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PAIN Management:  OPIOIDS, Antagonists, Other

Opiates

Codeine Fentanyl
Hydrocodone Hydromorphone (Dilaudid ® )
Levorphanol (Levo-Dromoran ®) Meperidine (Demerol ®)
Methadone (Dolophine ®) Morphine sulfate
Oxycodone (Roxicodone) Propoxyphene (Darvon ®)
tapentadol- NUCYNTA®  

Non-Narcotic analgesics:

Fioricet® Fiorinal®
Soma compound® Tramadol (Ultram®)

Agonist-Antagonists

Buprenorphene (Buprenex®)  
Butorphanol (Stadol®) Dezocine (Dalgan®)
Nalbuphine (Nubain®) Pentazocine (Talwin®)

Antagonists

Nalmefene (Revex®) Naltrexone
Naloxone (Narcan®)  

Other

Suboxone ® (Buprenorphine and naloxone) Ziconotide (Prialt ®)
Original table
Old table  
Please see package insert for additional information and possible updates. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.    [  Read the disclaimer    |   <<Back     ]

Codeine  top of page

CLINICAL PHARMACOLOGY
The major effects of codeine are on the central nervous system and the bowel. Opioids act as agonists, interacting with stereospecific and saturable binding sites or receptors in the brain and other tissues.

Codeine is readily absorbed from the gastrointestinal tract with the maximum analgesic effect occurring 60 minutes post administration. Codeine retains at least one half its analgesic activity when administered orally.

Dosing (Adult):
Pain: Oral, M, IV, SC: 30 mg (15-60mg) q4-6h prn. (Max 360mg/day).
Cough (non-productive): 10-20mg q4-6h prn (Max: 120 mg/day).

Analgesic:  Oral: 30 mg every 4-6 hours as needed; patients with prior opiate exposure may require higher initial doses. Usual range: 15-120 mg every 4-6 hours as needed

I.M., SubQ: 30 mg every 4-6 hours as needed; patients with prior opiate exposure may require higher initial doses. Usual range: 15-120 mg every 4-6 hours as needed; more frequent dosing may be needed

Antitussive: Oral (for nonproductive cough):
Adults: 10-20 mg/dose every 4-6 hours as needed; maximum: 120 mg/day
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COMBINATION:
Tylenol with Codeine
(APAP/codeine)
#2: 300/15,
#3: 300/30mg,
#4: 300/60 mg: 1-2 tabs orally every 4 to 6 hours as needed.

Antitussive: Based on codeine (15-30 mg/dose) every 4-6 hours (maximum: 360 mg/24 hours based on codeine component)

Analgesic: Based on codeine (30-60 mg/dose) every 4-6 hours (maximum: 4000 mg/24 hours based on acetaminophen component)

Dosing adjustment in renal impairment:
Clcr 10-50 mL/minute: Administer 75% of dose
Clcr<10 mL/minute: Administer 50% of dose

Comments: Oral dose = 2/3 effectiveness of IV route when converting. Adult doses > 60mg fail to give commensurate relief of pain but merely prolong analgesia and are associated with an appreciably increased incidence of side effects.

Supplied:
Injection, as phosphate: 15 mg/mL (2 mL); 30 mg/mL (2 mL)
Solution, oral, as phosphate: 15 mg/5 mL (5 mL, 500 mL)
Tablet, as phosphate: 30 mg, 60 mg
Tablet, as sulfate: 15 mg, 30 mg, 60 mg

Combinations:
CODEINE PHOSPHATE/ ACETAMINOPHEN: Tylenol #2: 15mg/300mg. Tylenol #3: 30mg (codeine)/300mg (APAP). Tylenol #4: 60mg (codeine)/300mg (APAP).
Pain: acetaminophen 300-1000 mg (Max 4000 mg/day); codeine 15-60 mg (Max: 360 mg/day) orally every 4 hours as needed. Pain: 15 ml (1 tbsp) orally every 4 hours as needed.
[Supplied: Suspension: 120 mg-12 mg/5 ml. Tablets: 300/15 mg, 300/30mg, 300/60mg, 650/30 mg]

Fentanyl  top of page

Doses should be titrated to pain relief/prevention. Monitor vital signs routinely. Single I.M. doses have a duration of 1-2 hours, single I.V. doses last 0.5-1 hour.


