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:
- First-line drug is morphine. Use hydromorphone in elderly or renally-impaired.
- Oral to parenteral conversion is ~2:1 for morphine and hydromorphone.
- These conversions are estimates. When changing opioids, use ~75% of the newly calculated dose to avoid overdosing.
- 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.
- Breakthrough (PRN) doses of opiates should be ½ of the regular (Q4H) dose, given Q1H (PO), Q30min (SC) or q10min (IV) PRN.
- 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.
- Always give an antinauseant and a laxative with opiates.
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