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Opioid Equianalgesic Table
Opioid Equianalgesic
Starting Dose in
Side Effect
Management Considerations
Opioid Naïve
Begin bowel regimen when opioid is initiated; provide a mild stimulant (e.g. senna, Patients
Miralax) plus a stool softener (e.g. Colace). Ensure adequate hydration & avoid www.floridapain.org
Consider clonazepam; dose reduction; or opioid rotation; consider hydration Principles of Pain Management for Adults
Consider prochloperazine, promethazine, metoclopramide, Dose reduction, opioid rotation. (Tolerance to side effect may develop within first week) Goals of pain management are to develop realistic Consider antihistamine, dose reduction, or opioid rotation expectations for pain relief with patient/family, improve Sedation often precedes respiratory depression. Hold opioid & sedating medications. function, minimize pain, & enhance quality of life If RR < 8/min, administer diluted naloxone (1 ml of 0.4mg/ml in 9 ml normal saline – 0.04 mg/ml), 2 ml every 2 minutes until respiratory status is stable. Ask the patient about the presence of pain Tolerance often develops. Hold sedating medications; consider dose reduction & CNS stimulants (e.g. caffeine, modafinil, methphenidate) Consider opioid rotation or dose reduction Is pain acute, chronic or mixed? Is it intermittent For references go to the FPI website: www.floridapain.org
Location, onset, duration, intensity (see pain assessment tools), quality, effect on function & quality of life, alleviating and aggravating factors, patient’s goal, response to prior treatment; Assessment Tools
*Immediate release opioids starting dose History of pain course, physical examination, Please refer to a drug information source for further information on
Assessment may vary in pediatric, geriatric, &/or available formulations, side effects, precautions, and contraindications.
Assess psychosocial factors: pre-existing psychiatric illness &/or depression/anxiety as a result of pain, history of substance abuse, family & social support Monitor outcomes & document the 4 A’s (Passik,
1.
To make equianalgesic conversions use the following information: New Opioid Dose (24 hr mg amount) =
Current Opioid (24 hr mg amount) X New Opioid Equianalgesic Potency Aberrant behavior (compulsive use, loss of control, use despite harm & diversion) For outpatient practitioners use the following for pain Sum the past 24-hour requirement of the current opioid(s) being used. goal setting (5-Rs & E): Reasonable, Reachable, List all opioids the patient has taken in past 24 hrs Recorded, Revisted, Revised, Exit Strategy List all parenteral opioids patient has taken in past 24 hrs If possible, determine the cause or mechanisms of the Set up equianalgesic equations for all listed in #2 (oral & parenteral opioids) pain (inflammatory, neuropathic, visceral, myofacial) The Current Opioid Dose (24 hr mg amount) Use an interdisciplinary, multi-drug, multimodal approach & consider patient preferences 10. Treat persistent pain with scheduled medications Calculate for the total New Opioid Dose (24 hr mg amount) 11. Assess, anticipate & manage side effects Reduce calculated dose of new opioid by 25-50% for incomplete cross 12. Educate regarding safe use of medications, side effects & management, when & how to report Divide this New Opioid Dose by the number of doses to be given per day uncontrolled pain to healthcare provider. based on route and duration of action of the medication 13. Reassess, reexamine, & readjust treatment plan until Use short-acting opioid (rescue) dose for breakthrough or incident pain, Disclaimer: This pain reference guide is intended to serve the user as a brief summary of commonly used
when using long-acting opioid for persistent pain analgesics & is not a complete pain reference resource. All medications should be ordered by physicians or The rescue is 10-15% of the oral 24 hr total daily dose licensed physician extenders. Reviewers and publishers are not responsible for the continued currency of the 14. Change pain medication if side effects unmanageable Schedule PRN rescue doses according to duration of action information or for accuracy, any omissions, the application of this information, or the consequences arising from. 15. Avoid intramuscular route & use oral route if possible If patient is using more than 3 rescue doses a day, consider No official endorsement by any federal agency or pharmaceutical company is intended or inferred. 16. Avoid meperidine & propoxyphene due to potential neurotoxicity, especially in the elderly Recalculate PRN doses if the long-acting dose(s) are increased Made possible by a grant from Endo Pharmaceuticals 17. With geriatric patients, start doses low & titrate slowly Commonly Used Non-Opioids & Commonly Used Co-Analgesics: When dosing, consider age, comorbidities, concomitant medications, renal & hepatic insufficiencies
Commonly us
Dose Range
Maximum Dose in
Comments/Common side effects
Interval
Rectal suppository and sustained-release preparation available; potential liver toxicity with chronic use; 2000 mg/d max with warfarin & in elderly Rectal suppository available & sustained-release preparation available** Contraindicated in sulfonamide allergy, may have decreased platelet effects; risk of cardiovascular events w/ chronic use; lower incidence of adverse GI effects & Lower incidence of GI bleeding, minimal anti-platelet activity** Available as gel (Voltaren) or patch (Flector) with minimal systemic absorption** Caution with severe hepatic dysfunction, diabetes, & gout** FDA approved for OA, RA, may be useful as migraine abortive** May cause peptic ulcers, constipation, heartburn, abdominal pain, nausea,headache, dizziness, pruritis, rash (discontinue if occurs), tinnitus or edema** Constipation; diarrhea; dizziness; drowsiness; gas; headache; nausea; stomach upset** Recommended to use for no longer than 5 days; in elderly, consider using 15 mg IV dose** May cause nausea, constipation, & itching** **Monitor closely for common adverse effects: GI irritation, ulceration & bleeding; renal toxicity & decreased platelet aggregation.

Starting Dose
Dose Range
Comments
Antidepressants
Tricyclic Antidepressants (TCAs)
Amitriptyline (Elavil)
Anticholinergic side effects, QT prolongation, titrate weekly; caution in elderly patients; doses may be divided into TID-QID dosing Selective Serotonin & Norepinephrine Reuptake Inhibitor (SNRI) Antidepressants
Titrate weekly by 20-30 mg as tolerated; FDA indicated for diabetic peripheral neuropathy & fibromyalgia 12.5 mg on day 1, 12.5 mg BID on day 2-3, 25 mg BID days 4-7; FDA indication for fibromyalgia Divide doses BID-TID for regular release; daily for XR; titrate by 75 mg Q 4 days Weak µ-agonist & Norepinephrine &/or Serotonin Reuptake Inhibitor
Predominantly NE reuptake inhibition & minimal 5-HT reuptake inhibition; caution in pt w/ seizure history NE & 5-HT reuptake inhibition; caution in pt w/seizure history Antiepileptics
Titrate weekly; saturable GI absorption-less absorbed as dose increased; FDA indicated for postherpetic neuralgia Refer to package insert for titration; titrate slowly & monitor for rash- Steven Johnson’s syndrome rare-- rash generally begins inside the mouth Titrate weekly; onset faster than gabapentin; FDA indicated for diabetic peripheral neuropathy, postherpetic neuralgia, & fibromyalgia Corticosteroids
Useful in bone pain; prednisone used short-term in rheumatoid arthritis; monitor for adrenal insufficiency; taper off if used > 7 days Local Anesthetic
Do not use on broken skin or w/ heating pad; may cut patch; minimal systemic absorption Antispasmotics/ Skeletal Muscle Relaxants
Baclofen
Best choice for central spasticity; titrate by 5-15 mg Q 3 days Anticholinergic side effects; caution in elderly; general CNS depressant May cause hypotension; administer tablet without food, capsule with food if sedated

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