Dosing (Adults):
Sedation for minor procedures/analgesia: I.M., I.V.: 0.5-1 mcg/kg/dose; higher doses are used for major procedures
Premedication: I.M., slow I.V.: 50-100 mcg/dose 30-60 minutes prior to surgery.
Adjunct to regional anesthesia: I.M., slow I.V.: 50-100 mcg/dose; if I.V. used, give over 1-2 minutes.
Severe pain: I.M.: 50-100 mcg/dose every 1-2 hours as needed; patients with prior opiate exposure may tolerate higher initial doses.
Adjunct to general anesthesia: Slow I.V.:
Low dose: Initial: 2 mcg/kg/dose; Maintenance: Additional doses infrequently needed
Moderate dose: Initial: 2-20 mcg/kg/dose; Maintenance: 25-100 mcg/dose may be given slow I.V. or I.M. as needed
High dose: Initial: 20-50 mcg/kg/dose; Maintenance: 25 mcg to one-half the initial loading dose may be given as needed

General anesthesia without additional anesthetic agents: Slow I.V.: 50-100 mcg/kg with O2 and skeletal muscle relaxant

Mechanically-ventilated patients (based on 70 kg patient): Slow I.V.: 0.35-1.5 mcg/kg every 30-60 minutes as needed; infusion: 0.7-10 mcg/kg/hour

Patient-controlled analgesia (PCA): I.V.: Usual concentration: 50 mcg/mL
Demand dose: Usual: 10 mcg; range: 10-50 mcg
Lockout interval: 5-8 minutes.


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Pain management: Transdermal:
Initial: To convert patients from oral or parenteral opioids to transdermal formulation, a 24-hour analgesic requirement should be calculated (based on prior opiate use). This analgesic requirement should be converted to the equianalgesic oral morphine dose. The initial fentanyl dosage may be approximated from the 24-hour morphine dosage and titrated to minimize adverse effects and provide analgesia. Change patch every 72 hours.    Titration: Short-acting agents may be required until analgesic efficacy is established and/or as supplements for "breakthrough" pain. The amount of supplemental doses should be closely monitored. Appropriate dosage increases may be based on daily supplemental dosage using the ratio of 45 mg/24 hours of oral morphine to a 12.5 mcg/hour increase in fentanyl dosage.    Frequency of adjustment: The dosage should not be titrated more frequently than every 3 days after the initial dose or every 6 days thereafter. Patients should wear a consistent fentanyl dosage through two applications (6 days) before dosage increase based on supplemental opiate dosages can be estimated.   Frequency of application: The majority of patients may be controlled on every 72-hour administration; however, a small number of patients require every 48-hour administration.
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Note:
Muscular rigidity may occur with rapid I.V. administration. During prolonged administration, dosage requirements may decrease.

SUPPLIED:
Infusion [premixed in NS]: 0.05 mg (10 mL); 1 mg (100 mL); 1.25 mg (250 mL); 2 mg (100 mL); 2.5 mg (250 mL)
Injection, solution, as citrate [preservative free]: 0.05 mg/mL (2 mL, 5 mL, 10 mL, 20 mL, 30 mL, 50 mL)
Lozenge, oral transmucosal, as citrate (Actiq®): 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg,
Transdermal system: 25 mcg/hour [6.25 cm 2 ] (5s); 50 mcg/hour [12.5 cm 2 ] (5s); 75 mcg/hour [18.75 cm 2 ]; 100 mcg/hour [25 cm 2 ] (5s)

Hydrocodone top of page

Maximum: 60 mg hydrocodone/day.

DOSING (Adults): >/= 50 kg: Average starting dose in opioid naive patients: Hydrocodone 5-10 mg 4 times/day; the dosage of acetaminophen should be limited to </= 4 g/day (and possibly less in patients with hepatic impairment or ethanol use).

Dosage ranges (based on specific product labeling): Hydrocodone 2.5-10 mg every 4-6 hours; maximum: 60 mg hydrocodone/day (maximum dose of hydrocodone may be limited by the acetaminophen content of specific product)


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COMBINATIONS:
Anexsia (hydrocodone/APAP 5/500, 7.5/650, 10/660) 1 tab orally every 4 to 6 hours as needed.

Vicodin (hydrocodone/APAP 5/500 or Vicodin ES (7.5/750): 1-2 tabs orally every 4 to 6 hours as needed. Max 8 tablets/day (Vicodin) or max 5 tablets/day (Vicodin ES).


Lorcet, Lortab (hydrocodone/APAP)
(5/500): 1-2 tabs orally every 4 to 6 hours as needed. // (7.5/650 & 10/650 ): 1 tab orally every 4 to 6 hours as needed.

Lortab (hydrocodone/APAP 2.5/500, 5/500): 1-2 tabs orally every 4 to 6 hours as needed. // (7.5/500, 10/500): 1 tab orally every 4 to 6 hours as needed.
-------------------------------------------------

Elderly: Doses should be titrated to appropriate analgesic effect; 2.5-5 mg of the hydrocodone component every 4-6 hours. Do not exceed 4 g/day of acetaminophen.

