Opioid Agonists2,3 |
Buprenorphine parenteral (Buprenex) | | 300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once | | 300 mcg intravenously slowly once, may be repeated after 30–60 minutes once; or 600 mcg intramuscularly once; $18.20/300 mcg | | |
Buprenorphine transdermal (BuTrans) | Not available | Not available | Not available orally. Transdermal doses available: 5, 10, and 20 mcg/h. Initiate 5 mcg/h patch for opioid-naïve patients (may currently be using nonopioid analgesics); $138.90/10 mcg/h. | Not available | Not available | Not available |
Buprenorphine sublingual (Belbuca) | Sublingual strip approved for pain | | In opioid-naive or opioid-intolerant patients, individualize dose every 12 h. Start: 75 mcg buccally every 12–24 hours for at least 4 days, then increase to 150 mcg buccally every 12 hours, then may increase by no more than 150 mcg buccally every 12 hours no more frequently than every 4 days. Maximum: 900 mcg/12 hours; $6.98/75 mcg. | | | |
Fentanyl | Not available | 100 mcg every hour | Not available | 50–100 mcg intravenously/intramuscularly every hour or 0.5–1.5 mcg/kg/h intravenous infusion; $0.80/100 mcg | Not available | 0.5–1 mcg/kg intravenously every 1–4 hours or 1–2 mcg/kg intravenously × 1, then 0.5–1 mcg/kg/h infusion |
Fentanyl oral transmucosal (Actiq); buccal (Fentora) | Not available | Not available | 200 mcg transmucosal; 100 mcg buccal; $18.80/200 mcg transmucosal; $86.82/200 mcg buccal | Not available | Not available | Not available |
Fentanyl transdermal | Conversion to fentanyl patch is based on total daily dose of oral morphine:2 morphine 60–134 mg/day orally = fentanyl 25 mcg/h patch; morphine 135–224 mg/day orally = fentanyl 50 mcg/h patch; morphine 225–314 mg/day orally = fentanyl 75 mcg/h patch; and morphine 315–404 mg/day orally = fentanyl 100 mcg/h patch | Not available | Not available orally 12.5–25 mcg/h patch every 72 hours; $14.42/25 mcg/h | Not available | 12.5–25 mcg/h patch every 72 hours | Not available |
Hydrocodone, extended release (Zohydro ER) | 20 mg1 | Not available | 10 mg every 12 hours; $9.98/10 mg | Not available | Not available | Not available |
Hydromorphone5 (Dilaudid) | 7.5 mg every 3–4 hours | 1.5 mg every 3–4 hours | 1–2 mg every 3–4 hours; $0.42/2 mg | 1.5 mg every 3–4 hours; $1.80/2 mg | 0.06 mg every 3–4 hours | 0.015 mg/kg every 3–4 hours |
Hydromorphone extended release (Exalgo) | 45–60 mg every 24 hours | Not available | 8 mg every 24 hours; $9.24/8 mg | Not available | Not available | Not available |
Levorphanol | 4 mg every 6–8 hours | Not available | 4 mg every 6–8 hours; $53.40/2 mg | Not available | 0.04 mg/kg every 6–8 hours | Not available |
Meperidine6 (Demerol) | 300 mg every 2–3 hours; usual dose 50–150 mg every 3–4 hours | 100 mg every 3 hours | Not recommended | 100 mg every 3 hours; $2.52/100 mg | Not recommended | 0.75 mg/kg every 2–3 hours |
Methadone (Dolophine, others) | 10–20 mg every 6–8 hours (when converting from < 100 mg long-term daily oral morphine7) | 5–10 mg every 6–8 hours | 5–20 mg every 6–8 hours; $0.31/10 mg | 2.5–10 mg every 6–8 hours; $21.00/10 mg | 0.2 mg/kg every 6–8 hours | 0.1 mg/kg every 6–8 hours |
Morphine5 immediate release (Morphine sulfate tablets, Roxanol liquid) | 30 mg every 3–4 hours (around-the-clock dosing); 60 mg every 3–4 hours (single or intermittent dosing) | 10 mg every 3–4 hours | 4–8 mg every 3–4 hours; used for breakthrough pain in patients already taking controlled-release preparations; $0.49/15 mg tab; $0.84/20 mg liquid | 10 mg every 3–4 hours; $2.25/10 mg | 0.3 mg/kg every 3–4 hours | 0.1 mg/kg every 3–4 hours |
Morphine controlled release (MS Contin) | 90–120 mg every 12 hours | Not available | 15–60 mg every 12 hours; $0.73/30 mg | Not available | Not available | Not available |
Morphine extended release (Kadian) | 180–240 mg every 24 hours | Not available | 20–30 mg every 24 hours; $5.69/30 mg | Not available | Not available | Not available |
Oxycodone (Roxicodone, OxyIR) | 20–30 mg every 3–4 hours | Not available | 5–10 mg every 3–4 hours; $0.15/5 mg | Not available | 0.2 mg/kg every 3–4 hours | Not available |
Oxycodone controlled release (Oxycontin) | 40 mg every 12 hours | Not available | 20–40 mg every 12 hours; $9.46/20 mg | | | |
Oxymorphone5,8 oral, immediate release (Opana) | 10 mg every 6 hours | Not available | 5–10 mg every 6 hours; $1.26/5 mg | Not available | | |
Combination Opioid Agonist–Nonopioid Preparations |
Codeine9,10 (with aspirin or acetaminophen)11 | 180–200 mg every 3–4 hours; commonly available dose in combination with acetaminophen, 15–60 mg of codeine every 4–6 hours | 130 mg every 3–4 hours | 60 mg every 4–6 hours; $0.64/60 mg | 60 mg every 2 hours intramuscularly/subcutaneously; not available in the United States | 0.5–1 mg/kg every 3–4 hours | Not recommended |
Hydrocodone8 (in Lortab, others)11 | 30 mg every 3–4 hours | Not available | 10 mg every 3–4 hours; $0.41/5 mg | Not available | 0.2 mg/kg every 3–4 hours | Not available |
Oxycodone10 (in Percodan, others)11 | 30 mg every 3–4 hours | Not available | 10 mg every 3–4 hours; $1.04/5 mg | Not available | 0.2 mg/kg every 3–4 hours | Not available |
Combination Opioid Agonist–Norepinephrine Reuptake Inhibitor Preparations |
Tapentadol (Nucynta) | Not known | Not known | Start 50–100 mg once, may repeat dose in 1 hour. Can increase to 50–100 mg every 4 hours. Maximum daily dose 600 mg; $13.06/100 mg. | Not available | | Not available |
Tapentadol, extended release (Nucynta ER) | Not known | Not known | Start 50 mg orally every 12 hours. Can increase by 50-mg increments twice daily every 3 days to dose of 100–250 mg twice daily; $16.71/100 mg. | Not available | | Not available |
Tramadol (Ultram) | Not known | Not known | Start 25 mg orally daily. Can increase by 25 mg every 3 days to 25 mg orally 4 times daily, then may increase by 50 mg/day every 3 days to 100 mg orally 4 times daily. Limit of 300 mg/day in patients > 75 years old; $0.83/50 mg. | Not available | | Not available |