MEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111

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1 POLICY: Medicare Part D Formulary-Level Cumulative Opioid and Opioid/Buprenorphine POS Edits MEDICARE Program Policies & Procedures POLICY NUMBER: Medicare D-111 Policy for contracts H3351, S3521 and H3335 P&T Committee Approval Date: 3/1/2018 Page 1 of 21 Original Effective Date: 01/01/2017 Current Effective Date: 3/1/2018 Revision Date: 1/1/2019 Sponsor Name & Title: Darlene Rocco, Director Pharmacy Management Signature: Approval Name & Title: Mona Chitre Vice President Pharmacy Management Signature: In the CMS Final Call Letter for CY2017, CMS outlined the expectation of Plan Sponsors to implement the following POS edits beginning 1/1/2017: Formulary-level hard or soft cumulative opioid POS edit Soft edit requirements: 90mg-120mgMED (morphine-equivalent dosing that can be overridden by the pharmacist using appropriate NCPDP codes Hard edit requirements: 200mg MED that cannot be overridden by the pharmacist using a NCPDP code Plans may incorporate a provider or pharmacy count in the edit. CMS recommends a minimum threshold of two prescribers if this functionality utilized. Individual quantity limits for opioids were not submitted to CMS for CY2017 in order to minimize the confusion with the MED requirement. Soft edit for concurrent use of opioids and buprenorphine. Soft edit triggers when an opioid prescription is presented following the initiation of buprenorphine for the treatment of opioid-use disorder. This is a soft edit that can be overridden by the pharmacist using appropriate NCPDP codes. 12 The Health Plan has experience with this methodology on the commercial/medicaid/exchange lines of business. PBM support: ESI participated in the 2015 pilot project intended to evaluate the feasibility and impact of the proposed POS edits ESI applied the formulary-level opioid requirement using the hard opioid POS edit for CY2017. ESI applied the soft edit requirement for concurrent opioids/buprenorphine for CY2017. A prescriber bypass list was also implemented for 1/1/2017 to prevent inappropriate rejections for members in hospice or palliative care or who have a cancer diagnosis. The prescription adjudication system reviews medical and prescription claims history to identify drugs or ICD-10 codes reflective of a cancer diagnosis. If a cancer drug or diagnosis found, the claim will pay without intervention. 1

2 Formulary-level opioid review criteria: All opioids (other than buprenorphine SL), included in OPIOID DRUGS INCLUDED IN POS EDIT CHART on page 3: 1. Is patient enrolled in a hospice program? a. If yes, submit to Medicare Part A. Refer to the Medicare D-Hospice DLP (DLP009). b. If no, continue with the criteria below 2. Patient has been diagnosed with cancer and appropriate pain management requires dosing that exceeds the restricted amount. Authorize a quantity limit override for 12 months. 3. Patient has a terminal illness and appropriate pain management requires dosing that exceeds the restricted amount. Authorize a quantity limit override for 12 months. 4. The prescriber states based on the patient s clinical circumstances that the amount of opioid prescribed is warranted in order to adequately manage the patient s pain. Authorize a quantity limit override for 12 months. For Buprenorphine Sublingual ONLY, included in OPIOID DRUGS INCLUDED IN POS EDIT CHART on page 3: 1. Buprenorphine SL is being used as maintenance opioid dependency. Authorize a quantity limit override for 12 months. Note: Belbuca is only indicated for pain management, not opioid dependency. 2. Is patient being enrolled in a hospice program? a. If yes, submit to Medicare Part A. Refer to the Medicare D-Hospice DLP (DLP009). b. If no, continue with the criteria below 3. Patient has been diagnosed with cancer and appropriate pain management requires dosing that exceeds the restricted amount. Authorize a quantity limit override for 12 months. 4. Patient has a terminal illness and appropriate pain management requires dosing that exceeds the restricted amount. Authorize a quantity limit override for 12 months. 5. The prescriber states based on the patient s clinical circumstances that the amount of opioid prescribed is warranted in order to adequately manage the patient s pain. Authorize a quantity limit override for 12 months. Background: The Centers for Medicare & Medicaid Services (CMS) published a pilot study in the September 6, 2012 memo Supplemental Guidance related to Improving Drug Utilization Review Controls in Part D in which they identified a methodology for establishing a threshold for high use of opioids based on morphine equivalent dose (MED). 1 This pilot study was conducted in the context of establishing a targeted population for reducing fraud, waste and abuse for opioids in the Medicare Part D program. Each opioid claim was converted to a daily oral morphine equivalent dose (MED) using the corresponding MED conversion factor based on the Consortium to Study Opioid Risks and Therapeutics (CONSORT) classification of opioid medications and morphine equivalent conversion factors per milligram of opioid. CMS believes the use of daily 120 mg MED (MED 120) calculations as a screening tool may help identify beneficiaries who are at risk for potential adverse effects or possible inappropriate use or diversion of opioids. 1 To identify beneficiaries with prescription opioids that exceeded the MED threshold, each claim is converted into the MED with the appropriate conversion factor (Table 1) associated with the opioid product of that prescription claim. 1 CMS determined a threshold MED of 120 mg/day as a result of a study that showed 100 mg or more per day MED had a 9-fold increase in overdose risk. Most overdoses were medically serious, and 12% were fatal. 1 Based on an analysis of ESI s Medicare prescription data, a cumulative threshold MED of 200 mg/day was determined to meet the intent of the QL with consideration to member impact. CMS published a table from the CONSORT trial that provided conversion factors per mg of opioid in the September 2012 supplemental guide for oral opioids. 1,5 In July 2013, the CDC published a new list of opiates conversions that included newer opiates, injectables and suppositories. Table 1 contains conversion factors for opiates for the dosage form listed to oral morphine as determined from CMS, the CDC list, additional personal communication with the CDC (Chris Jones, CDC, October 21, 2013) and the literature. 2

