How pain management is the neverending clinical challenge – supplemental material

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.

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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.