Dosage adjustment in hepatic impairment: Use with caution. Limited, low-dose therapy usually well tolerated in hepatic disease/cirrhosis; however, cases of hepatotoxicity at daily acetaminophen dosages <4 g/day have been reported. Avoid chronic use in hepatic impairment.

SUPPLIED:
Capsule (Bancap HC®, Ceta-Plus®, Lorcet®-HD, Margesic® H, Stagesic®): Hydrocodone bitartrate 5 mg and acetaminophen 500 mg

Elixir: Hydrocodone bitartrate 7.5 mg and acetaminophen 500 mg per 15 mL (480 mL)

Lortab®: Hydrocodone bitartrate 7.5 mg and acetaminophen 500 mg per 15 mL (480 mL) [contains alcohol 7%; tropical fruit punch flavor]

Solution, oral (hycet™): Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg per 15 mL (480 mL) [contains alcohol 7%; tropical fruit punch flavor]

Anexsia®:
5/500: Hydrocodone bitartrate 5 mg and acetaminophen 500 mg
7.5/650: Hydrocodone bitartrate 7.5 mg and acetaminophen 650 mg
Co-Gesic® 5/500: Hydrocodone bitartrate 5 mg and acetaminophen 500 mg

Lorcet® 10/650: Hydrocodone bitartrate 10 mg and acetaminophen 650 mg
Lorcet® Plus: Hydrocodone bitartrate 7.5 mg and acetaminophen 650 mg

Lortab®:
2.5/500: Hydrocodone bitartrate 2.5 mg and acetaminophen 500 mg
5/500: Hydrocodone bitartrate 5 mg and acetaminophen 500 mg
7.5/500: Hydrocodone bitartrate 7.5 mg and acetaminophen 500 mg
10/500: Hydrocodone bitartrate 10 mg and acetaminophen 500 mg

Norco®:
Hydrocodone bitartrate 5 mg and acetaminophen 325 mg
Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg
Hydrocodone bitartrate 10 mg and acetaminophen 325 mg

Vicodin®: Hydrocodone bitartrate 5 mg and acetaminophen 500 mg
Vicodin® ES: Hydrocodone bitartrate 7.5 mg and acetaminophen 750 mg
Vicodin® HP: Hydrocodone bitartrate 10 mg and acetaminophen 660 mg

Zydone®:
Hydrocodone bitartrate 5 mg and acetaminophen 400 mg
Hydrocodone bitartrate 7.5 mg and acetaminophen 400 mg
Hydrocodone bitartrate 10 mg and acetaminophen 400 mg

Hydromorphone (Dilaudid ®)  top of page

Dosing (Adults):
Give 2 to 4 mg orally every 4 to 6 hours as needed.
1-4 mg IM/SC/IV every 4 to 6 hours as needed.
3 mg rectally every 6 to 8 hours as needed.

(Higher doses/more frequent administration may be required in opiate tolerant patients).

Oral: (opiate naive) Start 2-4 mg q3-4h prn. Usual range: 2-8 mg q3-4h prn.
 IV: (opiate naive) Start: 0.2 - 0.6 mg q2-3h prn. Pain, acute: 1-2 mg IV (slow - over 2-3 min) q3h prn.

Mechanically-ventilated pts: 0.7 - 2 mg q1-2h prn or start infusion: 0.5 - 1 mg/hr.
PCA: Usual concentration: 0.2 mg/ml. Demand dose (usual): 0.1 - 0.2 mg (range: 0.05 - 0.5mg). Lockout: 5-15 min. 4 hour limit: 4-6 mg.
Epidural: Bolus: 1-1.5 mg. Infusion conc: 0.05 - 0.075 mg/ml. Infusion rate: 0.04 - 0.4 mg/hr. Demand dose: 0.15mg. Lockout: 30 minutes.
 IM/SC: (opiate naive) Start: 0.8 - 1 mg q4-6h prn. Usual range: 1-2 mg q3-6h prn.
   Acute pain: 1-2 mg   IM/SC q4-6h prn.
Rectal: 3 - 6mg q3-8h prn.
===================
INDIVIDUALIZATION OF DOSAGE
The dosage of opioid analgesics like hydromorphone hydrochloride should be individualized for any given patient, since adverse events can occur at doses that may not provide complete freedom from pain.

Safe and effective administration of opioid analgesics to patients with acute or chronic pain depends upon a comprehensive assessment of the patient. The nature of the pain (severity, frequency, etiology, and pathophysiology) as well as the concurrent medical status of the patient will affect selection of the starting dosage.