3 OPIOID DRUGS INCLUDED IN POS EDIT: BUPRENORPHINE TRANSDERMAL BUPRENORPHINE INJECTION BUPRENORPHINE SUBLINGUAL (TABLET AND FILM) BUTORPHANOL INJECTION BUTORPHANOL NASAL SOLUTION CODEINE PHOSPHATE INJECTION CODEINE SULFATE TABLETS CAPSULES AND SOLUTION DIHYDROCODEINE TABLETS, CAPSULES AND SOLUTION FENTANYL CITRATE TRANSMUCOSAL LOZENGES FENTANYL CITRATE BUCCAL TABLETS FENTANYL CITRATE NASAL SOLUTION FENTANYL CITRATE SUBLINGUAL SPRAY FENTANYL CITRATE SUBLINGUAL TABLET FENTANYL INJECTION FENTANYL TRANSDERMAL PATCHES TABLETS AND SOLUTION HYDROMORPHONE INJECTION HYDROMORPHONE TABLETS AND SOLUTION HYDROMORPHONE RECTAL LEVORPHANOL MEPERIDINE TABLETS, AND SOLUTION MEPERIDINE INJECTION METHADONE INJECTION METHADONE TABLETS AND SOLUTION TABLETS, CAPSULES AND SOLUTION INJECTION RECTAL NALBUPHINE INJECTION TABLETS, CAPSULES AND SOLUTION OXYMORPHONE TABLETS PENTAZOCINE INJECTION PENTAZOCINE CONTAINING TABLETS TAPENTADOL TABLETS TRAMADOL TABLETS, CAPSULES AND SOLUTION /NALOXONE EXTENDED RELEASE TABLETS 3

4 Table 1 Morphine equivalent conversion factors per milligram of opioid 1 OPIATE ROUTE OF ADMINISTR ATION EQUIVALENT CONVERSION FACTOR PER MG OF OPIOID Buprenorphine Transdermal 12.6 ( converting from mcg/hr for 7 days) See Table 3 Buprenorphine Injection 75 2,8 Buprenorphine± film SL/Buccal 10-75± (CMS recommends 10) Butorphanol* Injection 15 9,11 Butorphanol nasal solution* Nasal 15 9,11 Codeine phosphate Injection Codeine sulfate Oral ,5,6 Dihydrocodeine Oral ,5,6 Fentanyl citrate lozenge (Actiq,generics) Transmucos al Fentanyl citrate (Fentora) Buccal Tab Fentanyl nasal solution (Lazanda) Nasal Fentanyl spray (Subsys) SL Fentanyl tablet (Abstral) SL Fentanyl Injection Fentanyl Transdermal 100 (or 7.2 when converting from mcg/hr for 3 days) See Table 2 Hydrocodone Oral 1 1,5,6 Hydromorphone Injection Hydromorphone Oral 4 1 Hydromorphone Rectal 4 2 Levorphanol Oral 11 1 Meperidine Injection Meperidine Oral Methadone:^ > 0 to 20 mg daily dose Methadone:^ > 20 to 40 mg daily dose Oral, Injection Oral, Injection 4 REF 3 2,3,4 1,

