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.
(IM, SubQ, IV)
|Morphine||30 mg||3-4||10 mg||3-4|
|Oxycodone SR||30 mg||8-12||
|Oxycodone IR||20-30 mg||3-4||NA||NA|
|Fentanyl*||25 mcg/hr||72||0.1 mg||1-2|
|Meperidine||300 mg||2-3||75 mg||3|
Dosing Conversion Guidelines2
|Current Analgesic||Daily Dosage (mg/day)|
|Recommended Fentanyl (Duragesic) dose||
|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
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.