Opioid Analgesics

These are general guidelines. Patient care requires individualization based on patient needs and responses. Lower doses should be used initially, then titrated up to achieve pain relief.

Drug	Route	Starting Dose (Adults > 50 Kg)	Onset	Peak	Duration	Metabolism	Half Life	Comments
Codeine	PO IM SQ	30 - 60 mg q 4 hr 15 - 30 mg q 4 hr 15 - 30 mg q 4 hr	30 min 15 - 30 min 30 - 60 min	1½ hr 30 - 60 min 2 - 4 hr	6 hr 4 - 6 hr 4 - 8 hr	Liver	2 - 4 hr	· IV use (even at low doses and when given very slowly) may cause marked decrease in blood pressure; IV use is not recommended. · IM or SQ routes are the preferred parenteral routes.
Fentanyl (Sublimaze^®) (Duragesic^®)	IM IV Trans-dermal	5 mcg/Kg q 1 - 2 hr 0.25 - 1 mcg/Kg as needed 25 mcg/hr	7 - 8 min Immediate 12 - 24 hr	20 - 50 min 1 - 5 min 24 hr	1 - 2 hr 30 - 60 min 48 - 72 hr	Liver	1 - 6 hr*	· Transdermal should NOT be used to treat acute pain. · Transdermal patch should be used only in opioid tolerant patients. Effects of patch last for 18 - 24 hours after the patch is removed. · Use of IV fentanyl is restricted to Oncology, Burn Service, Palliative Care, Intensive Care Units or based on recommendation by the Pain Service. Appropriate monitoring is required. Refer to Nursing Policies 8.021 and 8.025.
Hydrocodone with acetaminophen** (Lortab^®, Vicodin^®)	PO	5 - 10 mg hydrocodone q 4 - 6 hr	60 min	2 hr	4 - 6 hr	Liver	4 hr	Available at UIHC as: · Tablet with 5 mg hydrocodone and 500 mg acetaminophen. · Elixir with 2.5 mg hydrocodone and 167 mg acetaminophen per 5 ml.
Hydromorphone (Dilaudid^®)	PO IM/SQ Slow IV	2 - 4 mg q 4 - 6 hr 2 mg q 4 - 6 hr 0.2 - 0.6 mg q 2 - 3 hr	30 min 15 - 20 min 15 - 20 min	60 min 60 min 60 min	4 - 5 hr 4 - 5 hr 4 - 5 hr	Liver	2 - 3 hr	· Chronic treatment may require q 3 - 4 hour dosing. · IV doses should be administered over at least 2-3 minutes.
Meperidine (Demerol^®)	IM/SQ IV	50 - 150 mg q 3-4 hr 25 - 50 mg q 1-2 hr	10 - 45 min 2 - 5 min	30 - 60 min 20 min	2 hr 2 hr	Liver	2 - 3 hr	· More than 72 hr of continuous use can cause accumulation of normeperidine which can lead to neuroexcitability (seizures). · Naloxone administration will increase neuroexcitibility. · Use with caution in the elderly and patients with renal dysfunction. · Not for use in chronic pain. Do not exceed 600 mg / 24 hours.

Opioid Analgesics (continued)