5 OPIATE Methadone:^ > 40 to 60 mg daily dose Methadone:^ > 60 mg daily dose ROUTE OF ADMINISTR ATION Oral, Injection Oral, Injection EQUIVALENT CONVERSION FACTOR PER MG OF OPIOID REF Morphine Injection 3 2 Morphine Oral 1 1,4 Morphine Rectal 1 2 Nalbuphine Injection 3 8 Oxycodone HCL Oral Oxycodone (Xtampza Oral 1.67 # Oxymorphone injection Oxymorphone Oral 3 1 Pentazocine Injection ,4 Pentazocine /acetaminophen Oral ,4 Tapentadol Oral 0.4 2,3,9 Tramadol Oral 0.1 3,4 ± CDC confirmation requested 11_15_13 * based on product labeling, differs from CDC recommendation of 7 all injection routes (IV/IM/SC/epidural) per CMS Medication list #conversion factor based on oxycodone equivalent per mg Xtampza ER product. ^ The CDC MME conversion factor to calculate morphine milligram equivalents is 3. CMS uses this conversion factor when analyzing Medicare population opioid use. CMS uses the graduated methadone MME conversion factor to calculate MME within the Overutilization Monitoring System (OMS) for identifying and reporting potential opioid overutilizers. 5

6 METHOD FOR CALCULATION OF THE CUMULATIVE DAILY EQUIVALENT DOSE (MED) The cumulative daily MED correlates with the risk of dose-related morbidity and mortality. The general algorithm used to determine the daily MED is as follows: 1. # of Opioid Dosage units per day is calculated as follows= (Opioid claim quantity) (Opioid claim days supply) 2. Oral MED Daily Dose per claim = (# Opioid Dosage Units per day) X (#mg Opioid per dosage unit) X (MED conversion factor) 3. Cumulative MED: Oral MED daily dose per claim for all opiates received A MED is calculated for each members opioid prescription claim using the appropriate conversion factor associated with the opioid product for the claim. After converting the member s opioid medications to their MED, a beneficiary s cumulative prescription opioid daily dose (MED) is calculated using the above algorithm to determine if he/she exceeded the 200 MED threshold. A prescription will reject at POS that, if filled, would cause the member to exceed the cumulative daily MED threshold of 200. The Center for Disease Control and Prevention (CDC) Morphine Milligram Equivalent Table, released in May 2014, specifically excludes all opioid cough and cold products from the calculations of MED. CMS states that testing confirms that the removal of these products does not significantly impact the identification of potential opioid overutilization. 3 Table 4 contains product specific quantity level limits-meqd 200 per 30 days for the individual chemical entity. The QL in Table 4 would equal the member s cumulative quantity level limits-meqd 200 per 30 days only if the member was not receiving multiple opioid prescriptions. TRANSDERMAL FENTANYL AND BUPRENORPHINE MED CONVERSION Typically, patients will be prescribed a Fentanyl or Buprenorphine patch for use every three (3) or seven (7) days, respectively. However, the timeframe for a patch may vary depending upon the doctor s instructions. Therefore, even though the duration of use of each patch may be prescribed for less than the typical number of days, the quantity of medication a patient receives each day remains constant. Table 2 contains the mg opioid per dosage unit, the MED conversion factor, the approximate MED, MEqD day and 90 day QL for transdermal fentanyl and Table 3 contains the same information for transdermal buprenorphine. Buprenorphine and fentanyl transdermal patches are expected to remain in place for 7 and 3 days, respectively, which is taken into account when calculating the MEqD day QL. Table 2: Transdermal Fentanyl MED conversion Dose Mg Opioid/ Dosage Unit for 3 days (FROM CMS) MED Conversion Factor (CMS) MED conversion Mcg/hr (CDC) MED MEqD day QL (Patche s) MEqD day QL (Patches) 12 mcg/hr mcg/hr mcg/hr mcg/hr mcg/hr mcg/hr mcg/hr mcg/hr For example, the MED calculated for a prescription written for Fentanyl 25 mcg/hr #10 patches for a 30-day supply would be calculated as follows: # opioid dosage units per day= 1/3 or Oral MED (CDC)= X 7.2 X 25= 60 6

