Drug (United States brand name) | Approximate equianalgesic doses* | Sample initial dose for opioid-naïve adult¶ | Serum half-life (in hours) | Duration of analgesic effect (in hours) | Comments |
Parenteral opioids | |||||
Fentanyl (Sublimaze) | 100 mcg IV | 25 to 50 mcg for moderate pain or 50 to 100 mcg for more severe pain IV/subcutaneous; repeat every two to five minutes as needed until adequate pain relief | 7 to 12 | 0.5 to 1 (IV) 1 to 2 (subcutaneous) |
|
Hydromorphone (Dilaudid) | 1.5 mg IV | 0.2 to 0.5 mg IV; repeat every five minutes as needed until adequate pain relief, then 0.2 to 0.5 mg IV every three to four hours as needed | 2 to 3 | 3 to 4 |
|
Morphine (Infumorph, others) | 10 mg IV | 1 to 3 mg IV; repeat every five minutes as needed until adequate pain relief; then 1 to 3 mg IV every three to four hours as needed | 2 to 3 | 4 to 5 |
|
Oral immediate-release opioids | |||||
Codeine | 200 mg orally | 15 to 60 mg orally every four to six hours as needed | 2 to 4 | 4 to 6 |
|
Hydrocodone (immediate-release only available in US in combination products, eg, Vicodin, Lorcet, others) | 30 mg orally | 5 to 10 mg orally every six hours as needed | 3 to 4 | 4 to 8 |
|
Hydromorphone (Dilaudid) | 7.5 mg orally | 2 to 4 mg orally every four hours as needed | 2 to 3 | 3 to 6 |
|
Morphine | 30 mg orally | 15 to 30 mg orally every four hours as needed | 2 to 3 | 3 to 6 |
|
Oxycodone (Oxy-IR, Roxicodone, others) | 20 mg orally | 5 to 10 mg orally every four to six hours as needed | 2 to 3 | 3 to 6 |
|
Oxymorphone (Opana) | 10 to 15 mg orally | 5 to 10 mg orally every four to six hours as needed | 7 to 9 | 3 to 6 | |
Tramadol (Ultram, others) | Not established | 50 to 100 mg every four to six hours as needed | 6 to 9 (includes active metabolite) | 4 to 6 |
|
Initial IV titration and continuous infusion of opioids for acute perioperative pain should only be administered in a closely monitored setting with pulse oximetry and end-tidal carbon dioxide monitoring capabilities. For dosing of continuous infusion delivery, refer to UpToDate content on pain control in critically ill patients.
Oral opioids should be prescribed starting with the minimum dose needed to alleviate pain and after maximizing non-opioid analgesic options. Extended-release preparations of oral opioids are generally not recommended for acute pain.
For PCA doses, refer to UpToDate content on management of acute perioperative pain.CYP: cytochrome P-450 metabolism; IV: intravenous; PCA: patient controlled analgesia; US: United States.
* Equianalgesic conversions serve only as a general guide to estimate opioid dose equivalents.
¶ Lower doses may be effective for patients who simultaneously receive non-opioid analgesics. A dose reduction of approximately 50% and a reduced frequency is warranted for older or debilitated adults or patients with impaired liver or kidney functioning, low cardiac output, or respiratory compromise.
Δ A list of inhibitors and inducers of CYP3A4 metabolism is available as a separate table in UpToDate.Courtesy of Edward Mariano, MD.
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