ࡱ> %` @7bjbjٕ 1/+QQQ8QD&R?tSSSSSTTT$hTTTTTSS?Z?Z?ZTSS?ZT?Z?ZΗSS  Q}U*F0?p^ XΗΗ$?ZTTTYXTTT?TTTT?F F Opioid Analgesics These are general guidelines. Patient care requires individualization based on patient needs and responses. Lower doses should be used initially, then titrated up to achieve pain relief. DrugRouteStarting Dose (Adults > 50 Kg)OnsetPeakDurationMetabolismHalf LifeCommentsCodeinePO IM SQ30 - 60 mg q 4 hr 15 - 30 mg q 4 hr 15 - 30 mg q 4 hr30 min 15 - 30 min 30 - 60 min1 hr 30 - 60 min 2 - 4 hr6 hr 4 - 6 hr 4 - 8 hrLiver2 - 4 hr( IV use (even at low doses and when given very slowly) may cause marked decrease in blood pressure; IV use is not recommended. ( IM or SQ routes are the preferred parenteral routes. Fentanyl (Sublimaze) (Duragesic) IM IV Trans-dermal 5 mcg/Kg q 1 - 2 hr 0.25 - 1 mcg/Kg as needed 25 mcg/hr 7 - 8 min Immediate 12 - 24 hr20 - 50 min 1 - 5 min 24 hr1 - 2 hr 30 - 60 min 48 - 72 hrLiver1 - 6 hr*( Transdermal should NOT be used to treat acute pain. ( Transdermal patch should be used only in opioid tolerant patients. Effects of patch last for 18 - 24 hours after the patch is removed. ( Use of IV fentanyl is restricted to Oncology, Burn Service, Palliative Care, Intensive Care Units or based on recommendation by the Pain Service. Appropriate monitoring is required. Refer to Nursing Policies 8.021 and 8.025.Hydrocodone with acetaminophen** (Lortab, Vicodin)PO5 - 10 mg hydrocodone q 4 - 6 hr60 min2 hr4 - 6 hrLiver4 hrAvailable at UIHC as: ( Tablet with 5 mg hydrocodone and 500 mg acetaminophen. ( Elixir with 2.5 mg hydrocodone and 167 mg acetaminophen per 5 ml.Hydromorphone (Dilaudid) PO IM/SQ Slow IV 2 - 4 mg q 4 - 6 hr 2 mg q 4 - 6 hr 0.2 - 0.6 mg q 2 - 3 hr 30 min 15 - 20 min 15 - 20 min 60 min 60 min 60 min 4 - 5 hr 4 - 5 hr 4 - 5 hr Liver 2 - 3 hr ( Chronic treatment may require q 3 - 4 hour dosing. ( IV doses should be administered over at least 2-3 minutes. Meperidine (Demerol)IM/SQ IV50 - 150 mg q 3-4 hr 25 - 50 mg q 1-2 hr10 - 45 min 2 - 5 min30 - 60 min 20 min2 hr 2 hrLiver2 - 3 hr( More than 72 hr of continuous use can cause accumulation of normeperidine which can lead to neuroexcitability (seizures). ( Naloxone administration will increase neuroexcitibility. ( Use with caution in the elderly and patients with renal dysfunction. ( Not for use in chronic pain. Do not exceed 600 mg / 24 hours. Opioid Analgesics (continued) DrugRouteDose (Adults > 50Kg)OnsetPeakDurationMetabolismHalf LifeCommentsMethadone (Dolophine)PO 2.5 mg 1 to 4 times daily 30 - 240 min 2 - 4 hr 4 - 24 hr Liver24 hr( Used in chronic pain. ( Continued dosing can result in accumulation and respiratory depression.Morphine (MS Contin) (Avinza)PO/SL IM IV SQ PO-SR PO-SR10 - 15 mg q 3 - 4 hr 4 - 10 mg q 3 - 4 hr 2 - 4 mg q 2 - 4 hr 4 -10 mg q 3 - 4 hr MS Contin: 15 mg q 12 hr Avinza: 30 mg daily15 min 15 - 60 min 2 - 5 min 15 - 30 min N/A N/A1 - 2 hr 30 - 60 min 20 min 30 - 60 min N/A N/A4 hr 4 hr 3 - 4 hr 4 - 7 hr 8 -12 hr 24 hrLiver1.5 - 2 hr 2 - 4 hr 15 hr(Oral liquid concentrate is available. Active metabolite renally eliminated; use caution in elderly and patients with renal insufficiency. ( Long-acting dosage forms should not be crushed. Long-acting dosage forms should not be used to treat acute pain. Avinza is not on the UIHC formulary, but is used by Medicaid.Oxycodone (Percocet)** (OxyContin) PO/SL PO-SR5 -10 mg q 4 - 6 hr-alone or with acetaminophen OxyContin: 10 mg q 12 hr15 - 30 min 60 min1 - 2 hr 2 - 3 hr4 - 6 hr 12 hrLiver4 hr( Available at UIHC as an immediate-release tablet and oral liquid concentration (Percocet contains oxycodone 5mg / acetaminophen 325mg Other strengths of Percocet are available outside UIHC. ( OxyContin is a sustained-release tablet. Do not crush. ( OxyContin should not be used to treat acute pain.