7 Table 3: Transdermal Buprenorphine MED conversion Dosage Form Mg Opioid/ Dosage Unit (for 7 days) MG Opioid per day MED Conversion Factor (from CDC accounting for mcg/hr Q7 day use) 3 Approximate MED based on CDC conversion factor MEqD day QLL based on CDC conversion factor (Patches) 5 mcg/hr mcg/hr mcg/hr mcg/hr mcg/hr For example, the MED calculated for a prescription written for Butrans 10 mcg/hr #4 for a day supply would be calculated as follows: a. # opioid dosage units per day= 1/7 or b. Oral MED= 10 X 12.6 X 0.142=18 c. 200/18 *4=45 (rounded) The CDC supplied a conversion factor for buprenorphine of 42 and then clarified the conversion factor to 12.6 in a subsequent communication to the plan sponsors (July 11, 2014). This conversion factor is very conservative compared with other sources citing a conversion of , thus the MEqD day QL is higher than most patients would be expected to receive. 2,3 MEqD 200 is rounded up to the nearest whole number for the patches. The Prescription Drug Monitoring Program (PDMP), US Department of Justice, published the following regarding MEqD calculations with claims data for transdermal fentanyl and buprenorphine: 10 Fentanyl and Buprenorphine patches are two (2) important exceptions to using the CMS formula to compute MMEs. The exception only applies to the Fentanyl and Buprenorphine patches; not the other dosage forms of either medication. Consequently, a standard has been established to account for possible variances in the length of time a patch is worn. The standard is based on the length of time a patient would normally be using the patch: three (3) days for Fentanyl and seven (7) days for Buprenorphine. In order for the formula to work properly and compute the MME accurately, the Days Supply value should be changed to equal three (3) times the quantity for Fentanyl patches and seven (7) times the quantity for Buprenorphine patches; regardless of the Days Supply value written on the prescription. EXAMPLE: 10 Fentanyl patches are prescribed for twenty (20) days. Since a Fentanyl patch is typically used for three (3) days, the Days Supply value should be thirty (30) for computing the MME. (drug strength)*(drug quantity)*(mme Conversion factor) (days supply) 7

8 OPIOID PRODUCT NAME ROUTE DOSAGE FORM 8 DOSAGE Unit STRENGTH (MG OPIOID PER DOSAGE UNIT) STRENGTH UNIT MME CONVERSION FACTOR (CF) MED 200 CALCULATION (200/[CF X MG]) X 30 PRODUCT- SPECIFIC, NON- CUMULATIVE CODEINE ACETAMINOPHEN / BUTALBITAL / CAFFEINE CAPSULE CA 30 MG / CODEINE PHOSPHATE DIHYDROCODEINE ACETAMINOPHEN / CAFFEINE / CAPSULE CA 16 MG DIHYDROCODEINE BITARTRATE DIHYDROCODEINE ACETAMINOPHEN / CAFFEINE / TABLET EA 32 MG DIHYDROCODEINE BITARTRATE CODEINE ACETAMINOPHEN / CODEINE PHOSPHATE SUSPENSION ML 2.4 MG/ML CODEINE ACETAMINOPHEN / CODEINE PHOSPHATE TABLET EA 15 MG CODEINE ACETAMINOPHEN / CODEINE PHOSPHATE TABLET TA 30 MG CODEINE ACETAMINOPHEN / CODEINE PHOSPHATE TABLET TA 60 MG ACETAMINOPHEN / BITARTRATE SOLUTION, ML 0.5 MG/ML ACETAMINOPHEN / SOLUTION ML MG/ML BITARTRATE ACETAMINOPHEN / TABLET EA 2.5 MG BITARTRATE ACETAMINOPHEN / TABLET TA 5 MG BITARTRATE ACETAMINOPHEN / TABLET TA 7.5 MG BITARTRATE ACETAMINOPHEN / TABLET TA 10 MG BITARTRATE ACETAMINOPHEN / SOLUTION ML 1 MG/ML HYDROCHLORIDE ACETAMINOPHEN / TABLET TA 2.5 MG HYDROCHLORIDE ACETAMINOPHEN / TABLET TA 5 MG HYDROCHLORIDE ACETAMINOPHEN / TABLET TA 7.5 MG HYDROCHLORIDE ACETAMINOPHEN / EXTENDED RELEASE TA 7.5 MG HYDROCHLORIDE EXTENDED RELEASE TABLETS (XARTEMIS) (BIPHASIC RELEASE) TABLET ACETAMINOPHEN / TABLET TA 10 MG HYDROCHLORIDE PENTAZOCINE ACETAMINOPHEN / PENTAZOCINE TABLET TA 25 MG HYDROCHLORIDE TRAMADOL ACETAMINOPHEN / TRAMADOL TABLET TA 37.5 MG HYDROCHLORIDE CODEINE ASPIRIN / BUTALBITAL / CAFFEINE / CAPSULE CA 30 MG CODEINE PHOSPHATE DIHYDROCODEINE ASPIRIN / CAFFEINE / DIHYDROCODEINE CAPSULE CA 16 MG BITARTRATE ASPIRIN/CARISOPRODOL/CODEINE TABLET TA 16 MG ASPIRIN / HYDROCHLORIDE TABLET EA MG