In non-opioid-tolerant patients, therapy with hydromorphone is typically initiated at an oral dose of 2-4 mg every four hours, but elderly patients may require lower doses.

In patients receiving opioids, both the dose and duration of analgesia will vary substantially depending on the patient's opioid tolerance. The dose should be selected and adjusted so that at least 3-4 hours of pain relief may be achieved. In patients taking opioid analgesics, the starting dose of DILAUDID should be based on prior opioid usage. This should be done by converting the total daily usage of the previous opioid to an equivalent total daily dosage of oral DILAUDID using an equianalgesic table.

Once the total daily dosage of DILAUDID has been estimated, it should be divided into the desired number of doses. Since there is individual variation in response to different opioid drugs, only 1/2 to 2/3 of the estimated dose of DILAUDID calculated from equivalence tables should be given for the first few doses, then increased as needed according to the patient's response.

Since the pharmacokinetics of hydromorphone are affected in hepatic and renal impairment with a consequent increase in exposure, patients with hepatic and renal impairment should be started on a lower starting dose.

In chronic pain, doses should be administered around-the-clock. A supplemental dose of 5-15% of the total daily usage may be administered every two hours on an "as-needed" basis.

Periodic reassessment after the initial dosing is always required. If pain management is not satisfactory and in the absence of significant opioid-induced adverse events, the hydromorphone dose may be increased gradually. If excessive opioid side effects are observed early in the dosing interval, the hydromorphone dose should be reduced. If this results in breakthrough pain at the end of the dosing interval, the dosing interval may need to be shortened. Dose titration should be guided more by the need for analgesia than the absolute dose of opioid employed.
Acute pain (moderate to severe): Note: These are guidelines and do not represent the maximum doses that may be required in all patients. Doses should be titrated to pain relief/prevention.

Oral: Initial: Opiate-naive: 2-4 mg every 3-4 hours as needed; patients with prior opiate exposure may require higher initial doses; usual dosage range: 2-8 mg every 3-4 hours as needed.

I.V.: Initial: Opiate-naive: 0.2-0.6 mg every 2-3 hours as needed; patients with prior opiate exposure may tolerate higher initial doses.

Note: More frequent dosing may be needed.

Mechanically-ventilated patients (based on 70 kg patient): 0.7-2 mg every 1-2 hours as needed; infusion (based on 70 kg patient): 0.5-1 mg/hour

I.M., SubQ: Note: I.M. use may result in variable absorption and a lag time to peak effect.
Initial: Opiate-naive: 0.8-1 mg every 4-6 hours as needed; patients with prior opiate exposure may require higher initial doses; usual dosage range: 1-2 mg every 3-6 hours as needed
=========================
Chronic pain: Adults: Oral: Note: Patients taking opioids chronically may become tolerant and require doses higher than the usual dosage range to maintain the desired effect. Tolerance can be managed by appropriate dose titration. There is no optimal or maximal dose for hydromorphone in chronic pain. The appropriate dose is one that relieves pain throughout its dosing interval without causing unmanageable side effects.

Controlled release formulation (Hydromorph Contin®, not available in U.S.): 3-30 mg every 12 hours. Note: A patient's hydromorphone requirement should be established using prompt release formulations; conversion to long acting products may be considered when chronic, continuous treatment is required. Higher dosages should be reserved for use only in opioid-tolerant patients.

Extended release formulation (Palladone™): For use only in opioid-tolerant patients requiring extended treatment of pain. Initial Palladone™ dose should be calculated using standard conversion estimates based on previous total daily opioid dose, rounding off to the most appropriate strength available. Doses should be administered once every 24 hours. Discontinue all previous around-the-clock opioids when treatment is initiated. Dose may be adjusted every 2 days as needed.
=======================

SUPPLIED:
Capsule, extended release, as hydrochloride (Palladone™): 12 mg, 16 mg, 24 mg, 32 mg

Injection, powder for reconstitution, as hydrochloride (Dilaudid-HP®): 250 mg.
Injection, solution, as hydrochloride: 1 mg/mL (1 mL); 2 mg/mL (1 mL, 20 mL); 4 mg/mL (1 mL); 10 mg/mL (1 mL, 5 mL, 10 mL)

Dilaudid®: 1 mg/mL (1 mL); 2 mg/mL (1 mL, 20 mL); 4 mg/mL (1 mL)
Dilaudid-HP®: 10 mg/mL (1 mL, 5 mL, 50 mL)

Liquid, oral, as hydrochloride (Dilaudid®): 1 mg/mL (480 mL)

