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Commonly used, oral and transdermal, long-acting pure mu-opioid agonists for chronic pain in adults (refer to notes)

Commonly used, oral and transdermal, long-acting pure mu-opioid agonists for chronic pain in adults (refer to notes)
Drug Brand name
(United States)
Sample initial dose in opioid-tolerant adults Serum half-life
(hours)
Duration of analgesic effect (hours) Comments
Oral, long-acting preparations
Hydrocodone Hysingla ER 20 mg orally every 24 hours 7 to 9 24
  • May interact with drugs that alter CYP3A4 and CYP2D6 metabolism
  • Converted to active metabolite by CYP2D6, which is subject to polymorphisms; individual effects vary
  • Hysingla ER and Zohydro ER have abuse-deterrent* properties
Zohydro ER 10 mg orally every 12 hours 13 ≤12 in patients with non-cancer back pain
Hydromorphone Exalgo 8 mg orally every 24 hours 11 24
  • Use reduced dose in renal and/or hepatic impairment
  • Exalgo has abuse-deterrent* properties
Hydromorph Contin (available in Canada) 3 mg orally every 12 hours Not specified ≥12
Morphine MS Contin 15 mg orally every 12 hours Not specified 8 to 12
  • Active metabolites are dependent on kidney function for clearance; avoid or use reduced dose frequency in organ dysfunction
  • Accumulation of metabolite may contribute to hyperalgesia or other neurotoxicity
  • Arymo ER has abuse-deterrent* properties
Kadian 30 mg orally daily in 1 or 2 divided doses 11 to 13 12 to 24
Arymo ER 15 mg orally every 8 or 12 hours Not specified 8 to 12
Oxycodone OxyContin, Oxaydo 10 mg orally every 12 hours 4.5 8 to 12
  • OxyContin and Oxaydo have abuse-deterrent* properties
Xtampza ER 9 mg orally every 12 hours 5.6 ≤12
  • Xtampza ER has abuse-deterrent* properties
Oxymorphone Generic only 5 mg orally every 12 hours 9 to 11 12
  • Take on empty stomach
  • Opana ER brand, an abuse-deterrent formulation, was withdrawn from the United States market in mid-2017 due to concerns related to IV injection abuse, including reports of thrombotic microangiopathy; generic extended-release preparations of oxymorphone remain available
Transdermal
Fentanyl Duragesic 12 or 25 mcg per hour, patch applied every 72 hours 17 following patch removal

48 to 72

Some analgesic effect may persist for up to 12 hours following patch removal
  • Onset of analgesic effect is delayed 12 to 24 hours after initial application
  • Approximate dose conversions for fentanyl transdermal and commonly used oral opioids are provided as a separate table in UpToDate
NOTES:
  • The total daily dose requirement for a long-acting opioid formulation should be established first with the use of an appropriate immediate-release opioid analgesic. Details for initiating and adjustment of dose vary by each agent. Refer to UpToDate reviews on chronic non-cancer and cancer pain management with opioids and individual drug monographs (ie, Lexicomp) for detailed information on individual agents.
  • Opioids have similar equianalgesic potency whether administered as an immediate-release form (ie, smaller, more frequently divided doses) or an extended-release preparation. To convert from an oral immediate-release to an extended-release preparation of the same opioid, use the sum of the doses of the immediate-release form administered during the usual interval of the extended-release form. As an example, morphine sulfate immediate-release 30 mg orally every 4 hours (total of 180 mg per day) may be converted to morphine sulfate extended-release 60 mg orally every 8 hours (total of 180 mg per day).
  • Approximate equianalgesic dose equivalents and information on oral immediate-release and parenteral pure mu-opioid agonists that are commonly used in management of chronic non-cancer and cancer-related pain are provided as separate tables within UpToDate.
CYP3A4: cytochrome P450 3A4; CYP2D6: cytochrome P450 2D6; IV: intravenous; mcg: microgram.
* Abuse-deterrent formulations have 1 or more properties that make intentional manipulation of the dose form more difficult (eg, resistant to crushing and dissolution) or less likely to produce an opioid effect (eg, altered to minimize absorption through nasal mucosa). No oral opioid formulation prevents ingestion of an excessive dose.
Courtesy of Kathleen Broglio, DNP, MN, ANP-BC, ACHPN and Russell K Portenoy, MD.
Additional data from:
  1. National Comprehensive Cancer Network. Adult Cancer Pain, Version 2.2016.
  2. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
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