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
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, 5th 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 (Sublimazẻ) |
0.1 - 0.2 mg |
-------------- |
Hydrocodone |
------------- |
30 mg |
Hydromorphone (Dilaudid̉) |
1.5 mg |
7.5 mg |
Meperidine (Demerol̉) |
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 mg oral morphine. For chronic dosing, 10 mg IV morphine = 30 mg
oral morphine.
(N)
Non-formulary at UIHC.
Example of opioid conversion:
1.
Patient
is receiving a total of 5 mg of parenteral hydromorphone in a 24-hour period
via a PCA pump. The goal is to convert
this to oral morphine for discharge.
When converting from PCA administration, add
the total amount of opioid that the patient received in the last
24 hours, including
a.
Basal
infusion
b.
Demand
boluses administered by the patient
2.
The
equianalgesic chart indicates that 1.5 mg of parenteral hydromorphone equals
7.5 mg of oral hydromorphone (a 5-fold
increase).
Guidelines for
Administering Naloxone for Reversal of Opioid-Induced Respiratory Depression
Opioid
overdose:
· 0.4 mg – 0.8 mg IV/IM/SQ,
titrated in accordance with the patient’s response; repeat as needed. If given IV, each 0.4 mg should be given over
15 seconds.
Opioid-induced
respiratory depression
· 0.04 mg/ml (40 mcg/ml)
dilution in syringe (mix 0.4 mg/1 ml of naloxone and 9 ml of normal saline in a
syringe for IV administration).
̃
Administer
0.5 ml of diluted solution (0.02 mg or 20 mcg) every 2 minutes until a change
in alertness is observed.
̃
Titrate
naloxone until patient is responsive or a total of 0.8 mg (20 ml of diluted
solution) has been given. Continue
looking for other causes of sedation and respiratory depression.
̃
Discontinue
naloxone when patient is responsive to physical stimulation, respiratory rate
is > 8 breaths per minute, and
able to take deep breaths when told to do so.
Special
considerations
· May need repeated doses or
continuous infusion. Depending on amount
and type of opioid given and time interval since last opioid administration,
the duration of action of some opioids may exceed that of naloxone.
· Titrate dose cautiously to
avoid precipitation of profound withdrawal, seizures, and severe pain.
Use of Oral Methadone for Chronic Pain
Methadone
Conversion Ratios
Current DOMED |
Conversion ratio (morphine : methadone) |
Conversion factor (approximate % of DOMED) |
<30 mg |
2 : 1 |
50% |
30 – 99 mg |
4 : 1 |
25% |
100 – 299 mg |
8 : 1 |
12.5% |
300 – 499 mg |
12 : 1 |
8.3% |
500 – 999 mg |
15 : 1 |
6.6% |
> 1,000 mg |
20 : 1 |
5% |
Example of conversion to oral methadone:
5. The patient’s current dose of 240 mg per day
of oral oxycodone is equal to 360 mg per day of oral morphine.
Pain Medicine Service
For difficulties
with pain management, contact the Pain Medicine Service at 6-2320 (clinic) or 3832 (on call pager).
References:
American Hospital Formulary Service Drug
Information 2005. American Society of
Health-System Pharmacists.
American Pain Society (2003). Principles of analgesic use in the treatment
of acute pain and cancer pain (5th ed.) Glenview, IL: Author.
U.S. Department of Health and Human Services. (1992).
Acute pain management: Operative or medical
procedures and trauma
(AHCPR Publication No. 92-0032).
Rockville, MD: Author.
VA/DoD Clinical Practice Guideline for the
Management of Opioid Therapy for Chronic Pain.
Department of Veterans Affairs
and Department of Defense. Version
1.0 March 2003.
Written
1990
Revised
7/26/1999
Revised 9/2003
Revised
4/2005