Suppository, rectal, as hydrochloride (Dilaudid®): 3 mg (6s)
Tablet, as hydrochloride (Dilaudid®): 2 mg, 4 mg, 8 mg

Levorphanol (Levo-Dromoran ®)  top of page

Dosing (Adults):
Acute pain (moderate to severe):
Oral: Initial: Opiate-naive: 2 mg every 6-8 hours as needed; patients with prior opiate exposure may require higher initial doses; usual dosage range: 2-4 mg every 6-8 hours as needed

I.M., SubQ: Initial: Opiate-naive: 1 mg every 6-8 hours as needed; patients with prior opiate exposure may require higher initial doses; usual dosage range: 1-2 mg every 6-8 hours as needed

Slow I.V.: Initial: Opiate-naive: Up to 1 mg/dose every 3-6 hours as needed; patients with prior opiate exposure may require higher initial doses

Chronic pain: Patients taking opioids chronically may become tolerant and require doses higher than the usual dosage range to maintain the desired effect. Tolerance can be managed by appropriate dose titration. There is no optimal or maximal dose for levorphanol in chronic pain. The appropriate dose is one that relieves pain throughout its dosing interval without causing unmanageable side effects.

Premedication: I.M., SubQ: 1-2 mg/dose 60-90 minutes prior to surgery; older or debilitated patients usually require less drug

Dosing adjustment in hepatic disease: Reduction is necessary in patients with liver disease

SUPPLIED:
Injection, solution, as tartrate: 2 mg/mL (1 mL, 10 mL)
Tablet, as tartrate: 2 mg

Meperidine (Demerol ®) top of page

Note: Doses should be titrated to necessary analgesic effect. When changing route of administration, note that oral doses are about half as effective as parenteral dose. Oral route not recommended for chronic pain. These are guidelines and do not represent the maximum doses that may be required in all patients.

Dosing (Adults):
Pain:
Oral: Initial: Opiate-naive: 50 mg every 3-4 hours as needed; usual dosage range: 50-150 mg every 2-4 hours as needed.
I.M., SubQ: Initial: Opiate-naive: 50-75 mg every 3-4 hours as needed; patients with prior opiate exposure may require higher initial doses; usual dosage range: 50-150 mg every 2-4 hours as needed

Preoperatively: 50-100 mg given 30-90 minutes before the beginning of anesthesia
Slow I.V.: Initial: 5-10 mg every 5 minutes as needed

Patient-controlled analgesia (PCA): Usual concentration: 10 mg/mL
Initial dose: 10 mg
Demand dose: 1-5 mg (manufacturer recommendations); range 5-25 mg (American Pain Society, 1999).
Lockout interval: 5-10 minutes

Elderly:
Oral: 50 mg every 4 hours
I.M.: 25 mg every 4 hours

Dosing adjustment in renal impairment: Avoid repeated administration of meperidine in renal dysfunction:
Clcr 10-50 mL/minute: Administer at 75% of normal dose
Clcr<10 mL/minute: Administer at 50% of normal dose

Dosing adjustment/comments in hepatic disease: Increased narcotic effect in cirrhosis; reduction in dose more important for oral than I.V. route

Administration
Meperidine may be administered I.M. (preferably), SubQ, or I.V.; I.V. push should be administered slowly, use of a 10 mg/mL concentration has been recommended. For continuous I.V. infusions, a more dilute solution (eg, 1 mg/mL) should be used.

SUPPLIED:
Injection, solution, as hydrochloride [ampul]: 25 mg/0.5 mL (0.5 mL); 25 mg/mL (1 mL); 50 mg/mL (1 mL, 1.5 mL, 2 mL); 75 mg/mL (1 mL); 100 mg/mL (1 mL)
Injection, solution, as hydrochloride [prefilled syringe]: 25 mg/mL (1 mL); 50 mg/mL (1 mL); 75 mg/mL (1 mL); 100 mg/mL (1 mL)
Injection, solution, as hydrochloride [for PCA pump]: 10 mg/mL (30 mL, 50 mL, 60 mL)

Injection, solution, as hydrochloride [vial]: 25 mg/mL (1 mL); 50 mg/mL (1 mL, 30 mL); 75 mg/mL (1 mL); 100 mg/mL (1 mL, 20 mL)

Syrup, as hydrochloride: 50 mg/5 mL (480 mL)
Tablet, as hydrochloride (Demerol®, Meperitab®): 50 mg, 100 mg

Methadone (Dolophine ®) top of page

Important Note: Methadone accumulates with repeated doses and dosage may need to be adjusted downward after 3-5 days to prevent toxic effects. Some patients may benefit from q8-12h dosing intervals.

