quick reference
Converter: Pain Management Opioid Dose Converter
Taper/Stop: Pain Management Taper Calculator
Adult Doses:
Morphine-
- (IV): 2-4 mg IV every 2–4 hours as needed
- (oral): 10–15 mg PO every 4 hours as needed
Fentanyl-
- (IV): 50-100 mcg IV every 30–60 minutes as needed.
Hydromorphone-
- (IV): 0.2–1 mg IV every 2–3 hours as needed
- (oral): 2–4 mg PO every 4–6 hours as needed
Oxycodone
-
Opioid naive: 5-10 mg PO q4hr PRN.
-
Opioid tolerant: 10-30 mg PO q4hr PRN
-
Roughly equianalgesic doses
- 5 mg IV morphine
- 15 mg PO morphine (1/3 as strong as IV).
- 50 mcg IV fentanyl (10x morphine dose in mg).
- 0.75 mg IV HYDROmorphone (7x more potent than IV morphine).
- 6 mg IV nalbuphine.
- 3.75 mg PO HYDROmorphone (4x more potent than PO morphine).
- 10 mg oxycodone (1.5x stronger than PO morphine).
- 15 mg HYDROcodone (1.5x weaker than PO oxycodone).
- 150 mg tramadol (10x less potent than PO morphine).
STOP-ACT:
Acute pain: 5 days
Post op: 7 days
General: <90 mme / day
- 10mg oxycodone q4 = 90mme
- Non-cancer patients: prescribe w/APAP
Pearls
- When switching between opioids: cut 30-50%
- Duration of IV is shorter than oral (2-3 hours vs 6-12 hours)
- Onset of IV is faster than Oral (minutes vs 30-60 min)
Metabolism hiccups
CYP2D6 is required to activate hydrocodone, tramadol, codeine, and oxycodone
CYP2D6 has great
Further Reading
Tramadol probably sucks
Tox & Hound: Tramadont
Tramadol or Tramadont - REBEL EM - Emergency Medicine Blog
Tramadon’t: a podcast with David Juurlink about the dangers of Tramadol
RX Pad: Just Tramadon’t! | Emergency Physicians Monthly
Tramadol or Trama-DON’T?
Tylenol plus Ibuprofen is probably enough for many patients
Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial - PMC
Full article: Ibuprofen/acetaminophen fixed-dose combination as an alternative to opioids in management of common pain types
Effect of Combination of Paracetamol (Acetaminophen) and Ibuprofen vs Either Alone on Patient-Controlled Morphine Consumption in the First 24 Hours After Total Hip Arthroplasty: The PANSAID Randomized Clinical Trial | Substance Use and Addiction Medicine | JAMA | JAMA Network
If you prescribe opioids, you will probably initiate a patient’s dependence/addiction/other adverse event at some point
Factors Associated With Opioid Overdose After an Initial Opioid Prescription | Substance Use and Addiction Medicine | JAMA Network Open | JAMA Network
Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study - PMC
Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015 | MMWR
Opioids are AMAZING for those who need them