9 BUPRENORPHINE BUPRENORPHINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY (EXPECTED TO REMAIN IN PLACE FOR 7 DAYS) BUPRENORPHINE BUPRENORPHINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY (EXPECTED TO REMAIN IN PLACE FOR 7 DAYS) BUPRENORPHINE BUPRENORPHINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY (EXPECTED TO REMAIN IN PLACE FOR 7 DAYS) BUPRENORPHINE BUPRENORPHINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY (EXPECTED TO REMAIN IN PLACE FOR 7 DAYS) BUPRENORPHINE BUPRENORPHINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY (EXPECTED TO REMAIN IN PLACE FOR 7 DAYS) TD 5 MCG/HR TD 7.5 MCG/HR TD 10 MCG/HR TD 15 MCG/HR TD 20 MCG/HR BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 75 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 150 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 300 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 450 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 600 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 750 MCG BUPRENORPHINE BUPRENORPHINE HYDROCHLORIDE SUBLINGUAL FILM TABLET, SUBLINGUAL TA 900 MCG BUPRENORPHINE BUPRENORPHINE INJECTION SYRINGE ML 0.3 MG/ML BUPRENORPHINE BUPRENORPHINE INJECTION AMPULE ML 0.3 MG/ML BUTORPHANOL BUTORPHANOL TARTRATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) BUTORPHANOL BUTORPHANOL TARTRATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) ML 1 MG/ML ML 2 MG/ML BUTORPHANOL BUTORPHANOL TARTRATE NASAL SOLUTION ML 10 MG/ML CODEINE CODEINE SULFATE SOLUTION, ML 6 MG/ML CODEINE CODEINE SULFATE TABLET EA 15 MG CODEINE CODEINE SULFATE TABLET EA 30 MG CODEINE CODEINE SULFATE TABLET TA 60 MG CODEINE CODEINE PHOSPHATE INJECTION SOLUTION ML 15 MG/ML CODEINE CODEINE PHOSPHATE INJECTION SOLUTION ML 30 MG/ML FENTANYL FENTANYL INJECTION SOLUTION ML 0.05 MG/ML

10 FENTANYL FENTANYL INJECTION SOLUTION ML 0.01 MG/ML FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS FENTANYL FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS TD 12 MCG/HR TD 25 MCG/HR TD 37.5 MCG/HR TD 50 MCG/HR TD 62.5 MCG/HR TD 75 MCG/HR TD 87.5 MCG/HR TD 100 MCG/HR FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 100 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 200 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 400 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 600 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 800 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 1200 MCG FENTANYL FENTANYL (SUBSYS) SUBLINGUAL LIQUID EA 1600 MCG FENTANYL FENTANYL CITRATE (LAZANDA) NASAL SOLUTION EA 100 MCG FENTANYL FENTANYL CITRATE (LAZANDA) NASAL SOLUTION EA 300 MCG FENTANYL FENTANYL CITRATE (LAZANDA) NASAL SOLUTION EA 400 MCG FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 100 MCG FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 200 MCG FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 300 MCG FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 400 MCG

11 FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 600 MCG FENTANYL FENTANYL CITRATE (FENTORA) BUCCAL TABLET, EFFERVESCENT TA 800 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 100 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 200 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 300 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 400 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 600 MCG FENTANYL FENTANYL CITRATE (ABSTRAL) SUBLINGUAL TABLET SUBLINGUAL EA 800 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 200 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 400 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 600 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 800 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 1200 MCG FENTANYL FENTANYL CITRATE (ACTIQ, GENERICS) BUCCAL LOZENGE ON A HANDLE EA 1600 MCG BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (ZOHYDRO) BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA BITARTRATE EXTENDED RELEASE (HYSINGLA TABLET EA 10 MG TABLET EA 15 MG TABLET EA 20 MG TABLET EA 30 MG TABLET EA 40 MG TABLET EA 50 MG TABLET EA 100 MG 1 60 TABLET EA 120 MG 1 50 TABLET EA 20 MG TABLET EA 30 MG TABLET EA 40 MG TABLET EA 60 MG TABLET EA 80 MG

12 / IBUPROFEN TABLET TA 2.5 MG / IBUPROFEN TABLET TA 5 MG / IBUPROFEN TABLET TA 7.5 MG / IBUPROFEN TABLET TA 10 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE INJECTION SOLUTION ML 1 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE TABLET TA 2 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE LIQUID ML 1 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE INJECTION SOLUTION AND AMPULE ML 2 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE RECTAL SUPPOSITORY EA 3 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE TABLET TA 4 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE TABLET TA 8 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE INJECTION SOLUTION AND AMPULE ML 4 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE INJECTION SOLUTION ML 10 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE (EXALGO, GENERIC) HYDROMORPHONE HYDROCHLORIDE (EXALGO, GENERIC) TABLET, EXTENDED RELEASE 24 HR TABLET, EXTENDED RELEASE 24 HR TA 8 MG TA 12 MG HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 16 MG (EXALGO, GENERIC) 24 HR HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE TABLET EXTENDED RELEASE EA 32 MG (EXALGO, GENERIC) 24 HR HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE / EPIDURAL PLASTIC BAG, INJECTION (ML) ML 0.02 MG/ML BUPIVACAINE HYDROCHLORIDE IN 0.9% SODIUM CHLORIDE / PF HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE / PF INJECTION AMPULE ML 1 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE / PF INJECTION AMPULE ML 2 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE / PF INJECTION AMPULE ML 4 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE / PF INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 INTRAVENOUS PATIENT CONTROLLED % SODIUM CHLORIDE ANALGESIA VIAL HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE ML 10 MG/ML ML 0.1 MG/ML INTRAVENOUS PREFILLED PUMP RESERVOIR ML 0.2 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL ML 0.4 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL ML 0.5 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL ML 0.6 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INJECTION PLASTIC BAG, INJECTION (ML) ML 1 MG/ML

