| Drug | Route | Equianalgesic Dose (mg) | Duration (h) | Plasma Half-Life (h) |
|---|---|---|---|---|
| Morphine | IM | 10 | 4 | 2-3.5 |
| Morphine | PO | 30 | 4 | 4 |
| Codeine | IM | 130 | 4 | 3 |
| Codeine | PO | 300 | 4 | |
| Oxycodone | PO | 30 | 3-4 | 4 |
| Hydromorphone (Dilaudid) | IM | 1.5 | 4 | 2-3 |
| Hydromorphone (Dilaudid) | PO | 7.5 | 4 | |
| Meperidine | IM | 75 | 3-4 | 2 |
| Meperidine | PO | 300 | 3-4 | normeperidine |
| Methadone | IM | 10 (note) | 6-8 (note) | 12-24 |
| Methadone | PO | 20 (note) | 6-8 (note) | 20-200 |
| Fentanyl | IV | 0.1 (100mcg) | ||
| Hydrocodone | PO | 30 | 3-4 | 4 |
Fentanyl Patch Conversion Table
| Current Opioid | Daily Dosage (mg/d) | |||
|---|---|---|---|---|
| Morphine PO | 60-134 | 135-224 | 225-314 | 315-404 |
| Morphine IV/IM | 10-22 | 23-37 | 38-52 | 53-67 |
| Oxycodone PO | 30-67 | 67.5-112 | 112.5-157 | 157.5-202 |
| Oxycodone IV/IM | 15-33 | 33.1-56 | 56.1-78 | 78.1-101 |
| Codeine PO | 150-447 | 448-747 | 748-1047 | 1048-1347 |
| Hydromorphone PO | 8-17 | 17.1-8 | 28.1-39 | 39.1-51 |
| Hydromorphone IV | 1.5-3.4 | 3.5-5.6 | 5.7-7.9 | 8-10 |
| Meperidine IM | 75-165 | 166-278 | 279-390 | 391-503 |
| Methadone PO | 20-44 | 45-74 | 75-104 | 105-134 |
| Methadone IM | 10-22 | 23-37 | 38-52 | 53-67 |
| – | Rec’d fentanyl transdermal dose (q72h) | |||
| Fentanyl transdermal (Duragesic) | 25 mcg/h | 50 mcg/h | 75 mcg/h |
100 mcg/h
|
Credit:
10. Pain Management
Resident editors: Rachel J. Stern, MD Margaret C. Lynch, MD Faculty Editors: Kara Bischoff, MD Wendy Anderson, MD
UpToDate:
Selected opioid analgesics for pain and equianalgesic doses
| Drug (US trade names) |
Equianalgesic (mg) doses See important NOTE* |
Sample initial dose for opioid naïve adult¶ (mg) |
Half-life (in hours) |
Duration of analgesic effect (in hours) |
Comments |
| Morphine | 10 IV/SQ/IMΔ |
2 to 5 IV every two to four hours 2 to 10 SQ every three to four hours |
2 to 3 | 3 to 4 | Standard for comparison for opioids; multiple routes available (including tablet, rectal suppository, concentrated enteral liquid, parenteral infusion). |
| 20 to 30 orally | 10 to 30 orally every four hours | 2 to 3 | 3 to 6 | ||
| Controlled-release morphine tablet (MS Contin, Oramorph SR) |
◊ | 15 orally twice daily | 8 to 12 | ||
| Sustained-release morphine capsule (Kadian) |
◊ | 30 orally daily in one or two divided doses | 12 to 24 | ||
| Extended-release morphine capsule (Avinza) |
◊ | 30 orally daily | 24 | ||
| Hydromorphone | 1.5 IV/SQ/IM |
0.3 to 1 IV every two to four hours 0.3 to 1 SQ/IM every three to four hours |
2 to 3 | 3 to 4 | High potency (nearly seven times more potent per mg than morphine) and solubility may be beneficial for patients requiring high opioid doses and for subcutaneous administration. Multiple routes available (including tablet, rectal suppository, enteral liquid, parenteral infusion). |
| 7.5 orally | 2 to 4 orally every three to four hours | 2 to 3 | 3 to 6 | ||
| Controlled-release hydromorphone§ (Canadian trade name: Hydromorph Contin) |
◊ | 3 orally every 12 hours | 12 to 24 | ||
| Extended-release hydromorphone (Exalgo) |
◊ | 8 orally every 24 hours | 24 | ||
| Codeine | 200 orally | 30 to 60 orally every four to six hours | 2 to 4 | 4 to 6 | Codeine is not recommended for chronic pain management because adverse effects increase disproportionately to analgesic effects, as dose is increased. Polymorphisms in drug metabolism, drug interactions and risk of accumulation are also disadvantages of codeine. |
| Oxycodone | 15 to 20 orally | 5 to 15 orally every four to six hours | 2 to 3 | 3 to 6 | Available as a single entity or combined with aspirin or acetaminophen. |
