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

  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

  - 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, 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

    1. Bolus doses administered by the medical/nursing staff

2.      The equianalgesic chart indicates that 1.5 mg of parenteral hydromorphone equals 7.5 mg of  oral hydromorphone (a 5-fold increase). 

  1. The patient’s current dose of 5 mg per day of parenteral hydromorphone is equal to 25 mg per day of oral hydromorphone.
  2. The next step is to convert 25 mg of oral hydromorphone to the daily oral morphine equivalent dose (DOMED).
  3. The equianalgesic chart indicates that 7.5 mg of oral hydromorphone is equal to 30 mg of oral morphine.
  4. The patient’s calculated dose of 25 mg of oral hydromorphone is equal to 100 mg of oral morphine.
  5. The oral dose of morphine should be reduced by 30% to 50% to prevent any risk of overdose after the conversion, since opioids do not have complete cross-tolerance.   A 33% dose reduction from the calculated dose of 100 mg is equal to 67 mg of oral morphine per day.
  6. The recommended dosing frequency of long-acting morphine (MS Contin® )  is every 12 hours (2 doses per day).
  7. MS Contin®   is available in 15 mg, 30 mg, 100 mg and 200 mg controlled-release tablets.  The tablet strength closest to the calculated dose is 30 mg. The proper starting dose should therefore be 30 mg of sustained-release morphine every 12 hours.

 

 

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

  1. Opioid-naïve patients
    1. Recommended starting dose range is 2.5 mg daily to 2.5 mg TID.
    2. For frail and/or older patients, the starting dose is 2.5 mg daily.
  1. Patients taking opioids
    1. Determine the daily oral morphine equivalent dose of current opioids.
    2. Convert daily oral morphine equivalent dose (DOMED) to oral methadone.
    3. Methadone dose should be adjusted every 5 days due to delayed onset of respiratory depression.

 

  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:

  1. Patient is taking 80 mg Oxycontin orally 3 times daily.
  2. The total daily dose of oxycodone is 240 mg daily.
  1. The next step is to convert 240 mg of oral oxycodone to the daily oral morphine equivalent dose (DOMED).
  2. The equianalgesic chart indicates that 20 mg of oral oxycodone is equal to 30 mg of oral morphine.

5.   The patient’s current dose of 240 mg per day of oral oxycodone is equal to 360 mg per day of oral morphine.

  1. The methadone conversion table indicates that a conversion factor for a DOMED of 360mg equals 8.3% or a 12 to 1 ratio of morphine to methadone.
  2. The patient’s DOMED of 360 mg is equal to 30 mg of methadone daily.
  3. The recommended dosing frequency of methadone for chronic pain is 1 to 3 times daily, so the proper daily methadone dose would be 10 mg three times daily.
  4. May need to use breakthrough medication as needed for the first week, while methadone achieves steady-state blood levels.

 

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