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While there are useful tables of oral and parenteral equivalents, there is substantial inter-patient variability in the relative potency of different opioid drugs and formulations. As such, it is preferable to underestimate a patient's 24-hour oral oxymorphone dose and provide rescue medication (e.g., immediate-release oxymorphone) than to overestimate the 24-hour oral oxymorphone dose and manage an adverse reaction. Consider the following general points:
In a phase 3 clinical trial with an open-label titration period, patients were converted from their prior opioid to OPANA^® ER using Table 1 as a guide for the initial OPANA^® ER dose.

• The table is not a table of equianalgesic doses
• The conversion ratios in this table are only to be used for the conversion from oral therapy with one of the listed opioid analgesics to OPANA^® ER
• Do not use this table to convert from OPANA^® ER to another opioid. Doing so will result in an overestimation of the dose of the new opioid and may result in fatal overdose

For example, a patient receiving oxycodone at a total daily dose of 40 mg would then be converted to a total daily dose of 20 mg of oxymorphone (40 mg x 0.5), dosed as OPANA^® ER 10 mg twice daily.

• Patients 65 years of age or older, patients with mild hepatic impairment, and patients with severe renal impairment have an increase in oxymorphone bioavailability. For patients on prior opioid therapy, start at 50% of the starting dose for a younger patient or a patient with normal hepatic or renal function and titrate slowly. Monitor patients closely for signs of respiratory or central nervous system depression.

^* It is extremely important to monitor all patients closely when converting from methadone to other opioid agonists. The ratio between methadone and other opioid agonists may vary widely as a function of previous dose exposure. Methadone has a long half-life and tends to accumulate in the plasma.
Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing OPANA^® ER and monitor all patients receiving OPANA^® ER for the development of these behaviors or conditions. Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.