| Controlled-release oxycodone (Oxycontin) |
◊ | 10 orally twice daily | 8 to 12 | ||
| Extended release oxycodone and acetaminophen (Xartemis XR) | ◊ | 15 mg oxycodone/650 mg acetaminophen orally every 12 hours | 8 to 12 | ||
| Extended-release oxycodone and naloxone (Targiniq ER) | ◊ | 10 mg oxycodone/5 mg naloxone orally every 12 hours | 8 to 12 |
Naloxone acts locally on gastrointestinal tract to counteract opioid-associated constipation. Naloxone component should deter some forms of abuse (crush and snorting, dissolve and injecting). |
|
| Hydrocodone | 30 orally | 5 to 10 orally every six hours | 3 to 4 | 4 to 8 |
Short-acting hydrocodone is available only in combination with acetaminophen or ibuprofen in US. Hydrocodone requires activation in the liver by CYP2D6; polymorphisms in drug metabolism, drug interactions, and risk of accumulation are disadvantages. Extended release hydrocodone (Zohydro ER) does not utilize abuse deterrent technology against common forms of abuse (crushing and inhaling or injecting). |
| Extended-release hydrocodone (Zohydro ER) | ◊ | 10 mg orally every 12 hours | ~13 | ≤12 in patients with non-cancer back pain | |
| Oxymorphone | 1 IV/SQ/IM |
0.5 IV every four to six hours 0.5 to 1.5 SQ/IM every four to six hours |
7 to 9 | 3 to 6 | |
| 10 PR§ | 5 every four to six hours (variable effect) | 4 to 6 | |||
| 15 orally | 5 to 10 every four to six hours | ||||
| Extended-release oxymorphone (Opana ER) |
◊ | 5 twice daily | 12 | ||
| Levorphanol | 2 IV/SQ/IM§ |
0.5 to 1 IV every three to six hours 0.5 to 1 SQ/IM every six to eight hours |
11 to 16 | 4 to 8 | With long half-life, accumulation possible after beginning or increasing dose. |
| 4 orally | 2 to 4 every six to eight hours | 11 to 16 | 4 to 8 | ||
| Methadone | 10 IV/SQ/IM¥‡ | 1.25 to 5 IV/SQ/IM every four to eight hours | 12 to 150 |
3 to 4 (initially) 6 to 8 Increases following repeated administration |
Due to its highly variable half-life (from 0.5 to 7 days) and wide inter-individual pharmacodynamics, methadone has the highest risk among opioids of overdose and accumulation during initial titration to effect (as steady state levels are approached) and during dose adjustment in chronic use. The high potency of commercially available formulation (a d,l racemic mixture) is presumably due to the d-isomer, which is a NMDA antagonist and can reverse tolerance and augment analgesia. Methadone may therefore be far more potent than indicated in the table, particularly at higher morphine-equivalent doses. When switching to methadone, the calculated equianalgesic methadone dose should be reduced by 75 to 90 percent, and initiated at no more than 30 mg daily. Due to challenges inherent in safe prescribing of methadone, it is not typically a first-line analgesic choice. |
| 20 orally¥‡ | 2.5 to 10 orally every four to eight hours | ||||
| Fentanyl IV/SQ |
100 micrograms IV/SQ (single fentanyl dose) 250 micrograms IV/SQ (after chronic fentanyl administration) |
25 to 50 micrograms IV/SQ every one to two hours | 7 to 12 |
0.5 to 1 IV† 1 to 2 SQ† Increases following repeated administration |
Can be administered as a continuous IV or SQ infusion. |
| Fentanyl transdermal (TD) system |
Approximate equivalent doses for oral morphine, IV/SQ morphine, and TD fentanyl 60 mg/day oral ≈ 20 mg/day IV/SQ ≈ 25 micrograms/hour TD 120 mg/day oral ≈ 40 mg/day IV/SQ ≈ 50 micrograms/hour TD 180 mg/day oral ≈ 60 mg/day IV/SQ ≈ 75 micrograms/hour TD 240 mg/day oral ≈ 80 mg/day IV/SQ ≈ 100 micrograms/hour TD |
12 to 25 micrograms every 72 hours | 17 after removal |
48 to 72 per patch Up to 12 after removal |
Not usually recommended for opioid naïve patients. Not recommended for acute pain. Onset of effect: 12 to 24 hours. |
