Appendices Duration of Action and Dosing of Opioid Analgesics

APPENDIX IV-1

Oral, transdermal, sublingual, buccal, and nasal preparations of different opioids; their analgesic potency and duration of action

Generic name of

Trade name of

Potency in relation

Duration of

opioid

opioid

to morphine = 1

action (h)

Morphine immediate

Morphine sulfate

1

4

release

MSIR

Oxy IR

1

4

OxyFast

1

4

Roxanol

1

4

Oramorph SR

1

8-12

Morphine sustained release

MS Contin

1

8-12

Kadian

1

18-24

Propoxyphene

Darvon

1/50-1/25

4-6

Oxymorphone Sup

Numorphan

12-15

3-6

Oxymorphone extended -

Opara

12-5

12

release

Buprenorphine subl.

Buprenex

20-30

8-10

Buprenorphine TDS

Transtec

20-30

72

Generic name of

Trade name of

Potency in

Duration of

opioid

opioid

relation to

action (h)

morphine = 1

Buprenorphine TDS

TranstecPro

20-30

92

Buprenorphine TDS

Butrans

5-20

92

Fentanyl TTS

Duragesic

800

72

Fentanyl OTFC

Actiq

800

20-30 min

Fentanyl buccal

Fentora

800

60 min

Methadone

Dolophine

3-5

22-48

Meperidine

Demerol

1/10

2-4

Pentazocine

Talwin

1/6

3-4

Butorphanol nasal

Stadol

8-11

3-4

spray

Codeine

Codeine Sulfate

1/10

4

Tramadol

Ultram

1/10-1/5

3-4

HydromorphoneTbl

Dilaudid

7

4-6

HydromorphoneCR

Palladone

7

8-12

Oxycodone Tbl

Roxicodone

2

4-6

Oxycodone SR

OxyContin

2

8-12

Morphine extended

Avinza

1

24

release

Hydromorphone

Jurnista

7

24

OROS technology

Potent oral and sublingual opioid analgesics Step 3 of the analgesic ladder, their initial dose for pain therapy

Opioid

Initial daily dose

Morphine fast release Morphine extended release Methadone

Hydromorphone sustained release Buprenorphine sublingual Oxycodone extended release Hydromorphone extended release Morphine sulfate extended release

4-6 times 10 mg 2-3 times 30/60 mg 3 times 10-20 mg 2-3 times 8/16 mg 3 times 0.2-0.4 mg 2 times 10/20 mg 2 times 4/8 mg Once 30/60/90/120 mg

APPENDIX IV-3

Equianalgesic doses of different opioids when compared to oral morphine

Opioid

Mean

Dose per

Equianalgesic dose

duration of

patient per day

to morphine = 1

action (h)

(mg)

Buprenorphine subl.

8-10

2-3 times

40-50

(Buprenex)

0.2 mg 2-3 times 0.4 mg

60-120

Pentazocine

2-4

6-8 times

25-35

(Talwin)

25 mg 6-8 times 50 mg

50-70

Meperidine

2-4

6-8 times

40-50

(Demerol)

50 mg 6-8 times 100 mg

75-100

Methadone

3-5

6 times 5 mg

60

(Dolophine)

6 times 10 mg

120

Morphine

4-5

6 times

60-180

(Oxy IR)

10-30 mg

Morphine

8-12

2 times

40-400

(MS Contin)

30-60-100 mg

Morphine

12-24

6-8 times

60-120-200

(Kadian)

50 mg 6-8 times 100 mg

Tramadol

3-6

3-4 times

30-40

(Ultram)

50 mg

60-80

Propoxyphene

4-6

6-8 times

40-50

(Darvon)

30 mg

Codeine

3-4

6-8 times

15-30

(Codeine Sulfate,

60 mg

Phosphate)

2-3 times

30-60

Opioid

Mean

Dose per

Equianalgesic dose

duration of

patient per day

to morphine = 1

action (h)

(mg)

Fentanyl TTS

72

diff. patch sizes

600-800

(Duragesic)

25-50-100 ^g/h

Fentanyl buccal

1

100-200-400-

600-800

(Fentora)

600-800 ^g

Buprenorphine TDS

96

diff. patch sizes

(TranstecPro)

35-52.5-75 ^g/h

200-400

(Butrans)

96

5-10-20 ^g/h

5-20

Oxycodone CR

8-12

2 times

(OxyContin)

10/20/40/80/160

15-30-60-120-240

Hydromorphone

8-12

2 times

10-20-40

(Palladone)

4/8/16 mg

Morphine ER

24

once

60-90-120-200

(Avinza)

30-60-90-120

Hydromorphone

24

once

10-20-40-60

OROS (Jurnista)

8-16-32-64mg

Indications for use of opioids with and/or without adjuvants

Indication

• Chronic pain, not attenuated by other methods.

• Intolerable side effects of peripheral analgesics or NSAIDs.

• Insufficient pain relief by NSAIDs.

• Contraindications for use of NSAIDs (e.g., peptic ulcer formation).

• Progression of underlying disease with the necessity to increase the dose of peripheral analgesic.

• Temporary increase in pain intensity where NSAIDs are insufficient.

• Painful syndromes which only respond to opioids.

Examples for use of opioids in chronc pain therapy

• Intense pain in OA where pain results in immobilization.

• Intense pain in osteoporosis where pain results in immobilization.

• Intense back pain, failed back surgery, stenosis of spinal canal, and/or chronic arachnoiditis.

• Post herpetic neuralgia.

• Peri-, post-operative pain for prevention of chronification.

Contraindications for use of opioids Relative

• Simultaneous use of benzodiazepines unless otherwise indicated.

• History of dependency.

• Intolerable side effects. Absolute

• Pain that can be treated sufficiently with other methods.

• Hypersensitivity to opioids.

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