Breakthrough pain management for opioid analgesics
After determining the total 24-hour dose of the currently prescribed analgesic, the prescribed opioid should be converted to an equivalent equianalgesic dose, based on the tables below.
Equinalgesic Dosing1
Opioid | Oral | Dosing Interval (hours) |
Parenteral (IM, SubQ, IV) |
Dosing Interval (hours) |
Morphine | 30 mg | 3-4 | 10 mg | 3-4 |
Hydromorphone | 7.5 mg | 3-4 |
1.5 mg Continue Reading |
3-4 |
Oxycodone SR | 30 mg | 8-12 |
NA |
NA |
Oxycodone IR | 20-30 mg | 3-4 | NA | NA |
Codeine | 200 mg | 3-4 | 120 | 3-4 |
Fentanyl* | 25 mcg/hr | 72 | 0.1 mg | 1-2 |
Levorphanol | 4 mg | 6-8 |
2 mg |
6-8 |
Meperidine | 300 mg | 2-3 | 75 mg | 3 |
Methadone | 10-20 mg | 6-8 |
5-10 mg |
6-8 |
*Transdermal patch. |
Dosing Conversion Guidelines2
Current Analgesic | Daily Dosage (mg/day) | |||
Oral morphine | 60-134 | 135-224 | 225-314 | 315-404 |
IM/IV morphine | 10-22 | 23-37 | 38-52 | 53-67 |
Oral oxycodone | 30-67 | 67.5-112 | 112.5-157 | 157.5-202 |
IM/IV oxycodone | 15-33 | 33.1-56 | 56.1-78 | 78.1-101 |
Oral codeine | 150-447 | 448-747 | 748-1047 | 1048-1347 |
Oral hydromorphone | 8-17 | 17.1-28 | 28.1-39 | 39.1-51 |
IV hydromorphone | 1.5-3.4 | 3.5-5.6 | 5.7-7.9 | 8-10 |
IM meperidine | 75-165 |
166-278 |
279-390 |
391-503 |
Oral methadone | 20-44 | 45-74 | 75-104 | 105-134 |
IM methadone | 10-22 | 23-37 |
38-52 |
53-67 |
↓ |
↓ | ↓ | ↓ | |
Recommended Fentanyl (Duragesic) dose |
25 mcg/h |
50 mcg/h | 75 mcg/h | 100 mcg/h |
The dosing equivalency can be calculated using the following formula, where ‘X’ is the total “new” dose/24 hrs.
“Old” Dose Equivalent = “New” Dose Equivalent
Total “Old” Dose/24 hrs X
Baseline doses can be adjusted using Wong-Baker’s scale adapted from Wong’s Essentials of Pediatric Nursing (7th ed. Maryland Heights, MO: Elsevier Inc; 2005:1259) to provide effective pain relief. If mild pain persists the dose can be increased by 25% to 30%. For moderate pain, the dose can be increased by 50%. For severe pain, the dose can be increased by 50% to 100%. A dose reduction of 50% should be considered for elderly patients, as well as patients with renal failure.1
The appropriate rescue dosing for breakthrough pain is 10% of the total 24-hour opioid dose and is given every 1 to 2 hours as needed. When using slow-release preparations, intermediate-release opioids are provided for breakthrough pain. The dose should be 1/6 to 1/3 of the dose given every 12 hours; this is equivalent to 50% to 100% dose given every 4 hours. In the elderly, the rescue dose should be 5% of the total 24-hour opioid dose administered every 4 hours as needed.1
REFERENCES
1. Schneider C, Yale SH, Larson M. Principles of pain management. Clin Med Res. 2003;1(4):337-340.
2. Duragesic [package insert]. Titusville, NJ: Ortho-McNeil-Janssen Pharmaceuticals Inc; 2009. http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=11988#footnote-13. Accessed August 2, 2013.