13 HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL ML 1.2 MG/ML HYDROMORPHONE HYDROMORPHONE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL ML 2 MG/ML IBUPROFEN / TABLET EA 5 MG HYDROCHLORIDE LEVORPHANOL LEVORPHANOL TARTRATE TABLET TA 2 MG MEPERIDINE MEPERIDINE HYDROCHLORIDE SOLUTION, ML 10 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE INJECTION SOLUTION ML 25 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE TABLET TA 50 MG MEPERIDINE MEPERIDINE HYDROCHLORIDE INJECTION SOLUTION ML 50 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE INJECTION VIAL ML 50 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE INJECTION SOLUTION ML 75 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE TABLET TA 100 MG MEPERIDINE MEPERIDINE HYDROCHLORIDE INJECTION SOLUTION ML 100 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE / PF INJECTION DISPOSABLE SYRINGE (ML) ML 50 MG/ML MEPERIDINE MEPERIDINE HYDROCHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PLASTIC BAG, INJECTION (ML) ML 10 MG/ML METHADONE METHADONE HYDROCHLORIDE SOLUTION ML 1 MG/ML > 0 TO </= 20 4; >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 METHADONE METHADONE HYDROCHLORIDE SOLUTION ML 2 MG/ML > 0 TO </= 20 4; >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 METHADONE METHADONE HYDROCHLORIDE SOLUTION-CONCENTRATED ML 10 MG/ML > 0 TO </= 20 4; >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: CALCULATION DEPENDENT ON DAILY DOSE CALCULATION DEPENDENT ON DAILY DOSE CALCULATION DEPENDENT ON DAILY DOSE

14 METHADONE METHADONE HYDROCHLORIDE TABLET TA 5 MG > 0 TO </= 20 4; CALCULATION DEPENDENT ON DAILY DOSE >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 METHADONE METHADONE HYDROCHLORIDE TABLET TA 10 MG > 0 TO </= 20 4; CALCULATION DEPENDENT ON DAILY DOSE >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 METHADONE METHADONE HYDROCHLORIDE INJECTION VIAL ML 10 MG/ML > 0 TO </= 20 4; CALCULATION DEPENDENT ON DAILY DOSE >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 METHADONE METHADONE HYDROCHLORIDE DISKETS TABLET, SOLUBLE TA 40 MG > 0 TO </= 20 4; CALCULATION DEPENDENT ON DAILY DOSE >20 TO </=40 8; > 40 TO </= 60 10; > 60 MG DAILY DOSE: 12 SULFATE TABLET, IR TA 15 MG SULFATE TABLET,IR TA 30 MG SULFATE INJECTION SOLUTION ML 0.5 MG/ML SULFATE INTRAVENOUS* SOLUTION ML 1 MG/ML SULFATE SOLUTION, ML 2 MG/ML SULFATE SOLUTION, ML 4 MG/ML SULFATE SOLUTION, ML 20 MG/ML SULFATE RECTAL SUPPOSITORY EA 5 MG

15 SULFATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) ML 5 MG/ML SULFATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) ML 8 MG/ML SULFATE RECTAL SUPPOSITORY EA 10 MG SULFATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) ML 10 MG/ML SULFATE INTRAMUSCULAR PEN INJECTOR (ML) ML MG/ML SULFATE / PF INJECTION AMPULE ML 0.5 MG/ML SULFATE / PF INJECTION AMPULE ML 1 MG/ML SULFATE / PF INJECTION AMPULE ML 10 MG/ML SULFATE / DEXTROSE 5 % IN WATER INJECTION PLASTIC BAG, INJECTION (ML) ML 1 MG/ML SULFATE INTRAVENOUS SOLUTION ML 50 MG/ML 3 40 SULFATE / DEXTROSE 5 % IN WATER INJECTION PATIENT CONTROLLED ANALGESIA SYRINGE ML 2 MG/ML SULFATE / DEXTROSE 5%- WATER / PF SULFATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) INTRAVENOUS PLASTIC BAG, INJECTION (ML) ML 1 MG/ML ML 15 MG/ML SULFATE RECTAL SUPPOSITORY EA 20 MG SULFATE / DEXTROSE 5 % IN WATER INJECTION PLASTIC BAG, INJECTION (ML) ML 1 MG/ML SULFATE INTRAVENOUS SOLUTION ML 50 MG/ML 3 40 SULFATE INTRAVENOUS PRE-FILLED SYRINGE ML 8 MG/ML SULFATE / PF INJECTION AMPULE ML 25 MG/ML 3 80 SULFATE IN 0.9 % SODIUM CHLORIDE INJECTION PREFILLED PUMP RESERVOIR ML 1 MG/ML SULFATE INTRAVENOUS PRE-FILLED SYRINGE ML 5 MG/ML SULFATE INTRAVENOUS PRE-FILLED SYRINGE ML 4 MG/ML SULFATE INTRAVENOUS PRE-FILLED SYRINGE ML 2 MG/ML SULFATE INTRAVENOUS SOLUTION ML 25 MG/ML 3 80 SULFATE INTRAAVENOUS PRE-FILLED SYRINGE ML 10 MG/ML