Dosing (Adults):
Pain:
Oral: Initial: 5-10 mg; dosing interval may range from 4-12 hours during initial therapy; decrease in dose or frequency may be required (~days 2-5) due to accumulation with repeated doses

Manufacturer's labeling: 2.5-10 mg every 3-4 hours as needed

I.V.: Manufacturers labeling: Initial: 2.5-10 mg every 8-12 hours in opioid-naive patients; titrate slowly to effect; may also be administered by SubQ or I.M. injection

Detoxification: Oral: 15-40 mg/day
Maintenance treatment of opiate dependence: Oral: 20-120 mg/day

Dosage adjustment in renal impairment: Clcr<10 mL/minute: Administer 50% to 75% of normal dose
Dosage adjustment in hepatic impairment: Avoid in severe liver disease

SUPPLIED:
Injection, solution, as hydrochloride: 10 mg/mL (20 mL)
Solution, oral, as hydrochloride: 5 mg/5 mL (500 mL); 10 mg/5 mL (500 mL)
Solution, oral concentrate, as hydrochloride: 10 mg/mL (30 mL)
Methadone Intensol™: 10 mg/mL (30 mL)
Methadose®: 10 mg/mL (30 mL) [cherry flavor]
Tablet, as hydrochloride (Dolophine®, Methadose®): 5 mg, 10 mg
Tablet, dispersible, as hydrochloride:
Methadose®: 40 mg
Methadone Diskets®: 40 mg

Morphine sulfate: top of page

Dosing (Adults):
(Regular release): 10-30mg orally every 4 hours.
(MS Contin): 15 to 60mg orally every 8 to 12 hours.
(Oral solution-Roxanol): 10-30 mg orally every 4 hours.
((Injection): usual range: 2-15 mg IM/SC/IV every 4 hours as needed.

Oral (Regular release): 5-30mg q4h prn.
Controlled release MS Contin®: 15-60mg orally every 8 to 12 hours.
Sustained release (Kadian®): See below.

Extended release (Avinza®): 30 - 120mg qd. The daily dose must be limited to a maximum of 1600 mg/day. Doses over 1600 mg/day contain a quantity of fumaric acid that has not been demonstrated to be safe, and which may result in serious renal toxicity. Patients receiving other oral morphine formulations may be converted to Avinza® by administering the patient's total daily oral morphine dose as Avinza® once-daily. Should not be given more frequently than every 24 hours.

 Rectal: 10-30 mg PR q4h prn.
 IM, IV, SC: 2.5 to 20 mg q2-6h prn. Usual: 10mg q4h prn.

 IV/SC continuous infusion: 0.8 - 10 mg/hr. Titrate to response. Usual range: up to 80mg/hr.

Epidural: Start 5 mg in lumbar region. If inadequate relief c/in 1 hr, give 1-2 mg. Max: 10 mg/24 hours.
Intrathecal (1/10th epidural dose): 0.2 - 1 mg. Repeat doses are not recommended.

[Supplied:
Capsule - immediate release (MSIR®): 15, 30mg.
Capsule - extended release (Avinza®): 30, 60, 90, 120mg.
Capsule - sustained release (Kadian®): 20,30, 50, 60, 100mg.
Infusion (premixed in D5W): 0.2 mg/ml (250, 500ml); 1 mg/ml (100, 250, 500ml)
Injection: 0.5 mg/ml (10 ml); 1 mg/ml (10, 30, 50 ml); 2 mg/ml (1 ml); 4 mg/ml (1 ml); 5 mg/ml (1, 30, 50 ml); 8 mg/ml (1 ml); 10 mg/ml (1, 2, 10 ml); 15 mg/ml (1 , 20 ml); 25 mg/ml (4, 10, 20, 40, 50ml); 50 mg/ml (10, 20, 40, 50ml).
Preservative free (Inj) Astramorph®: 0.5 mg/ml (2, 10ml); 1 mg/ml (2, 10 ml). Infumorph®: 10 mg/ml (20 ml); 25 mg/ml (20ml). Duramorph®: 0.5 and1 mg/ml (10 ml)
Oral solution: 10 mg/5ml (5, 100, 500 ml); 20 mg/ml(30, 120, 240ml); 20mg/5ml(30, 120 ml). Roxanol®: 20 mg/ml(30, 120 ml). Roxanol 100®: 100mg/5ml (240 ml).
Suppository: 5, 10, 20, 30mg.
Tablet (MSIR®): 15, 30mg.
Tablet - Controlled release (MS Contin®): 15, 30, 60, 100, 200mg. (Oramorph®): 15, 30, 60, 100mg. ]

