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Commonly used, oral, immediate-release and parenteral pure mu-opioid agonists for chronic pain: Adult dosing and approximate equivalence (refer to notes)

Commonly used, oral, immediate-release and parenteral pure mu-opioid agonists for chronic pain: Adult dosing and approximate equivalence (refer to notes)
Drug
(United States brand name)
Approximate equivalent doses* Sample initial dose
(opioid naïve)
Serum half-life
(hours)
Duration of effect
(hours)
Comments
Oral immediate-release preparations
Hydromorphone
(Dilaudid)
7.5 mg 1 to 2 mg orally every 3 to 4 hours 2 to 3 3 to 6
  • High potency
  • Use reduced dose in renal and/or hepatic impairment
Morphine 30 mg 15 to 30 mg orally every 4 hours 2 to 3 3 to 6
  • 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
Oxycodone
(Oxy-IR, Roxicodone)
20 mg 5 to 15 mg orally every 4 to 6 hours 2 to 3 3 to 6
  • Available as a single entity or combined with acetaminophen, aspirin, or ibuprofen; dose limits apply to combinations
Oxymorphone
(Opana)
10 to 15 mg 5 to 10 mg orally every 4 to 6 hours 7 to 9 3 to 6
  • Take on empty stomach
Parenteral preparations
Fentanyl
(Sublimaze)
0.1 mg (100 mcg) 25 to 50 mcg IV or SQ every 1 to 2 hours 7 to 12

0.5 to 1 (IV)

1 to 2 (SQ)
  • Duration of effect increases after repeated use
  • Can also be administered as a continuous IV or SQ infusion
Hydromorphone
(Dilaudid)
1.5 mg IV/SQ 0.2 to 0.4 mg IV/SQ every 2 to 4 hours 2 to 3 3 to 4
  • High potency (small volume) useful for SQ administration
  • Can also be administered as a continuous IV or SQ infusion
Morphine
(Infumorph, others)
10 mg IV/SQ

2 to 5 mg IV every 2 to 4 hours

2 to 5 mg SQ every 3 to 4 hours
2 to 3 3 to 4
  • Can also be administered as a continuous IV or SQ infusion
  • Active metabolites are dependent on kidney function for clearance; avoid or use reduced dose frequency in organ dysfunction
  • Accumulation of metabolites may contribute to hyperalgesia or other neurotoxicity
Oxymorphone
(Opana)
1 mg IV/SQ

0.5 mg IV every 4 to 6 hours

0.5 to 1.5 mg SQ every 4 to 6 hours
7 to 9 3 to 6  
NOTES:
  • Immediate-release opioids are generally prescribed initially on an as-needed basis. Regularly scheduled dosing may be required for pain control in some patients (eg, patients with cancer pain or for acute pain in patients who chronically use opioids).
  • Equianalgesic conversions serve only as a general guide to estimate opioid dose equivalents. For a review of multiple factors that must be considered for safely individualizing conversion of opioid analgesia, refer to UpToDate reviews of cancer pain management with opioids.
  • 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 oral immediate-release to an extended-release preparation of the same opioid, use the sum of doses of immediate-release 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).
  • For information about extended-release and long-acting preparations, and fentanyl transmucosal preparations for breakthrough pain, refer to the separately available table within UpToDate and the individual drug monographs.
  • Methadone is not included in this table as the oral and parenteral conversion ratio is variable. For guidance on initiating methadone or switching to or from methadone from other opioids, refer to UpToDate topics on cancer pain management with opioids.
mcg: micrograms; IV: intravenous; SQ: subcutaneous.
* When switching to a new opioid, the calculated dose of the new opioid should be reduced by 25 to 50% to adjust for lack of complete mu receptor cross-tolerance. For a review of multiple factors that must be considered for safely individualizing conversion of opioid analgesia, refer to UpToDate topic on cancer pain management with opioids: Optimizing analgesia.
¶ Dose reduction of approximately 50% required for older or debilitated adults, or patients with low cardiac output or respiratory compromise.
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 1.2022.
  2. Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.
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