Author RN, HI, DT, AO, NK, MY, KI, MA, TT, SY, EK, HH, HM, HM, AR and ES declare they have no financial interests. Dr. YM received honoraria from Daiichi-Sankyo, Takeda Pharmaceutical, Shionogi, Kyowa Kirin, Teikoku Seiyaku, Terumo, and Hisamitsu Pharmaceutical.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Rumi Nishimura and Eriko Satomi. The first draft of the manuscript was written by Rumi Nishimura and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a non-mandatory questionnaire survey targeting healthcare professionals. The study was approved by the Institutional Review Board of the National Cancer Center, Japan (6000-085). Formal approval of the study protocol by an ethics committee was not required according to the Japanese national policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSolano JP, Gomes B, Higginson IJ (2006) A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 31(1):58-69. https://doi: 10.1016/j.jpainsymman.2005.06.007.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (2018) WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva, Switzerland. https://iris.who.int/server/api/core/bitstreams/809a021b-e75c-4f9c-b002-6fb13bf1a0f5/content\u003c/li\u003e\n\u003cli\u003eSchuster M, Bayer O, Heid F, Laufenberg-Feldmann R (2018) Opioid Rotation in Cancer Pain Treatment. Dtsch Arztebl Int 115(9):135-142. doi: 10.3238/arztebl.2018.0135\u003c/li\u003e\n\u003cli\u003eLotsch J (2005) Opioid metabolites. J Pain Symptom Manage 29(5 Suppl): S10-24. doi: 10.1016/j.jpainsymman.2005.01.004.\u003c/li\u003e\n\u003cli\u003eReddy A, Sinclair C, Crawford GB, McPherson ML, Mercadante S, Hui D, Haider A, Arthur J, Tanco K, Dalal S, Dev R, Amaram-Davila J, Adile C, Liu D, Schuler U, Jammi S, Shelal Z, Del Fabbro E, Davis M, Bruera E (2022) Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey. J Palliat Med 25(10):1557-1562. https://doi: 10.1089/jpm.2022.0266\u003c/li\u003e\n\u003cli\u003eMinistry of Health, Labour and Welfare (2008) Guidelines for conducting palliative care training programs for physicians involved in cancer treatment. Ministry of Health, Labour and Welfare. https://www.mhlw.go.jp/web/t_doc?dataId=00tb5159\u0026amp;dataType=1\u0026amp;pageNo=1) Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003ePEACE project (2025) Completers of palliative care training. Japanese Society for Palliative Medicine. https://www.kanwacare.net/jspm-peace/.assets/5_syuryo_r7.pdf Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eKanda Y (2013) Investigation of the freely-available easy-to-use software \u0026ldquo;EZR\u0026rdquo; (Easy R) for medical statistics. Bone Marrow Transplant 48,452-458. https://doi: 10.1038/bmt.2012.244\u003c/li\u003e\n\u003cli\u003eDavis MP, Davies A, McPherson ML, Reddy AS, Paice JA, Roeland EJ, Walsh D, Mercadante S, Case AA, Arnold RM, Satomi E, Crawford G, Bruera E, Bohlke K, Ripamonti C (2025) Opioid conversion in adults with cancer: MASCC-ASCO-AAHPM-HPNA-NICSO guideline. Support Care Cancer 33(3):243. https://doi: 10.1007/s00520-025-09286-z.\u003c/li\u003e\n\u003cli\u003eThe Food and Drug Administration (2023) The label for oxycontin\u0026reg;. Drugs@FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/022272s048lbl.pdf Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eDaiichi Sankyo, Inc. (2025) The label for oxycodone injection. Pharmaceuticals and Medical Devices Agency. https://www.pmda.go.jp/PmdaSearch/iyakuDetail/ResultDataSetPDF/430574_8119400A1033_2_01 Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eThe Food and Drug Administration (2023) The label for morphine sulfate injection. Drugs@FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/202515s037lbl.pdf Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eThe Food and Drug Administration (2023) The label for hydromorphone hydrochloride injection. Drugs@FDA https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/200403s048lbl.pdf Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eShionogi \u0026amp; Co., Ltd. (2024) The label for morphine hydrochloride injection. Pharmaceuticals and Medical Devices Agency. https://www.pmda.go.jp/PmdaSearch/iyakuDetail/ResultDataSetPDF/343018_8114401A1112_2_06 Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eDaiichi Sankyo, Inc. (2025) The label for naruvein\u0026reg; injection. Pharmaceuticals and Medical Devices Agency. https://www.pmda.go.jp/PmdaSearch/iyakuDetail/ResultDataSetPDF/430574_8119401A1020_2_01 Accessed 27 November 2025\u003c/li\u003e\n\u003cli\u003eReddy 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 KH, Wu J, Liu D, Williams J, Yennurajalingam S, Bruera E (2017) The Conversion Ratio From Intravenous Hydromorphone to Oral Opioids in Cancer Patients. J Pain Symptom Manage. 