Kadian® Conversion from Other Oral Morphine Formulations to Kadian® Patients on other oral morphine formulations may be converted to Kadian® by administering one-half of the patient's total daily oral morphine dose as Kadian® capsules every 12 hours (twice-a-day) or by administering the total daily oral morphine dose as Kadian® capsules every 24 hours (once-a-day). Kadian® should not be given more frequently than every 12 hours.
[Supplied: capsule: 20, 30, 50, 60, 100mg]

Oxycodone (Roxicodone®) top of page

Dosing (Adults):  5 mg orally every 6 hours as needed. [5 mg tab]
(OxyContin- Extended release): 10-40 mg orally every 12 hours. [10, 20, 40, 80, 160mg ]

Pain: (Regular release)- 2.5 - 5 mg po q6h prn.
(Controlled release): 10 - 40 mg po q12h (Much higher doses possible in opiate tolerant patients).
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COMBINATIONS:
Percocet (oxycodone 5 mg/APAP 325 mg): 1 tab orally every 6 hours as needed.
Percodan (Oxycodone 5 mg/ ASA 325mg): 1 tab orally every 6 hours as needed.
Roxicet (oxycodone/APAP 5/325, 5/500): 1 tablet orally every 6 hours as needed.
Tylox (oxycodone 5mg /APAP 500mg): 1 tab orally every 6 hours as needed.

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[Supplied: (oxycodone hydrochloride)
Capsule - immediate release: OxyIR®: 5 mg.
Oral solution (Roxicodone®): 5 mg/5ml (5 ml, 500ml).
Oral solution concentrate (Oxydose®, Oxyfast®, Roxicodone Intensol®): 20mg/ml (30ml)
Tablet: Precolone®: 5 mg. Roxicodone®: 5, 15, 30mg.
Tablet - controlled release (Oxycontin®): 10, 20, 40, 80, 160mg ]

--------------------------
Combinations:
Initial dose based on oxycodone content. Max dose based on APAP content. Dosing: 1 tab q4-6h prn.
[Supplied: Caplet: (Roxicet®): 5/500mg.
Capsule: Tylox®: 5/500mg
Oral Solution: Roxicet®: 5 mg-325mg/5 ml (5ml, 500ml).
Tablet: Endocet®: 5/325 mg. Perocet®: 2.5/325mg, 5/325mg, 7.5/325mg, 7.5/500mg, 10/325mg, 10/650mg. Roxicet®: 5/325mg. Percodan: 5/325mg - 1 tab q6h prn.

Propoxyphene (Darvon ®) top of page

Dosing (Adults):
Propoxyphene Hydrochloride: 65 mg every 3-4 hours as needed for pain; maximum: 390 mg/day
Propoxyphene Napsylate: 100 mg every 4 hours as needed for pain; maximum: 600 mg/day

Darvocet-N® 100: 1 tablet every 4 hours as needed; maximum: 600 mg propoxyphene napsylate/day

Darvocet-N® 50: 1-2 tablets every 4 hours as needed; maximum: 600 mg propoxyphene napsylate/day

Note: Dosage of acetaminophen should not exceed 4 g/day (6 tablets of Darvocet-N® 100); possibly less in patients with ethanol

Elderly:
Hydrochloride: 65 mg every 4-6 hours as needed for pain
Napsylate: 100 mg every 4-6 hours as needed for pain

Dosing adjustment in renal impairment: Serum concentrations of propoxyphene may be increased or elimination may be delayed. Avoid use in Clcr<10 mL/minute. Specific dosing recommendations not available for less severe impairment.

Not dialyzable (0% to 5%)

Dosing adjustment in hepatic impairment: Serum concentrations of propoxyphene may be increased or elimination may be delayed; specific dosing recommendations not available.

SUPPLIED:
Tablet: Propoxyphene hydrochloride 65 mg and acetaminophen 650 mg, propoxyphene napsylate 100 mg, and acetaminophen 650 mg
Darvocet A500™: Propoxyphene napsylate 100 mg and acetaminophen 500 mg [contains lactose]

Darvocet-N® 50: Propoxyphene napsylate 50 mg and acetaminophen 325 mg

Darvocet-N® 100, Pronap-100®: Propoxyphene napsylate 100 mg and acetaminophen 650 mg

Capsule, as hydrochloride (Darvon®): 65 mg
Tablet, as napsylate (Darvon-N®): 100 mg

tapentadol- NUCYNTA®: top of page


NUCYNTA (tapentadol hydrochloride) tablet, film coated


INDICATIONS AND USAGE:
NUCYNTA® is an opioid analgesic indicated for the relief of moderate to severe acute pain in patients 18 years of age or older.

