Commonly Used Opioid Equianalgesic Doses
Medication / Oral Dose
Codeine / 100 mg
Morphine / 10 mg
Oxycodone / 5 mg
Hydromorphone / 2 mg
Tylenol #1= 300mg Acetaminophen + 8mg Codeine
Tylenol #2= 300mg Acetaminophen + 15mg Codeine
Tylenol #3= 300mg Acetaminophen + 30mg Codeine
Tylenol #4= 300mg Acetaminophen + 60mg Codeine
Percocet = 325mg Acetaminophen + 5mg Oxycodone
Key Points to Remember:
1. First-line drug is morphine. Use hydromorphone in elderly or renally-impaired.
2. Oral to parenteral conversion is ~2:1 for morphine and hydromorphone.
3. These conversions are estimates. When changing opioids, use ~75% of the newly calculated dose to avoid overdosing.
4. Regular doses of immediate release opiates should be given Q4H. Sustained-release (SR) opioids should be started only when a stable dose is reached, and given Q8H/Q12H.
5. Breakthrough (PRN) doses of opiates should be ½ of the regular (Q4H) dose, given Q1H (PO), Q30min (SC) or q10min (IV) PRN.
6. Monitor and titrate frequently. Check the frequency of PRN use over 24h, and adjust the regular (Q4H) doses accordingly. Watch for oversedation and respiratory depression.
7. Always give an antinauseant and a laxative with opiates.
*Adapted from Librach, SL and Squires, BP. The pain manual: principles and issues in cancer pain management. Pegasus Healthcare International. November 2002
Fentanyl Patch and Breakthrough Dosing
Total Daily Morphine /Fentanyl Patch Dose
/ Breakthrough Dose (Morphine Q1H PRN)45-134 mg PO / 25mcg/hr / 10 mg PO
135-224 mg PO / 50 mcg/hr / 20 mg PO
225-314 mg PO / 75mcg/hr / 30 mg PO
315-404 mg PO / 100mcg/hr / 40 mg PO
*Adapted from The Compendium of Pharmaceuticals and Specialties. 33rd ed. Canadian Pharmacists Association.
Common Adjuvant Analgesic Medications**Neuropathic Pain
Medication / Notes / Adverse Effects
Nortriptyline 10mg (titrate up to 75mg as tolerated) PO QHS, / Titrate up over 10-14d. Effect delayed 1-2 weeks, may need to further increase dose (100+mg/d) / Sedation, delirium, dry mouth, urinary retention, esp. in elderly
Gabapentin 300mg PO OD, titrate to TID over 3 days / Titrate as tolerated, may need 1.2-1.8g/d. Effect delayed 1-2 weeks / Sedation, expensive (not covered by Ont. Drug Benefit Plan), renal dosing
Carbamazepine 100mg PO BID / Titrate up by 200mg/d until relief obtained (max 1.2-1.6g/d). Must taper slowly. / CNS depression, hepatitis, bone marrow suppression
Dexamethasone 4mg IV/PO Q6H / Rapid action- taper soon, reduces perineural swelling / Can cause hyperglycemia, rarely psychosis. Little long term relief.
Bone Pain- NB: Both agents minimally efficacious
Medication / Notes / Adverse Effects
NSAIDs / Rapid onset, inexpensive. Consider gastric protection. / GI upset, bleeding, constipation, exacerbation of renal failure
Pamidronate 60-90mg IV / Possibly for refractory pain, onset in 2-3 days / Hypocalcemia, may accumulate in renal failure
Adapted from Librach, SL. and Squires, BP. The pain manual: principles and issues in cancer pain management. Pegasus Healthcare International. November 2002
**NB: These are examples of commonly used adjuvant medications and doses. Adjuvant therapies are best prescribed and adjusted with the assistance of a pain-control specialist.
