▪ Codeine | | | Weak analgesic with no effect in 10% of patients |
| Tablet: 15 mg, 30 mg, 60 mg | PO: 15 mg-60 mg every 4 h-6 h | |
| Injectable: 15 mg/mL, 30 mg/mL 25 mg/300 mg 30 mg/300 mg 60 mg/300 mg | | |
□ With acetaminophen | | Maximum: See PI for acetaminophen dosing | |
— (Tylenol #2) | | | |
— (Tylenol #3) | | | |
— (Tylenol #4)
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▪ Propoxyphene | | | Do not prescribe to patients who are suicidal or addiction prone. |
□ (Darvocet N-100) | Tablet: 100 mg propoxyphene/325 mg acetaminophen | | |
| | 1-2 tablets every 4 h | Prescribe with caution for patients taking tranquilizers, antidepressants or patients who use alcohol in excess, and elderly. |
| | Do not exceed 6 tablets per day | |
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| High dose of acetaminophen per tablet.
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▪ Hydrocodone | | PO: 5 mg-15 mg every 4 h | Less potent and shorter acting than morphine |
□ With ibuprofen | | Elderly: 2.5 mg-5 mg | |
— (Vioprofen) | 7.5 mg/200 mg every 4 to 6 h 2.5 mg/500 mg, 5 mg/500 mg, 7.5 mg/500 mg, 10 mg/500 mg | | |
□ With acetaminophen | | | |
— (Lortab) | | | |
| Elixer: 2.5 mg hydrocodone/167 mg acetaminophen 5 mg/500 mg 7.5 mg/750 mg 10 mg/650 mg | | |
— (Vicodin) | | | |
— (Vicodin ER) | | | |
— (Lorcet)
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▪ Fentanyl | | | |
□ Intravenous | Injectable: 50 μg/mL | Initial dosing: 25 μg-50 μg IV 5-15 min. | Not recommended for intermittent use because of short half-life. |
— (Sublimaze) | | | |
| | | Consider PCA use for acute postoperative pain. |
| | After initial dosing: initial with 10 μg/h to 20 μg/h. Titrate to goal pain control in 10-μg/h increments until 100 μg/h | |
□ Transdermal | | | |
— (Duragesic) | Patch: 12.5 μg, 25 μg, 50 μg, 75 μg, 100 μg | Starting dose: 25 μg every 72 h in opioid-naïve patients with dose increases every 3 days | Transdermal patches are contraindicated in the management of acute or postoperative pain, for mild or intermittent pain response to PRN opioids or nonopioids and in doses>25 μg/h at initiation of opioid therapy. |
| | | Fentanyl patch reaches peak effect in 24 h, maintains constant blood level for 18 h after removal. |
□ Lozenges | | | |
— (Actiq)
| Oral lollilet: 200 μg/unit, 400 μg/unit, 600 μg/unit, 800 μg/unit, 1200 μg/unit, 1600 μg/unit
| Initial dose 200 μg May use 1 additional unit 15 min after previous unit completed for single breakthrough episode Maximum 4 units/d
| Indicated only for the management of breakthrough cancer pain in opioid-tolerant patients. Contraindicated in the management of acute or postoperative pain or opioid naïve patient. Only approved for cancer pain in opioid-tolerant patients. Unit should be allowed to dissolve, not chewed or bitten. Caution around children. Must be disposed of properly according to manufacturer's recommendations.
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▪ Hydromorphone | | | |
□ (Dilaudid) | Liquid: 1 mg/mL | PO:1 mg-2 mg every 3-4h | Slightly shorter duration of action than morphine. |
| Tablet: 1 mg, 2 mg, 3 mg, 4 mg, 8 mg | | PCA use for acute postoperative pain. |
| Suppository: 3 mg | PR: 3 mg every 6-8 h | Less pruritus than with morphine. |
| Injectable: 1 mg/mL, 2 mg/mL, 4 mg/mL
| IV: 0.5 mg-1 mg every 3-4 h
| Short half-life, a good choice for elderly.
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▪ Meperidine | | | |
□ (Demerol)
| Injectable: 25 mg/mL, 50 mg/mL, 75 mg/mL
| Oral use not recommended IV use limited to: treatment of rigors, documented allergy to all other opioids, moderate sedation (patient with normal renal function and no history of seizures) IV: 25-50 mg every 1-2 h Maximum dose: 600 mg/24 h
| Toxic metabolite accumulates with repetitive dosing to cause CNS excitation/seizures. Contraindication: renal failure, history of seizures, or MAOI use within 2 weeks. Use with caution in patients receiving St John's Wort.
