1

Brigham and Womens / Dana Farber Guidelines for Opiate Administration / Pain Management Tables (2002)]
[references available from Faulkner Hospital Pharmacy ext. 7247]

Pain Management Tables (7/02)1

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Available Dosing Forms and Selected Comments
Drug Dosing Interval / Common Dosage Comments: - decreased incidence vs. other NSAIDs
Maximum Daily Dose Forms (mg) # - increased incidence vs. other NSAIDs
Acetaminophen 4-6 hours / 4000 mg Tabs: 325, 500 Less than 2 grams/day appears to be tolerated in patients with cirrhosis, monitor closely; essentially no anti-inflammatory
(Tylenol) Soln: 160 mg/5 mL activity; low risk of GI side effects; no effect on platelets
Supp: 120, 325, 650 (Included for comparison; no anti-inflammatory activity)
Drops: 80 mg/ 0.8 mL
Aspirin 4-6 hours / 4000 mg Tab: 81, 325 High risk of GI bleeding; use caution in preexisting liver disease and avoid in severe liver disease; least potent inhibitor of renal
EC Tab: 81, 325 prostaglandins
Supp: 300, 600

Celecoxib 12 hours / 400 mg Tab: 100 incidence of GI ulcerations; minimal to no inhibition of platelet function; cross allergy with sulfonamides
(Celebrex)
Choline Magnesium 8-12 hours / 3000 mg Tab: 750 GI bleeding* vs. aspirin and perhaps vs. NSAIDs as a class, possibly due to minimal anti-platelet activity; use caution in
Trisalicylate (salicylate content) preexisting liver disease and avoid in severe liver disease
(Trilisate)
Ibuprofen 4-8 hours / 3200 mg Tab: 200, 400, 600 Repeated studies have shown doses of 1500 mg/day or less to have the lowest risk of inducing serious GI complications among
(Advil, Motrin) Susp: 100 mg/5 mL non-salicylate NSAIDs; these studies did not include etodolac (Lodinenon-formulary) or nabumetone (Relafen); low risk of
inducing hepatotoxicity, but should be avoided in severe hepatic impairment; possible nephrotoxicity
Indomethacin 8-12 hours / 200 mg Cap: 25, 50 High risk of nephrotoxicity vs. other NSAIDs; headache, tinnitus, dizziness, GI side effects; may aggravate depression or other
(Indocin) Supp: 50 mg psychological disturbances secondary to CNS penetration
Ketorolac 6 hours / 120 mg Injectable: High incidence of headache; nephrotoxicity and GI complications; use no longer than 5 days; use 15 mg in patients greater than
(Toradol) - 15 mg/mL 65 years of age, less than 50 kg, or with renal impairment
- 30 mg/mL
Nabumetone 12-24 hours / 2000 mg Tab: 500, 750 GI bleeding* and side effects; reduce dose in hepatic dysfunction. Daily to twice daily dosing.
(Relafen)
Naproxen 8-12 hours / 1500 mg Tab: 250, 375 hepatotoxicity ( dose 50% in hepatic disease) and possible nephrotoxicity; high tissue penetration; potent inhibitor of
(Naprosyn) leukocyte function; pregnancy category B (1st and 2nd trimester only)
Meclofenamate 4-6 hours / 400 mg Cap: 50 High incidence of diarrhea, GI side effects; do not use for more than 1 continuous week
(Meclomen)
Rofecoxib 24 hours / 25 mg chronic Tab: 12.5 incidence of GI ulcerations; minimal to no inhibition of platelet function
(Vioxx) 50 mg acute (5 days)
Salsalate 8-12 hours / 3000 mg Tab: 500 See choline magnesium trisalicylate
(Disalcid)
# Supp = suppository; Susp = suspension; EC = enteric coated; Soln = oral solution * Limited data versus COX 2 inhibitors

NSAID Selection*
Situation or Patient Population
GI Bleed, history of
Hepatic dysfunction, current
Hepatic dysfunction, high risk
Lactation
Peptic Ulcer
Renal dysfunction, current
Renal dysfunction, pts at risk for
Thrombocytopenia
Warfarin, concurrent use
Consider Generally Avoid
Acetaminophen, celecoxib, ibuprofen, nabumetone, rofecoxib, non-acetylated salicylates** Aspirin, indomethacin, ketorolac, meclofenamate
Acetaminophen (reduced doses) Aspirin, ibuprofen
Ibuprofen Naproxen
Acetaminophen, ibuprofen, ketorolac, naproxen Aspirin, non-acetylated salicylates**
Acetaminophen, celecoxib, rofecoxib, non-acetylated salicylates** Aspirin, indomethacin, ketorolac, meclofenamate
Acetaminophen (reduced doses) Aspirin, choline magnesium trisalicylate, indomethacin
Aspirin, non-acetylated salicylates** Ibuprofen, indomethacin, naproxen
Acetaminophen, rofecoxib, celecoxib, non-acetylated salicylates** All other agents inhibit platelet function and prolong bleeding time to some degree
Acetaminophen, rofecoxib, celecoxib, non-acetylated salicylates** All other agents inhibit platelet function and prolong bleeding time to some degree