54(3):280-288. http://doi: 10.1016/j.jpainsymman.2017.07.001.\u003c/li\u003e\n\u003cli\u003eDavis MP, Davies A, McPherson ML, Reddy A, Paice JA, Roeland E, Walsh D, Mercadante S, Case A, Arnold R, Satomi E, Crawford G, Bruera E, Ripamonti C (2024) Opioid analgesic dose and route conversion ratio studies: a scoping review to inform an eDelphi guideline. Support Care Cancer. 32(8):542. http://doi: 10.1007/s00520-024-08710-0. (Erratum in: Support Care Cancer. 2024. 20;32(9):596. http://doi: 10.1007/s00520-024-08820-9) \u003c/li\u003e\n\u003cli\u003eMyrand SP, Sekiguchi K, Man MZ, Lin X, Tzeng RY, Teng CH, Hee B, Garrett M, Kikkawa H, Lin CY, Eddy SM, Dostalik J, Mount J, Azuma J, Fujio Y, Jang IJ, Shin SG, Bleavins MR, Williams JA, Paulauskis JD, Wilner KD (2008) Pharmacokinetics/genotype associations for major cytochrome P450 enzymes in native and first- and third-generation Japanese populations: comparison with Korean, Chinese, and Caucasian populations. Clin Pharmacol Ther. 84(3):347-61.http://doi: 10.1038/sj.clpt.6100482.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Opioid, opioid conversion, opioid rotation, opioid conversion ratio, opioid rotation ratio, opioid switching","lastPublishedDoi":"10.21203/rs.3.rs-8216751/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8216751/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study was conducted to confirm the actual opioid conversion ratios (CRs) and opioid rotation ratios (ORRs) in clinical practice in Japan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A cross-sectional survey was conducted between March 7th to 20th, 2024, targeting palliative care physicians and pharmacists in the following three societies: Japanese Society for Palliative Medicine, Japanese Society for Pharmaceutical Palliative Care and Sciences, and Japanese Association of Supportive Care in Cancer. The primary endpoint was to determine the CRs and ORRs used by participants, which were measured in the survey.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e433 responses (68.1% physicians and 31.9% pharmacists) were received. 30.3% conducted\u0026thinsp;\u0026gt;\u0026thinsp;30 opioid rotations in the past 6 months. For most CRs and ORRs obtained from all the participants, values for the median, first quartile, third quartile, and mode were consistent. Among groups of professions and number of opioid rotations frequency, there were no differences in the median opioid ratios involving morphine, hydromorphone and oxycodone. However, there were significant differences in the ORRs involving intravenous (IV) fentanyl, specifically in the rotation ratios between IV fentanyl and IV morphine.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere was great consistency in the CRs and ORRs used by physicians and pharmacists in palliative care in Japan. This would suggest that education on the ratios is well established for medical professionals in Japan.\u003c/p\u003e","manuscriptTitle":"Opioid rotation and conversion ratios used by palliative physicians and pharmacists in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 12:21:18","doi":"10.21203/rs.3.rs-8216751/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b38d6bbc-c9b5-4571-b12f-634dceb788b0","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-26T09:12:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 12:21:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8216751","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8216751","identity":"rs-8216751","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}