Davis's Drug Guide

Equianalgesic Dosing Guidelines

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General

OPIOID ANALGESICS STARTING ORAL DOSE COMMONLY USED FOR SEVERE PAIN

EQUIANALGESIC DOSESTARTING ORAL DOSE
NAMEORAL*PARENTERAL†ADULTSCHILDRENCOMMENTSPRECAUTIONS AND CONTRAINDICATIONS
a. Morphine-like agonists (mu agonists)
morphine30 mg10 mg15–30 mg0.3 mg/kgStandard of comparison for opioid analgesics. Sustained release preparations MS Contin, OramorphSR release over 8–12 hr. Other formulations (Kadian and Avinza) last 12–24 hr. Generic sustained release morphine preparations are now available.For all opioids, caution in patients with impaired ventilation, bronchial asthma, increased intracranial pressure, liver failure.
hydromorphone (Dilaudid)7.5 mg1.5 mg4–8 mg0.06 mg/kgSlightly shorter duration than morphine.
fentanyl__0.1 mg
oxycodone20 mg10–20 mg0.3 mg/kg
methadone10 mg5 mg5–10 mg0.2 mg/kgGood oral potency, long plasma half-life (24–36 hr).Accumulates with repeated dosing, requiring decreases in dose size and frequency, especially on days 2–5. Use with caution in older adults.
levorphanol (Levodromoran)4 mg (acute), 1 mg (chronic)2 mg (acute), 1 mg (chronic)2–4 mg0.04 mg/kgLong plasma half-life (12–16 hr, but may be as long as 90–120 hr after one wk of dosing).Accumulates on days 2 and 3. Use with caution in older adults.
oxymorphone (Opana)10 mg1 mg5 mg rectal suppository ~5 mg morphine parenteral.Like parenteral morphine.
meperidine (Demerol)Not recommendedNot recommendedNot RecommendedSlightly shorter acting than morphine accumulates with repetitive dosing causing CNS excitation; avoid in children with impaired renal function or who are receiving monoamine oxidase inhibitors.‡Use with caution. Normeperidine (toxic metabolite) accumulates with repetitive dosing causing CNS excitation and a high risk of seizure. Avoid in children, renal impairment, and patients on monoamine oxidase inhibitors.‡
b. Mixed agonists–antagonists (kappa agonists)
nalbuphine (Nubain)10 mgNot available orally, not scheduled under Controlled Substances Act.Incidence of psychotomimetic effects lower than with pentazocine; may precipitate withdrawal in opioid-dependent patients.
butorphanol (Stadol)2 mgLike nalbuphine. Also available in nasal spray.Like nalbuphine.
pentazocine (Talwin)50 mg30 mg
c. Partial agonist
buprenorphine (Buprenex)0.4 mgLower abuse liability than morphine; does not produce psychotomimetic effects. Sublingual tablets now available both plain and with naloxone for opioid-dependent patient management for specially certified physicians. These tablets are not approved as analgesics.May precipitate withdrawal in narcotic-dependent patients; not readily reversed by naloxone; avoid in labor.
*Starting dose should be lower for older adults.
†These are standard parenteral doses for acute pain in adults and can also be used to convert doses for IV infusions and repeated small IV boluses. For single IV boluses, use half the IM dose. IV doses for children >6 mo. = parenteral equianalgesic dose times weight (kg)/100.
‡Irritating to tissues with repeated IM injections.

Modified from American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, ed.6. American Pain Society, 2008.

GUIDELINES FOR PATIENT-CONTROLLED INTRAVENOUS OPIOID ADMINISTRATION FOR ADULTS WITH ACUTE PAIN

DRUG*USUAL STARTING DOSE AFTER LOADINGUSUAL DOSE RANGEUSUAL LOCKOUT (MIN)USUAL LOCKOUT RANGE (MIN)
Morphine (1 mg/mL)1 mg0.5–2.5 mg85–10
Hydromorphone (0.2 mg/mL) 0.2 mg0.05–0.4 mg85–10
Fentanyl (50 mcg/mL)20 mcg10–50 mcg65–8
*Standard concentrations for most PCA machines are listed in parentheses.

Modified from American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, ed.6. American Pain Society, 2008.

FENTANYL TRANSDERMAL DOSE BASED ON DAILY MORPHINE DOSE

ORAL 24-HR MORPHINE (mg/day)TRANSDERMAL FENTANYL (mg/day)FENTANYL TRANSDERMAL (mcg/hr)
30–900.625
91–1501.250
151–2101.875
211–2702.4100
271–3303.0125
331–3903.6150
391–4504.2175
451–5104.8200
511–5705.4225
571–6306.0250
631–6906.6275
691–7507.2300
For each additional 60 mg/day+0.6 +25
*A 10-mg IM or 60-mg oral dose of morphine every 4 hr for 24 hr (total of 60 mg/day IM or 360 mg/day oral) was considered approximately equivalent to fentanyl transdermal 100 mcg/hr.

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