| Oral transmucosal fentanyl citrate lozenge (ACTIQ) |
– | NR | 7.6 |
2 (200 mcg) 3.25 (800 mcg) |
Not recommended for opioid naïve patients. Recommended starting dose for breakthrough pain, 200 micrograms, even with high “baseline” opioid doses. Onset of effect: 4 minutes. |
| Fentanyl citrate sublingual tablet (Abstral) |
– | NR | 11.5 to 25 | 1 | Applies to sublingual tablet, sublingual spray, buccal tablet and nasal spray: not recommended for opioid naïve patients. Recommended starting dose for breakthrough pain, 100 micrograms, even with high “baseline” opioid doses. Half-life and duration of effect are dose dependent. Onset of effect: 5 to 15 minutes. |
| Fentanyl sublingual spray (Subsys) | – | NR | 5 to 12 | ≥1 | |
| Fentanyl buccal tablet (Fentora) |
– | NR | 13.3 | 1 to 2 | |
| Fentanyl nasal spray (Lazanda) | – | NR | 15 to 25 | ≥1 | |
| Fentanyl buccal soluble film (Onsolis) | – | NR | 19 | ≥1 | Not recommended for opioid naïve patients. Recommended starting dose for breakthrough pain, 200 micrograms, even with high “baseline” opioid doses. Onset of effect: 15 minutes. |
| Buprenorphine injection (Buprenex) |
0.3 to 0.4 IV/IM | 0.3 every six to eight hours | 2 to 3 | 6 | Partial agonist. Mu receptor antagonism, and associated risk of precipitating withdrawal symptoms, increased in patients dependent upon high opioid doses. Effects may be altered by drug interactions involving CYP3A4. Respiratory depression only partially reversed by naloxone. |
| Buprenorphine transdermal patch (Butrans) |
5 or 10 microgram per hour patch | 5 microgram per hour patch applied every seven days | 26 upon removal | 7 days per patch | Slow onset of up to 72 hours following initial patch application requires tapering of previous opioid analgesia. Prolonged duration of effect following patch removal. Rate of absorption from patch may be increased with application of external heat or fever. Risk of QTc prolongation increases with doses ≥20 mcg per hour. (See buprenorphine injection for additional detail). |
| Mixed mechanism | |||||
| Tapentadol (Nucynta, Nucynta ER) | 75 mg orally |
50 to 100 mg every six hours (immediate release) 50 mg every 12 hours (extended release) |
~4 to 5 |
~3 to 6 immediate release Insufficient data: extended release |
Mixed mu opioid agonist and norepinephrine reuptake inhibitor. For chronic pain, titrate extended release preparation in increments of 100 mg daily, divided twice daily, no more frequently than every three days. Maximum dose 500 mg daily. Dose adjustment needed for moderate hepatic insufficiency. Not recommended for patients with severe renal or hepatic insufficiency (use contraindicated according to licensed information in some countries). Risk of interaction with other serotoninergic drugs. |
| Tramadol (Ultram, Ultram ER, ConZip, Rybix ODT, others) | – |
50 to 100 mg every four to six hours (immediate release) 100 mg once daily (extended release) |
~6 to 9 (includes active metabolite) |
~4 to 6 immediate release, initial use; ~3 to 11 immediate release, chronic use Insufficient data: extended release |
Mixed weak mu opioid agonist and reuptake inhibitor of norepinephrine and serotonin. For chronic pain, titrate extended release preparation in increments of 100 mg daily no more frequently than every five days. Maximum dose 300 mg daily. Risk of drug interactions with other serotoninergic drugs and inhibitors or inducers of CYP3A4 and/or 2D6. Dose adjustment needed for moderate renal or severe hepatic insufficiency. Not recommended for patients with severe renal insufficiency or at risk for seizures, depression, or suicide. Effects of tramadol not fully reversed by naloxone, which may increase seizure risk. |
