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


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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.