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▪ Methadone | | | Cardiac and respiratory deaths have been reported during initiation and conversion of patients to methadone. |
□ (Dolophine) | Tablet: 5 mg, 10 mg | PO: 5 mg-10 mg every 6-8 h | |
| Oral solution: 1 mg/mL, 10 mg/mL | Elderly: 2.5 mg every 6-8 h | |
| | | Respiratory depression is the chief hazard associated with methadone administration. |
| Injectable: 10 mg/mL | | |
| | | Cases of QT interval prolongation and serious arrhythmia have been observed during methadone treatment. |
| | | Accumulates with repeated dosing and requires decreases in dose and frequency especially on days 2-5. |
| | | Long half-life, peak effect in 4-10 days. |
| | | Dose decreased for renal impairment. |
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| Consult a conversion chart for converting from another opioid to methadone.
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▪ Morphine IR | | | Metabolites may accumulate with prolonged use, especially in renal failure leading to sedation, pruritus, confusion, respiratory depression. |
□ (MSIR, Roxanol) | Tablet: 10 mg, 15 mg, 30 mg | PO: 10 mg-30 mg every 3-4 h | |
| Liquid: 2 mg, 4 mg, 20 mg | IV: 2 mg-5 mg every 2-4 h | |
| | | PCA use for acute postoperative pain. |
| Suppository: 5 mg, 10 mg, 15 mg, 30 mg | PR: 5 mg-10 mg every 4-6h | |
| | | Liquid contains alcohol. |
| Injectable: 2 mg/mL, 4 mg/mL, 8 mg/mL, 10 mg/mL | Continuous infusion: Initiate at 1 mg/h to 2 mg/h. | |
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| Titrate to goal pain control in 1-mg/h increments, until 6 mg/h, then increase in 2-mg/h increments.
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▪ Morphine CR | | | |
□ (MS Contin) | Tablet: 15 mg, 30 mg, 60 mg, 100 mg, 200 mg | PO: 30 mg every 12 h | Tablet not to be cut, crushed, or chewed. |
| | Elderly: 15 mg every 12 h | |
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| Dose should be based on or adjusted to IR requirements.
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▪ Morphine ER | Capsules | | Indicated for once-daily administration for the relief of moderate to severe pain requiring continuous, around-the-clock opioid therapy for an extended period of time. |
□ (Avinza) | 30 mg, 60 mg, 90 mg, 120 mg | PO: 30 mg daily | |
□ (Kadian) | 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg | PO: 50% of other oral morphine dose every 12 h, or 100% daily | |
| | | Capsules should be swallowed whole or sprinkled on applesauce. |
| | Dose should be based on or adjusted to IR requirements | Do not chew or crush because of risk of rapid release and absorption of a potential fatal dose of morphine. |
| | | Consumption of alcohol while taking Avinza may result in the rapid release and absorption of a potentially fatal dose of morphine. |
| | | G-tube administration: flush 16 French or larger G-tube with 10 mL of water. Open capsule and sprinkle into 15 mL of apple juice. Using 30-mL catheter tip syringe, draw up juice and medication. |
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| Holding the syringe horizontally, slowly administer the solution into the G-tube. Flush with another 10 mL of apple juice.
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▪ Oxycodone (IR) | Tablet: 5 mg, 15 mg, 30 mg | PO: 5 mg-10 mg every 3-4 h | Simultaneous use of aspirin, ibuprofen, or acetaminophen limits dose of combination products. |
□ (Roxicodone) | | | |
| Solution: 5 mg/5 mL | Elderly: 2.5 mg- 5 mg | |
□ (OxyIR) | Capsule: 5 mg | | |
□ With acetaminophen | 2.5 mg/325 mg, 5 mg/325 mg, 7.5 mg/500 mg, 10 mg/650 mg | | |
— (Percocet, Endocet Roxicet)
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▪ Oxycodone (CR) | Tablet: 10 mg, 20 mg, 40 mg, 80 mg | PO: 10 mg-20 mg every 12 h | Indication for the management of moderate to severe pain when continuous, around-the-clock analgesics needed for an extended period of time. |
□ (OxyContin) | | Elderly: 10 mg every 12 h | |
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| Tablet not be crushed or chewed because of rapid release and absorption of potentially fatal oxycodone.
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▪ Oxymorphone (IR) | Tablet: 5 mg, 10 mg | PO: 5 mg-10 mg every 4-6 h | Not indicated as first- or second- line therapy for pain management. Patients stabilized on oxymorphone as outpatients may continue therapy when admitted. |
□ (Opana)
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| Must be given on an empty stomach 1 h before or 2 h after a meal.
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▪ Oxymorphone ER | Tablet: 5 mg, 10 mg, 20 mg, 40 mg | PO: 5 mg every 12 h Dose should be based on or adjusted to IR requirements | Indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time. |
□ (Opana ER) | | | Not intended for use as a PRN analgesic. |
| | | Tablets are to be swallowed whole and are not to be broken, chewed, dissolved, or crushed. Taking broken, chewed, dissolved or crushed tablets leads to rapid released and absorption of a potentially fatal dose of oxymorphone. |
| | | Patients must not consume alcoholic beverages, or prescription or nonprescription medications containing alcohol. The co-ingestion of alcohol may result in increased plasma levels and a potentially fatal overdose of oxymorphone. |