Constipation***
First Attempt / Glycerin or Bisacodyl Suppository 10mg PR x1Wait 2 hours
Second Attempt / Senokot 8.6mg x4-12 tabs daily- stop after 1 week
Milk of Magnesia or Lactulose 30cc PO BID
Third Attempt
(after 3-4 days) / Fleet enema PR x1 if stool in rectum
Saline or tapwater enemas
Fourth Attempt / Magnesium citrate +/- repeat enemas +/- manual disimpaction
***These are intended as recommendations, and should not be used unless obstruction is ruled out.
Common Antinauseant Regimens
Situation / Recommended TherapyMedication
(Numerous classes) / Opioids - Dopamine ant. and consider improved constipation regimen if necessary
Second-line - Serotonin/Histamine ant.
Metabolic (e.g. Kidney/Liver failure, hypercalcemia) / Dopamine/Histamine ant. +/- steroids +/- hydration
Mechanical Obstruction / Surgical option if available
Nonsurgical - Octreotide 100mcg q8-12h, titrate upwards q24h to effect.
Constipation (NB- rule out obstruction) / Stimulant Laxatives (Senna or Bisacodyl) +/- Metoclopramide 20mg IV q6h +/- Erythromycin 250-500mg IV/PO q6h
Sepsis / Dopamine/Histamine ant. + antibiotics
Mucosal Irritation (NSAIDs, GERD) / Proton pump inhibitors +/- Antacids +/- prostaglandins
Myocardial (Ischemia or CHF) / Dopamine/Histamine ant., opioids, oxygen and anxiolytics
Chemotherapy-induced (esp. Platinum-based, cyclophosphamide, anthracyclines) / Acute (<24 hours) - (Serotonin ant. + Dexamethasone 20mg IV +/- metoclopramide 2-3 mg/kg IV) ONCE prior to chemotherapy
Delayed (>24 hours) - (Dexamethasone 8mg BID + dopamine ant. +/- serotonin ant.) x 2-4 days
Radiation-induced (esp. total body, cranial, upper abdomen, mantle) / Serotonin/Dopamine ant. before each fraction
Metastatic Malignancy / Cerebral metastases - Steroids + Dopamine/Histamine ant.
Liver - Dopamine/Histamine ant.
Movement (Vestibular stim.) / Cholinergic ant.
Agitation / Benzodiazepines
Common Antinausea Medications
Class / Medication and Typical DosageSerotonin Antagonist / Ondansetron (Zofran) 8mg IV or PO BID-TID
Granisetron (Kytril) 1mg IV or 2mg PO BID
Dopamine Antagonist / Metoclopramide (Maxeran) 2-3mg/kg IV before and 2h after chemotherapy or 10-20mg (0.5mg/kg) PO/IV BID-QID
Prochlorperazine (Stemetil) 10-20mg PO or 5-10mg IV q6h
Haloperidol (Haldol) 0.5-2mg IV/SC q6h
Histamine Antagonist / Diphenhydramine (Benadryl) 25-50mg IV/PO q4h
Hydroxyzine (Atarax) 25-100mg PO q6h
Cholinergic Antagonist / Scopolamine 1.5mg patch behind ear 4h before needed, replace every 3 days if needed; or 0.1-0.4 mg SC/IV q4h
Glycopyrrolate 0.2mg SC/IV q4h
Steroids / Dexamethasone 6-20mg IV/PO daily
Cannabinoids / Tetrahydrocannabinol 2.5-5mg PO TID
ASCO Antiemetics Guidelines. Gralla et al. J Clin Oncol 17(9):2971
Ian Anderson Program in End-of-Life Care. University of Toronto 2000
Commonly Used Sedative Medications
Class / Example / Use / Side effectsBenzodiazepine / Lorazepam (Ativan) 0.5-1mg PO/SL/SC/IV
Midazolam (Versed) 5mg SC x1 dose, can repeat in 10 minutes / Sedation
Heavy Sedation / Hypotension
Antidepressant / Nortriptyline (Aventyl) 10mg PO QHS
Trazodone (Desyrel) 50mg PO QHS / Nocturnal sedation / Dry mouth, blurred vision, constipation
Neuroleptic / Haloperidol (Haldol) 0.5-1mg PO/IV QHS PRN
Methotrimeprazine (Nozinan) 5-10 mg PO QHS or 25mg SC q4h for acute sedation / Sedation
Heavy Sedation / Hypotension, extrapyramidal symptoms
Ian Anderson Program in End-of-Life Care. University of Toronto 2000