16 SULFATE IN 0.9 % SODIUM CHLORIDE INJECTION PREFILLED PUMP RESERVOIR ML 5 MG/ML SULFATE RECTAL SUPPOSITORY EA 30 MG SULFATE LIPOSOMAL / PF EPIDURAL VIAL (SDV,MDV OR ADDITIVE) (ML) SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE ML 10 MG/ML CA 10 MG SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE CA 20 MG SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE CA 30 MG SULFATE (KADIAN) CAPSULE, EXTENDED RELEASE EA 40 MG SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE CA 50 MG SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE EA 60 MG SULFATE (KADIAN) CAPSULE, EXTENDED RELEASE EA 70 MG SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE CA 80 MG 1 75 SULFATE (KADIAN, GENERIC) CAPSULE, EXTENDED RELEASE EA 100 MG 1 60 SULFATE (KADIAN) CAPSULE, EXTENDED RELEASE EA 130 MG SULFATE (KADIAN) CAPSULE, EXTENDED RELEASE EA 150 MG

17 SULFATE (KADIAN) CAPSULE, EXTENDED RELEASE EA 200 MG 1 30 SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR SULFATE (AVINZA, GENERIC) CAPSULE,EXTENDED RELEASE 24HR CA 30 MG CA 45 MG CA 60 MG CA 75 MG 1 80 CA 90 MG CA 120 MG 1 50 SULFATE (MS CONTIN, GENERIC) TABLET, EXTENDED RELEASE TA 15 MG SULFATE (MS CONTIN, GENERIC) TABLET, EXTENDED RELEASE TA 30 MG SULFATE (MS CONTIN, GENERIC) TABLET, EXTENDED RELEASE TA 60 MG SULFATE (MS CONTIN, GENERIC) TABLET, EXTENDED RELEASE TA 100 MG 1 60 SULFATE (MS CONTIN, GENERIC) TABLET, EXTENDED RELEASE TA 200 MG 1 30 SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 20/0.8 MG SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 30/1.2 MG SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 50/2.0 MG SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 60/2.4 MG SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 80/3.2 MG

18 SULFATE/NALTREXONE (EMBEDA) EXTENDED RELEASE CAPSULE CA 100/4 MG 1 60 SULFATE CAPSULE,EXTENDED RELEASE 24HR NALBUPHINE NALBUPHINE HYDROCHLORIDE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) CA 20 MG ML 10 MG/ML NALBUPHINE NALBUPHINE HYDROCHLORIDE INJECTION SOLUTION ML 20 MG/ML PENTAZOCINE NALOXONE HYDROCHLORIDE / TABLET TA 50 MG PENTAZOCINE HYDROCHLORIDE HYDROCHLORIDE TABLET TA 5 MG HYDROCHLORIDE CAPSULE CA 5 MG HYDROCHLORIDE TABLET TA 10 MG HYDROCHLORIDE TABLET TA 15 MG HYDROCHLORIDE TABLET TA 20 MG HYDROCHLORIDE TABLET TA 30 MG HYDROCHLORIDE SOLUTION, ML 1 MG/ML HYDROCHLORIDE SOLUTION, ML 20 MG/ML HYDROCHLORIDE (OXECTA) TABLET, ONLY TA 5 MG HYDROCHLORIDE (OXECTA) TABLET, ONLY TA 7.5 MG HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 10 MG HYDROCHLORIDE (XTAMPZA TABLET EXTENDED RELEASE EA 9 MG HYDROCHLORIDE TABLET EXTENDED RELEASE EA 15 MG HYDROCHLORIDE (XTAMPZA TABLET EXTENDED RELEASE EA 13.5 MG HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 20 MG HYDROCHLORIDE (XTAMPZA TABLET EXTENDED RELEASE TA 18 MG HYDROCHLORIDE CONCENTRATE, ML 20 MG/ML HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 30 MG