NMDA: N-methyl-D-aspartic acid; IV: intravenously; SQ: subcutaneously; IM: intramuscularly; PR: per rectum; NR: Preparation not recommended for initial treatment of opioid naïve patients. The total daily dose requirement for long-acting formulation should be established first with the use of an appropriate immediate-release opioid analgesic. See text.
* Equivalence to a 10 mg dose of parenteral morphine sulfate, except fentanyl transdermal as shown. NOTE: Equianalgesic conversions serve only as a general guide to estimate opioid dose equivalents. For a review of multiple factors that must be considered for safely individualizing conversion of opioid analgesia, refer to UpToDate topic on Cancer pain management with opioids: Optimizing analgesia.
¶ Dose reduction of approximately 50 percent required for older or debilitated adults or patients with low cardiac output or respiratory compromise.
Δ IM route not preferred due to pain at injection site.
◊ Opioids such as morphine and hydromorphone have the same equianalgesic potency whether administered in an immediate release or a sustained or extended release form. To convert from oral immediate release to extended release, use sum of doses of immediate release preparation administered during usual interval for the extended release form. For example, morphine sulfate immediate release 30 mg every four hours (180 mg daily) converts to morphine sulfate controlled release 60 mg every eight hours (180 mg daily).
§ Not presently available in the United States.
¥ Variable.
‡ These conversion rates, which differ from those available in other tables and references, represent the recommendations of an expert panel convened to evaluate equianalgesic dosing (Knotkova H. J Pain Symptom Manage 2009; 38:418).
† Bolus administration to opioid naïve patients.
* Equivalence to a 10 mg dose of parenteral morphine sulfate, except fentanyl transdermal as shown. NOTE: Equianalgesic conversions serve only as a general guide to estimate opioid dose equivalents. For a review of multiple factors that must be considered for safely individualizing conversion of opioid analgesia, refer to UpToDate topic on Cancer pain management with opioids: Optimizing analgesia.
¶ Dose reduction of approximately 50 percent required for older or debilitated adults or patients with low cardiac output or respiratory compromise.
Δ IM route not preferred due to pain at injection site.
◊ Opioids such as morphine and hydromorphone have the same equianalgesic potency whether administered in an immediate release or a sustained or extended release form. To convert from oral immediate release to extended release, use sum of doses of immediate release preparation administered during usual interval for the extended release form. For example, morphine sulfate immediate release 30 mg every four hours (180 mg daily) converts to morphine sulfate controlled release 60 mg every eight hours (180 mg daily).
§ Not presently available in the United States.
¥ Variable.
‡ These conversion rates, which differ from those available in other tables and references, represent the recommendations of an expert panel convened to evaluate equianalgesic dosing (Knotkova H. J Pain Symptom Manage 2009; 38:418).
† Bolus administration to opioid naïve patients.
Additional data from:
- Swarm R, et al. Adult Cancer Pain. National Comprehensive Cancer Network Guidelines in Oncology version 2.2012, available at www.NCCN.org.
- Lotsch J, Walter C, Parnham MJ, et al. Pharmacokinetics of non-intravenous formulations of fentanyl. Clin Pharmacokinet 2013; 52:23.
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