DOSAGE AND ADMINISTRATION:
As with many centrally-acting analgesic medications, the dosing regimen of NUCYNTA® should be individualized according to the severity of pain being treated, the previous experience with similar drugs and the ability to monitor the patient.
Initiate NUCYNTA® with or without food at a dose of 50 mg, 75 mg, or 100 mg every 4 to 6 hours depending upon pain intensity. On the first day of dosing, the second dose may be administered as soon as one hour after the first dose, if adequate pain relief is not attained with the first dose. Subsequent dosing is 50 mg, 75 mg, or 100 mg every 4 to 6 hours and should be adjusted to maintain adequate analgesia with acceptable tolerability. Daily doses greater than 700 mg on the first day of therapy and 600 mg on subsequent days have not been studied and are, therefore, not recommended

DOSAGE FORMS AND STRENGTHS:
Tablets: 50 mg, 75 mg, 100 mg


CONTRAINDICATIONS:
1] Impaired pulmonary function (significant respiratory depression, acute or severe bronchial asthma or hypercapnia in unmonitored settings or the absence of resuscitative equipment)
2] Paralytic ileus
3] Concomitant use with monoamine oxidase inhibitors (MAOI) or use within 14 days

WARNINGS AND PRECAUTIONS
1] Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction.
2] CNS effects: Additive CNS depressive effects when used in conjunction with alcohol, other opioids, or illicit drugs.
3] Elevation of intracranial pressure: May be markedly exaggerated in the presence of head injury, other intracranial lesions.
4] Abuse potential may occur. Monitor patients closely for signs of abuse and addiction.
5] Impaired mental/physical abilities: Caution must be used with potentially hazardous activities.
6] Seizures: Use with caution in patients with a history of seizures.
7] Serotonin Syndrome: Potentially life-threatening condition could result from concomitant serotonergic administration.

ADVERSE REACTIONS
The most common adverse events were nausea, dizziness, vomiting and somnolence.

To report SUSPECTED ADVERSE REACTIONS, contact PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. at 1-800-526-7736 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

DRUG INTERACTIONS
-Use NUCYNTA® with caution in patients currently using specified centrally-acting drugs or alcohol.
-Do not use NUCYNTA® in patients currently using or within 14 days of using a monoamine oxidase inhibitor (MAOI).


USE IN SPECIFIC POPULATIONS
Labor and delivery: should not use during and immediately prior to labor and delivery. Monitor neonates, whose mothers have been taking NUCYNTA®, for respiratory depression.

Nursing mothers: should not breast-feed.

Pediatric use: safety and effectiveness not established in patients less than 18 years of age.

Renal or hepatic impairment: not recommended in patients with severe renal or hepatic impairment. Use with caution in patients with moderate hepatic impairment.

Elderly: care should be taken when selecting an initial dose.


NUCYNTA® ER (tapentadol) extended-release oral tablets C-II


INDICATIONS AND USAGE
NUCYNTA® ER is an opioid agonist indicated for the management of:

-moderate to severe chronic pain in adults.
-neuropathic pain associated with diabetic peripheral neuropathy (DPN) in adults.
-when a continuous, around-the-clock opioid analgesic is needed for an extended period of time.

Limitations of Use
NUCYNTA® ER is not for use:
– As an as-needed (prn) analgesic
– For pain that is mild or not expected to persist for an extended period of time
– For acute pain
– For postoperative pain, unless the patient is already receiving chronic opioid therapy prior to surgery, or if the postoperative pain is expected to be moderate to severe and persist for an extended period of time.

DOSAGE AND ADMINISTRATION
Individualize dosing based on patient's prior analgesic treatment experience, and titrate as needed to provide adequate analgesia and minimize adverse reactions.
The initial dose in patients not currently taking opioid analgesics is 50 mg twice a day.
Instruct patients to swallow NUCYNTA® ER tablets whole.
Use a gradual downward titration when NUCYNTA® ER is discontinued in a physically dependent patient.
Reduce the dose of NUCYNTA® ER in patients with moderate hepatic impairment.
NUCYNTA® ER use in patients with severe renal impairment is not recommended.
Conservative initial dosing of NUCYNTA® ER in elderly patients is recommended due to possible decreased renal and hepatic function.

DOSAGE FORMS AND STRENGTHS
Extended-Release Tablets: 50 mg, 100 mg, 150 mg, 200 mg, 250 mg

CONTRAINDICATIONS
Significant respiratory depression.
Acute or severe bronchial asthma .
Known or suspected paralytic ileus .
Hypersensitivity to tapentadol or to any other ingredients of the product.
Concurrent use of monoamine oxidase inhibitors (MAOI) or use within the last 14 days.

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