Drug	Route	Dose (Adults > 50Kg)	Onset	Peak	Duration	Metabolism	Half Life	Comments
Methadone (Dolophine^®)	PO	2.5 mg 1 to 4 times daily	30 - 240 min	2 - 4 hr	4 - 24 hr	Liver	24 hr	· Used in chronic pain. · Continued dosing can result in accumulation and respiratory depression.
Morphine (MS Contin^®) (Avinza^®)	PO/SL IM IV SQ PO-SR PO-SR	10 - 15 mg q 3 - 4 hr 4 - 10 mg q 3 - 4 hr 2 - 4 mg q 2 - 4 hr 4 -10 mg q 3 - 4 hr MS Contin: 15 mg q 12 hr Avinza: 30 mg daily	15 min 15 - 60 min 2 - 5 min 15 - 30 min N/A N/A	1½ - 2 hr 30 - 60 min 20 min 30 - 60 min N/A N/A	4 hr 4 hr 3 - 4 hr 4 - 7 hr 8 -12 hr 24 hr	Liver	1.5 - 2 hr 2 - 4 hr 15 hr	·Oral liquid concentrate is available. ·Active metabolite renally eliminated; use caution in elderly and patients with renal insufficiency. · Long-acting dosage forms should not be crushed. · Long-acting dosage forms should not be used to treat acute pain. · Avinza^® is not on the UIHC formulary, but is used by Medicaid.
Oxycodone (Percocet^®)** (OxyContin^®)	PO/SL PO-SR	5 -10 mg q 4 - 6 hr-alone or with acetaminophen OxyContin: 10 mg q 12 hr	15 - 30 min 60 min	1 - 2 hr 2 - 3 hr	4 - 6 hr 12 hr	Liver	4 hr	· Available at UIHC as an immediate-release tablet and oral liquid concentration ·Percocet^® contains oxycodone 5mg / acetaminophen 325mg ·Other strengths of Percocet^® are available outside UIHC. · OxyContin^® is a sustained-release tablet. Do not crush. · OxyContin^® should not be used to treat acute pain.

*Analgesic duration of action does not correlate with half-life.

** Do not give more than 4 grams of acetaminophen per day (from all sources).

SR - sustained release product

Guidelines for Patient-Controlled Intravenous Opioid Administration (PCA) for Adults with Acute Pain

The amount of opioid required to achieve comfort varies from patient to patient. Adjust dosing to achieve patient comfort with minimal side effects.

Drug^§^#	Usual Loading Dose	Usual PCA Demand Bolus (Range)	Usual Lockout Range	Usual Basal Rate
Morphine (1 mg/ml)	5 – 10 mg	1 mg (0.5 - 2.5 mg)	5 - 10 min	None or 1 - 2 mg/hr
Hydromorphone (Dilaudid^®) (0.2 mg/ml)	0.5 – 1.5 mg	0.2 mg (0.05 - 0.4 mg)	5 - 10 min	None or 0.1 - 0.4 mg/hr

Partially adapted from the Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, American Pain Society, 5^th Ed. 2003.

§ Standard concentrations are listed in parentheses.

#Contact the Pain Service for other alternatives.

Also refer to UIHC Policy and Procedure for Patient Controlled Analgesia

Basal infusion rates are discouraged unless the patient has been taking scheduled opioids for more than one week. The addition of basal infusions to PCA increases the incidence and severity of opioid-induced adverse effects, including respiratory depression.

Initial Fentanyl Transdermal Dosage (use only when converting another opioid TO fentanyl patch)*

Oral 24-hour morphine equivalent (mg/day)	Fentanyl transdermal (mcg/hr)
60 -134	25
135-224	50
225-314	75
315-404	100
405-494	125
495-584	150
585-674	175
675-764	200
765-854	225
855-944	250
945-1034	275
1035-1124	300

*Note: Do not use this table to convert from fentanyl transdermal system to other opioid analgesics because these conversion dosage recommendations are conservative. Use of this table for conversion from fentanyl to other opioids can overestimate the dose of the new agent and may result in an overdosage.

Equianalgesic Chart

Doses listed are equivalent to 10 mg of parenteral morphine. Doses should be titrated according to individual response. When converting to another opioid, the dose of the new agent should be reduced by 30-50% due to incomplete cross-tolerance between opioids.

Analgesic	Dosage
	Parenteral	Oral
Fentanyl (Sublimaze^Ò)	0.1 - 0.2 mg	--------------
Hydrocodone	-------------	30 mg
Hydromorphone (Dilaudid^Ò)	1.5 mg	7.5 mg
Meperidine (Demerol^Ò)	75 - 100 mg	300 mg §(N)
Morphine	10 mg	30 mg §§
Oxycodone	-------------	20mg

§ Dosage in this range may lead to neuroexcitability.

§§ For a single dose, 10 mg IV morphine = 60