Commonly used opioid equianalgesic doses

Pain and Symptom Control Card
Commonly Used Opioid Equianalgesic Doses
Tylenol #1= 8mg Codeine + 300mg Acetaminophen Medication
Oral Dose
Tylenol #2= 15mg Codeine + 300mg Acetaminophen Tylenol #3= 30mg Codeine + 300mg Acetaminophen Tylenol #4= 60mg Codeine + 300mg Acetaminophen Percocet = 5mg Oxycodone + 325mg Acetaminophen NB: A Tylenol#3 is equivalent to ~3mg of oral morphine plus 300mg Acetaminophen A Percocet is equivalent to ~10mg of oral morphine plus 325mg Acetaminophen Key Points to Remember: 1. First-line drug is morphine. Use hydromorphone in elderly or renally-impaired. 2. Oral to parenteral conversion is roughly 2:1 for morphine and hydromorphone. 3. These conversions are estimates. When changing opioids, use ~75% of the newly 4. Routine doses of immediate release opiates should be given Q4H. 5. Breakthrough (PRN) doses of opiates should be ½ of the regular (Q4H) dose or 10% of the total daily dose. Frequency depends on route: Q1H (PO), Q30min (SC) or q15min (IV). 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 stimulant laxative (e.g. sennokot) with opiates.
Sample Initial Order: Morphine 5mg PO Q1H PRN

After 24h- if pt requested 12 doses (x 5mg) = 60mg total Divide total dose by 6 to get Q4H dose (60/6 = 10mg) New Order: Morphine 10mg PO Q4H + 5mg PO Q1H PRN

Reassess every 24h and adjust accordingly. Fentanyl Patch and Breakthrough Dosing
Total Daily Morphine
Fentanyl Patch Dose
Breakthrough Dose
*Adapted from Health Canada Dosing Conversion Guidelines (March 8, 2010) Common Adjuvant Analgesic Medications**
Neuropathic Pain
Medication
Adverse Effects
Bone Pain
Medication
Adverse Effects
**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
****Do NOT give laxatives until a bowel obstruction has been ruled out. The following is a suggested stepwise approach to a constipated patient. First Attempt
Fleet enema, Sennokot 8.6mg x2 tabs QHS +/- MOM 30cc PO BID Second Attempt
Add bisacodyl 5mg PO QHS/10mg PR QAM +/- Lactulose 30cc PO BID (after 2 days)
Third Attempt
Magnesium citrate +/- repeat enemas +/- manual disimpaction Consider methylnaltrexone 0.15mg/kg SC for opioid-induced constipation Common Antinauseant Regimens- 2 Step Guide
STEP 1: Find the appropriate antinauseant class for the etiology
Etiology
Recommended Class of Medication
Medication
Opioids - Dopamine ant. and consider improved constipation Second-line - Serotonin/Histamine ant. Metabolic (e.g.
Dopamine/Histamine ant. +/- steroids +/- hydration Mechanical
Obstruction
Nonsurgical - Cholinergic ant. +/- Octreotide 100mcg q8-12h,
Constipation (NB- rule
Enemas + Stimulant Laxatives (Senna or Bisacodyl) + Metoclopramide 20mg IV q6h +/- Erythromycin 250-500mg IV/PO q6h Mucosal Irritation
Proton pump inhibitors +/- Antacids +/- prostaglandins Myocardial (Ischemia
Dopamine/Histamine ant., opioids, oxygen and anxiolytics Chemotherapy-
Acute (<24 hours) - (Serotonin ant. + Dexamethasone 20mg IV +/- induced (esp.
metoclopramide 2-3 mg/kg IV) ONCE prior to chemotherapy Delayed (>24 hours) - (Dexamethasone 8mg BID + dopamine ant. Radiation-induced
Serotonin/Dopamine ant. before each fraction Metastatic Malignancy
Cerebral metastases - Steroids + Dopamine/Histamine ant. Liver - Dopamine/Histamine ant. Movement (Vestibular
Agitation/Anticipation
STEP 2: Choose a medication from the appropriate class
Medications and Typical Dosages
Serotonin
Ondansetron (Zofran) 8mg IV or PO BID-TID Antagonist
Granisetron (Kytril) 1mg IV or 2mg PO BID Dopamine
Metoclopramide (Maxeran) 10mg PO/IV BID-QID or 2-3mg/kg IV Antagonist
Prochlorperazine (Stemetil) 10-20mg PO or 5-10mg IV q6h Haloperidol (Haldol) 0.5-2mg IV/SC q6h Histamine
Diphenhydramine (Benadryl) 25-50mg IV/PO q4h Antagonist
Cholinergic
Scopolamine hydrobromide 1.5mg patch behind ear 4h before Antagonist
needed, replace every 3 days if needed; or 0.1-0.4 mg SC/IV q4h Steroids
Cannabinoids
ASCO Antiemetics Guidelines. Gralla et al. J Clin Oncol 17(9):2971 Ian Anderson Program in End-of-Life Care. University of Toronto 2000 Version 2.1 Aug 25th, 2010, by James Downar and Hershl Berman. Copyright James Downar. See J Gen Intern Med 2008 Aug;23(8):1222-7 for publication of a study of this card.

Source: http://robwu.ktp.utoronto.ca/team6/PainSymptoms.pdf