*Analgesic duration of action does not correlate with half-life. ** Do not give more than 4 grams of acetaminophen per day (from all sources). SR - sustained release product Guidelines for Patient-Controlled Intravenous Opioid Administration (PCA) for Adults with Acute Pain The amount of opioid required to achieve comfort varies from patient to patient. Adjust dosing to achieve patient comfort with minimal side effects. Drug(Usual Loading DoseUsual PCA Demand Bolus (Range)Usual Lockout RangeUsual Basal RateMorphine (1 mg/ml)5 10 mg1 mg (0.5 - 2.5 mg)5 - 10 minNone or 1 - 2 mg/hrHydromorphone (Dilaudid) (0.2 mg/ml)0.5 1.5 mg0.2 mg (0.05 - 0.4 mg)5 - 10 minNone or 0.1 - 0.4 mg/hrPartially adapted from the Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, American Pain Society, 5th Ed. 2003. Standard concentrations are listed in parentheses. (Contact the Pain Service for other alternatives. Also refer to UIHC Policy and Procedure for Patient Controlled Analgesia Basal infusion rates are discouraged unless the patient has been taking scheduled opioids for more than one week. The addition of basal infusions to PCA increases the incidence and severity of opioid-induced adverse effects, including respiratory depression. Initial Fentanyl Transdermal Dosage (use only when converting another opioid TO fentanyl patch)* Oral 24-hour morphine equivalent (mg/day)Fentanyl transdermal (mcg/hr)60 -13425135-22450225-31475315-404100405-494125495-584150585-674175675-764200765-854225855-944250945-10342751035-1124300*Note: Do not use this table to convert from fentanyl transdermal system to other opioid analgesics because these conversion dosage recommendations are conservative. Use of this table for conversion from fentanyl to other opioids can overestimate the dose of the new agent and may result in an overdosage. Equianalgesic Chart Doses listed are equivalent to 10 mg of parenteral morphine. Doses should be titrated according to individual response. When converting to another opioid, the dose of the new agent should be reduced by 30-50% due to incomplete cross-tolerance between opioids. AnalgesicDosage ParenteralOralFentanyl (Sublimaze()0.1 - 0.2 mg--------------Hydrocodone -------------30 mgHydromorphone (Dilaudid()1.5 mg7.5 mgMeperidine (Demerol()75 - 100 mg300 mg (N)Morphine10 mg30 mg Oxycodone -------------20mg Dosage in this range may lead to neuroexcitability. For a single dose, 10 mg IV morphine = 60 mg oral morphine. For chronic dosing, 10 mg IV morphine = 30 mg oral morphine. (N) Non-formulary at UIHC. Example of opioid conversion: Patient is receiving a total of 5 mg of parenteral hydromorphone in a 24-hour period via a PCA pump. The goal is to convert this to oral morphine for discharge. When converting from PCA administration, add the total amount of opioid that the patient received in the last 24 hours, including Basal infusion Demand boluses administered by the patient Bolus doses administered by the medical/nursing staff The equianalgesic chart indicates that 1.5 mg of parenteral hydromorphone equals 7.5 mg of oral hydromorphone (a 5-fold increase). The patients current dose of 5 mg per day of parenteral hydromorphone is equal to 25 mg per day of oral hydromorphone. The next step is to convert 25 mg of oral hydromorphone to the daily oral morphine equivalent dose (DOMED). The equianalgesic chart indicates that 7.5 mg of oral hydromorphone is equal to 30 mg of oral morphine. The patients calculated dose of 25 mg of oral hydromorphone is equal to 100 mg of oral morphine. The oral dose of morphine should be reduced by 30% to 50% to prevent any risk of overdose after the conversion, since opioids do not have complete cross-tolerance. A 33% dose reduction from the calculated dose of 100 mg is equal to 67 mg of oral morphine per day. The recommended dosing frequency of long-acting morphine (MS Contin ) is every 12 hours (2 doses per day). MS