19 HYDROCHLORIDE (XTAMPZA TABLET EXTENDED RELEASE TA 27 MG HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 40 MG HYDROCHLORIDE (XTAMPZA TABLET EXTENDED RELEASE HYDROCHLORIDE TABLET, EXTENDED RELEASE HYDROCHLORIDE TABLET, EXTENDED RELEASE 19 TA 36 MG TA 60 MG TA 80 MG OXYMORPHONE OXYMORPHONE HYDROCHLORIDE INJECTION SOLUTION ML 1 MG/ML OXYMORPHONE OXYMORPHONE HYDROCHLORIDE (OPANA TABLET TA 5 MG AND GENERIC) OXYMORPHONE OXYMORPHONE HYDROCHLORIDE (OPANA TABLET TA 10 MG AND GENERIC) OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 5 MG OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE TABLET, EXTENDED RELEASE OXYMORPHONE OXYMORPHONE OXYMORPHONE OXYMORPHONE OXYMORPHONE OXYMORPHONE OXYMORPHONE OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA OXYMORPHONE HYDROCHLORIDE (OPANA TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TABLET, ONLY,EXTENDED RELEASE 12 HR TA 10 MG TA 15 MG TA 20 MG TA 30 MG TA 40 MG 3 50 TA 7.5 MG TA 5 MG TA 7.5 MG TA 10 MG TA 15 MG TA 20 MG TA 30 MG TA 40 MG 3 50

20 PENTAZOCINE PENTAZOCINE LACTATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) TA 30 MG/ML PENTAZOCINE PENTAZOCINE NALOXONE TABLET TA 50 MG TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EA 50 MG TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET, EXTENDED RELEASE TA 50 MG TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EA 75 MG TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EA 100 MG TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET, EXTENDED RELEASE TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EXTENDED RELEASE TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EXTENDED RELEASE TAPENTADOL TAPENTADOL HYDROCHLORIDE TABLET EXTENDED RELEASE TRAMADOL TRAMADOL HYDROCHLORIDE TABLET DISPERSIBLE AND TABLET TRAMADOL TRAMADOL HYDROCHLORIDE TABLET,EXTENDED RELEASE MULTIPHASE 24 HR TA 100 MG EA 150 MG EA 200 MG EA 250 MG EA 50 MG TA 100 MG TRAMADOL TRAMADOL HYDROCHLORIDE TABLET,EXTENDED RELEASE MULTIPHASE 24 HR TRAMADOL TRAMADOL HYDROCHLORIDE TABLET,EXTENDED RELEASE MULTIPHASE 24 HR TA 200 MG TA 300 MG

21 REFERENCES 1. McPherson ML. Demystifying Opioid Conversion Calculations: A Guide to Effective Dosing, with 2011 Update. Bethesda, MD: American Society of Health-System Pharmacists; CMS OMS HPMS Announcement to part D sponsors. July 11, 2014 Medicare Part D Overutilization Monitoring System-July 2014 Updates available at 3. Center for Disease Control and Prevention, Morphine Equivalent Conversion Factors for Opioids, Version CDC, Atlanta, GA, Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy 2010 Update. Available at Accessed 11/15/ Opioid Dose calculator: available at or Accessed 11/15/ Kane SP. Opioid Conversion Calculator ClinCalc: Updated July 20, Accessed August 19, Practical Pain management Opioid calculator. Accessed August19, Global RPH Advanced Opioid Converter. Available at Accessed 11/15/ US Department of Justice. Prescription Drug Monitoring Program Technical Assistance. Accessed 11/15/ Butorphanol Product Labeling. Available at Accessed 11/15/ Appendix 9 Equianalgesic dosage table Buprenorphine (IM/IV): 0.4 Butorphanol (IM/IV): 2.0 Codeine (IM/IV): 120 Codeine (PO): 200 Fentanyl (IM/IV): 0.1 Fentanyl (Transdermal): 0.2 Hydrocodone (PO): 30 Hydromorphone (IV/IM/SC): 1.5 Hydromorphone (PO): 7.5 Levorphanol (acute PO): 4.0 Levorphanol (chronic PO): 1.0 Meperidine (IV/IM/SC): 75 Meperidine (PO): 300 Methadone (acute IV): 5.0 Methadone (acute PO): 10 Morphine (IV/IM/SC): 10 Morphine (acute PO): 60 Morphine (chronic PO): 30 Nalbuphine (IV/IM/SC): 10 Oxycodone (PO): 20 Oxymorphone (IV/IM/SC): 1.0 Oxymorphone (PO): 10 Tapentadol (PO):

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