* Only formulary items are listed ** non-acetylated salicylates include salicylate salts (choline magnesium trisalicylate) and salsalate
Equianalgesic Opioid Dose Chart and Available Formulations***
Drug Equianalgesic Doses (mg) Available Strengths Comments
IV / IM Oral and Dosage Forms
Morphine 10 30 (chronic) Tab: 15 mg
(MSIR, MS Contin*) CR* Tabs: 15, 30, 60 mg
Soln: 10 mg/5 mL
Suppository: 10 mg
Injectable
Hydromorphone 1.5 7.5 Tab: 2 mg Caution: Do NOT confuse with Morphine.
(Dilaudid) Injectable
Oxycodone N/A 20 Tab: 5 mg Caution: Each Percocet 5 mg/325 mg contains 5 mg Oxycodone and 325 mg Acetaminophen.
(Roxicodone, OxyContin*) CR* Tab: 10, 20 mg Percocet should be ordered as 5 mg/325 mg tablets (only strength on formulary).
Soln: 5 mg/5 mL
Hydrocodone N/A 30 Caution: Each Vicodin tablet contains 5 mg Hydrocodone and 500 mg Acetaminophen.
Codeine 130 200 Tab: 15, 30 mg Doses greater than 60 mg not recommended. Increased nausea and constipation.
Injectable
Fentanyl 0.1 N/A Transdermal Patch: Transdermal patch 25 mcg/hour is equianalgesic to approximately 50 mg of oral morphine per day.
(Sublimaze, 25, 50, 75, 100 mcg/hour
(100 mcg)
Duragesic patch) Injectable
Meperidine 75 300 Tab: 50 mg Not recommended for pain management.
(Demerol) Injectable CNS excitation from metabolite accumulation.
Dose MAX = 600 mg/day; limit to 48 hours.
Methadone 5 to 10 acute 10 to 20 acute Tab: 5, 10 mg Long half life; accumulates with repeated dosing; may require dose decrease on days 2 to 5
(Dolophine) Soln: 5 mg/5 mL
1 to 2 chronic 2 to 4 chronic
Tramadol ** Tab: 50 mg Ceiling dose 400 mg/day (300 mg/day for elderly).
(Ultram) 50 mg of tramadol is equianalgesic to approximately 60 mg of oral codeine.
* CR = Controlled release; Soln = oral solution **Not an opioid; binds to opiate receptors

***These are NOT suggested starting doses; these are doses of opioids that produce approximately the same
amount of analgesia. Published trials vary in the suggested doses that are equianalgesic to morphine. By using
the Equianalgesic Opioid Dose Chart, you can determine a dose of a new (NEW) opioid and/or route of
administration that is approximately equal in analgesic effect to the dose of the former (OLD). Titration to
clinical response is necessary. Recommended doses do not apply to patients with renal or hepatic insufficiency
or other conditions affecting drug metabolism and kinetics. Elderly patients generally require lower doses,
titrated slowly to the desired effect or intolerable side effects. (reference: www.med.umich.edu/PAIN/APAINMGT)
****Incomplete cross-tolerance: Some studies and written clinical impressions suggest that during high-dose
chronic treatment with one strong opioid, patients become somewhat tolerant to that drug but remain relatively
sensitive to different opioids. This is one reason to consider reducing the dose of the NEW drug by 25% to 50%.
(reference: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain; 4th Edition; 1999)
Equianalgesic Conversion Example:
Patient takes OxyContin 20 mg po Q 12 hours and Percocet (5 mg/325 mg) 1 tablet po Q 3 to 4 hours PRN.
Only 1 Percocet (5 mg/325 mg) has been required for breakthrough pain every day. Convert to continuous IV infusion of morphine.
[{OxyContin 20 mg = oxycodone 20 mg CR} and {Percocet (5 mg/325 mg) = oxycodone 5 mg and acetaminophen 325 mg}]
STEP I DAILY OPIOID REQUIREMENT: Calculate patients total daily opioid requirement
(NOTE if taking different opioids, need to convert each to one common opioid)
-- Total daily dose of oxycodone from OxyContin 20 mg 20 mg x 2 doses 40 mg
-- Total daily dose of oxycodone from 1 Percocet (5 mg/325 mg) 5 mg
40 mg oxycodone + 5 mg oxycodone 45 mg oxycodone/day

STEP II OLD to NEW: Convert the daily requirement of the old opioid to that of the new opioid.
EQUIANALGESIC DOSE CONVERSION FORMULA: *** EXAMPLE:
Opiate Allergy: True allergic reactions to opioids are rare (i.e., IgE involvement). Symptoms are usually Equianalgesic Dose for OLD (Chart) = 24-hour dose of OLD (total) 20 mg po oxycodone = 45 mg po oxycodone
secondary to mast cell activation and subsequent histamine release. Selection of another opioid class is usually Equianalgesic Dose for NEW (Chart) (x) 24-hour dose of NEW 10 mg IV morphine (x) mg IV morphine
necessary only if patient has had a true allergic reaction and not simply a sensitivity to histamine release.
(x) = 22.5 mg IV morphine/day (i.e., 22.5 mg IV morphine/day is equianalgesic to 45 mg po oxycodone/day)
class (chemical structure) opiates
diphenylheptanes methadone, propoxyphene STEP III INCOMPLETE CROSS TOLERANCE: ****
phenanthrenes codeine, hydrocodone, hydromorphone, morphine, Consider incomplete cross tolerance and decrease total daily opiate dose by 25% to 50% 11.25 mg to 16.9 mg
oxycodone, levorphanol (non-formulary)
phenylpiperidines fentanyl, meperidine, sufentanil (non-formulary) STEP IV NEW DRUG DOSE:
11.25 mg to 16.9 mg/day divided by 24 hours/day 0.45 mg to 0.7 mg of morphine per hour.