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PRN doses should be 10-20% of the TDD from the previous day
(TDD includes scheduled AND PRN doses)
PRN doses are usually given every 4 hours for most opioids; can
be given every 2 hours if inadequate pain relief
PO / PR / IV / IM are all equally efficacious and route should only depend upon what is
best tolerated by the patient
Metoclopramide effective for gastric stasis-induced n/v, not prophylaxis of n/v
Indication
Neuropathic Pain
Baclofen
Muscle spasticity
Buprenorphine
Transdermal
Moderate-to-severe
chronic pain
Carbamazepine
Dexamethasone
Neuropathic Pain
Duloxetine
Gabapentin
Lidocaine
Patch
Prednisone
Pregabalin
Spinal cord
compression,
bony metastases
Diabetic
Peripheral
Neuropathy
Neuropathic Pain
Herpetic Neuralgia
Spinal cord compression, bony metastases
Neuropathic Pain
Clinical Considerations
Anticholinergic side effects (drying, dizzy, constipation, urinary retention, confusion). Avoid in elderly.
Caution in renal insufficiency.
Max 20mcg/hr transdermally. Replace patch every 7
days.
Opioid-experienced patient must be titrated to less
than 30mg per day of oral morphine or equiv before
starting transdermal therapy.
Monitor serum levels. Multiple drug-drug interactions.
Minimize duration of high dose therapy. Also alleviates n/v in palliative care. Rapid infusion can cause
n/v.
Caution in hepatic impairment, elderly. Do not use
with MAOIs. Consider lower initial dose when tolerability is a concern.
Adjust for renal dysfunction.
Department of Pharmacy
Pocket Reference for
Opioid Management of
Pain
Drug
Morphine
FentaNYL inj.
HYDROcodone
Injection
(mg)
Oral
(mg)
Duration of
Analgesia (hr)
Onset of
Action (min)
Clinical Considerations
10
30
Oral: 3 4
IV: 5 -10
Oral: 15 30
Avoid in renal insufficiency, elderly due to active metabolite accumulation. 10 mg rectal suppository = 10 mg
PO. Do not crush CR formulations.
NA
IV: 0.5 1
IV: 1 2
30
Oral: 3 4
Oral: 10 20
IV: 5
Oral: 15 30
0.1
(= 100mcg)
NA
HYDROmorphone
1.5
OxyCODONE
NA
20
IR: 3 4
CR: 8 12
IR: 10 15
CR: 10 20
MethadoneY
2.5
Oral: 4 12
IV: 10 - 20
Oral: 30 60
Equipotent Oral
Starting Dose
Morphine
FentaNYL
NA
NA
NA
NA
Drug
HYDROmorphone
OxyCODONE
Clinical Considerations /
Maximal Daily Doses
Typically not more than 5-10 mg IV or
15-30 mg oral dose used for peds > 50 kg
IV Morphine
TDD (mg/day)
Transdermal
FentaNYL
(mcg/hr)
50
100
150
200
250
300
350
400
450
500
550
600
17
33
50
67
83
100
117
133
150
167
183
200
25
50
75
100
125
150
175
200
225
250
275
300
HYDROmorphone
FentaNYL*
1 mg/ml
0.2 mg/ml
10 mcg/ml
1 mg
0.2 mg
10 mcg
Lockout Time
6 15 min
6 15 min
6 15 min
Usual 1-hour
Max Dose
25 mg
4 mg
150 mcg
Standard
Concentrations
PCA Bolus
Dose
Ibuprofen
Ketorolac
Naproxen
NA
Pediatric defined as age greater than 1 year or children/adolescents (excludes neonates and infants)
High Dose
Concentrations
PCA Bolus
Dose
Lockout Time
Morphine
High
Dose
HYDROmorphone
High Dose
FentaNYL
High
Dose*
5 mg/ml
1 mg/ml
50 mcg/ml
5 mg
1 mg
50 mcg
6 15 min
6 15 min
6 15 min
Usual 1-hour
80 mg
20 mg
1300 mcg
Max Dose