Table 1: Opioid Analgesic Drugs
|
DRUG |
ORAL EQUIVALENT |
STARTING DOSAGE |
AGING EFFECTS |
PRECAUTIONS AND |
|
Short-acting drugs |
|
|
Anticipate increased sensitivity and duration of action with advancing age |
Best for episodic or intermittent pains |
|
Morphine sulfate |
30 mg |
15-30 mg q 4h |
Intermediate half-life |
Start low and titrate to comfort and functional |
|
Codeine |
120 mg |
30-60 mg q 4 h |
Acetaminophen-NSAID combinations limit dose; constipation is a major issue |
Anticipate and prevent side effects; begin bowel program early; do not exceed recommended maximum dose of fixed-dose combination formulations |
|
Hydrocodone |
30 mg |
5-10 mg q 3-4 h |
Acetaminophen-NSAID combinations limit dose; toxicity similar to morphine |
Anticipate and prevent side effects; begin bowel program early; do not exceed recommended maximum dose of fixed-dose combination formulations |
|
Oxycodone |
20-30 mg |
5-10 mg q 3-4 h |
Acetaminophen-NSAID combinations limit dose; toxicity similar to morphine; oxycodone is available as a single agent |
Anticipate and prevent side effects; begin bowel program early; do not exceed recommended maximum dose of fixed-dose combination formulations |
|
Hydromorphone |
7.5 mg |
1.5 mg q 3-4 h |
Half-life may be shorter than morphine (3 h); toxicity similar to morphine |
Similar to morphine; start low and titrate to comfort and functional goals |
|
Long-Acting Drugs |
|
|
Anticipate increased sensitivity and duration of action with advancing age |
Best for continuous pain |
|
Sustained-release morphine |
30 mg |
15-30 mg q 12 or 24 h |
Occasionally requires more frequent dosing than recommended on package insert if increasing dose for pain control results in increased adverse effects |
Escalate dose slowly because of possible drug accumulation; short-acting opioid analgesic often necessary for breakthrough pain |
|
Sustained-release oxycodone |
20-30 mg |
10-20 mg q 12 h |
Similar to sustained-release morphine |
Similar to sustained-release morphine |
|
Transdermal fentanyl |
Not applicable |
>25 mcg /h patch not recommended in opioid-naïve patients |
Effective activity may exceed 72 hour usual duration of action |
Titrate slowly using short-acting analgesics for breakthrough pain; peak effects of first dose may take 18-24 hours; a responsible caregiver should be available during dose titration |