Contin is available in 15 mg, 30 mg, 100 mg and 200 mg controlled-release tablets. The tablet strength closest to the calculated dose is 30 mg. The proper starting dose should therefore be 30 mg of sustained-release morphine every 12 hours. Guidelines for Administering Naloxone for Reversal of Opioid-Induced Respiratory Depression Opioid overdose: ( 0.4 mg 0.8 mg IV/IM/SQ, titrated in accordance with the patients response; repeat as needed. If given IV, each 0.4 mg should be given over 15 seconds. Opioid-induced respiratory depression ( 0.04 mg/ml (40 mcg/ml) dilution in syringe (mix 0.4 mg/1 ml of naloxone and 9 ml of normal saline in a syringe for IV administration). Administer 0.5 ml of diluted solution (0.02 mg or 20 mcg) every 2 minutes until a change in alertness is observed. Titrate naloxone until patient is responsive or a total of 0.8 mg (20 ml of diluted solution) has been given. Continue looking for other causes of sedation and respiratory depression. Discontinue naloxone when patient is responsive to physical stimulation, respiratory rate is > 8 breaths per minute, and able to take deep breaths when told to do so. Special considerations ( May need repeated doses or continuous infusion. Depending on amount and type of opioid given and time interval since last opioid administration, the duration of action of some opioids may exceed that of naloxone. ( Titrate dose cautiously to avoid precipitation of profound withdrawal, seizures, and severe pain. Use of Oral Methadone for Chronic Pain Opioid-nave patients Recommended starting dose range is 2.5 mg daily to 2.5 mg TID. For frail and/or older patients, the starting dose is 2.5 mg daily. Patients taking opioids Determine the daily oral morphine equivalent dose of current opioids. Convert daily oral morphine equivalent dose (DOMED) to oral methadone. Methadone dose should be adjusted every 5 days due to delayed onset of respiratory depression. Methadone Conversion Ratios Current DOMEDConversion ratio (morphine : methadone)Conversion factor (approximate % of DOMED)<30 mg2 : 150%30 99 mg4 : 125%100 299 mg8 : 112.5%300 499 mg12 : 18.3%500 999 mg15 : 16.6%> 1,000 mg20 : 15% Example of conversion to oral methadone: Patient is taking 80 mg Oxycontin orally 3 times daily. The total daily dose of oxycodone is 240 mg daily. The next step is to convert 240 mg of oral oxycodone to the daily oral morphine equivalent dose (DOMED). The equianalgesic chart indicates that 20 mg of oral oxycodone is equal to 30 mg of oral morphine. 5. The patients current dose of 240 mg per day of oral oxycodone is equal to 360 mg per day of oral morphine. The methadone conversion table indicates that a conversion factor for a DOMED of 360mg equals 8.3% or a 12 to 1 ratio of morphine to methadone. The patients DOMED of 360 mg is equal to 30 mg of methadone daily. The recommended dosing frequency of methadone for chronic pain is 1 to 3 times daily, so the proper daily methadone dose would be 10 mg three times daily. May need to use breakthrough medication as needed for the first week, while methadone achieves steady-state blood levels. Pain Medicine Service For difficulties with pain management, contact the Pain Medicine Service at 6-2320 (clinic) or 3832 (on call pager). References: American Hospital Formulary Service Drug Information 2005. American Society of Health-System Pharmacists. American Pain Society (2003). Principles of analgesic use in the treatment of acute pain and cancer pain (5th ed.) Glenview, IL: Author. U.S. Department of Health and Human Services. (1992). Acute pain management: Operative or medical procedures and trauma (AHCPR Publication No. 92-0032). Rockville, MD: Author. VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Department of Veterans Affairs and Department of Defense. 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