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Pain Management
Opiates:  updated list
Codeine Dosing:
Pain
: Oral, M, IV, SC: 30 mg (15-60mg) q4-6h prn. (Max 360mg/day).  
Cough (non-productive): 10-20mg q4-6h prn (Max: 120 mg/day). 

Comments: Oral dose = 2/3 effectiveness of IV route when converting. Adult doses > 60mg fail to give commensurate relief of pain but merely prolong analgesia and are associated with an appreciably increased incidence of side effects.

[Supplied: codeine phosphate (inj): 30 mg (1,2 ml); 60 mg (1,2 ml);  Solution: 15 mg/5 ml. Tablet: 30, 60 mg.
Codeine sulfate: 15, 30, 60mg tablet.]

CODEINE
Combinations:
PHOSPHATE/ ACETAMINOPHEN
Tylenol #2: 15mg/300mg. Tylenol #3: 30mg (codeine)/300mg (APAP).  Tylenol #4: 60mg (codeine)/300mg (APAP). 
Pain: acetaminophen 300-1000 mg (Max 4000 mg/day); codeine 15-60 mg (Max: 360 mg/day) orally every 4 hours as needed.   Pain: 15 ml (1 tbsp) orally every 4 hours as needed.
[Supplied: Suspension: 120 mg-12 mg/5 ml.   Tablets:  300/15 mg, 300/30mg, 300/60mg, 650/30 mg] 
Fentanyl patch Duragesic ® Apply 1 patch every 3 days.

Sedation for minor procedures: IM/IV: 0.5 - 1 mcg/kg. Higher doses for major procedures.
Preoperative sedation /adjunct to regional anesthesia/ postop pain: IM/IV 50-100 mcg/dose.
Continuous sedation (ICU etc): Start 25-50 mcg bolus, f/b continuous infusion of 1-3 mcg/kg/hr. Titrate to response.
Breakthrough cancer pain: (Transmucosal - Actiq®): Start 200mcg x1. Monitor pt closely. May redose in 15min if necessary. Titrate dose so that can be treated with a single dose (usually requires 1-2 days to determine). Consumption should be limited to 4 doses/day, otherwise reevaluate maintenance opiate for an increase.
Transdermal: Start 25 mcg/hr q72h. If patient is currently receiving opiates, convert to fentanyl patch equiv. Rarely patients may require q48h dosing schedule. Renal: consider 50% reduction of dose in renal failure.

[Supplied
Fentanyl citrate (inj)
: 50 mcg/ml (2,5,10, 20, 30, 50ml). Sublimaze®: 50 mcg/ml (2, 5, 10, 20 ml)
Lozenge Actiq®: 200, 400, 600, 800, 1200, 1600 mcg.  
Transdermal (Duragesic®)
: 25, 50, 75, 100 mcg/hr ]

Apply to non-irritated/non-irradiated flat skin surface (chest, back, flank or upper arm). Press firmly in place with the palm of the hand for 30 seconds, ensuring complete contact, especially around the edges hair at the application site should be clipped (not shaved) prior to system application. Clean site prior to application if needed with clear water only - do not use soaps, oils, lotions, alcohol. Dry completely prior to system application.  Do not alter/cut the system.

HydrocodoneLimit APAP to 4 grams/day or less. Dosing (tablets with 5 mg hydrocodone): 1-2 tablets q4-6h prn or 5-10 ml q4-6h prn. (Tablets with 7.5 or 10 mg hydrocodone): 1 tab q4-6h prn 
Maximum: 60 mg hydrocodone/day.


[Supplied: Capsule: Bancap HC®, Ceta-Plus®, Hydrocet®, Hydrogesic®, Lorcet-HD®  (5/500mg).
Elixir Lortab®:  2.5 mg - 167mg/ 5 ml (480 ml)  
Tabets: 2.5/500mg,  5/500mg,  7.5/500mg,  7.5/650 mg, 7.5/750 mg, 10mg/325mg, 10/500mg, 10/650mg.
Anexsia ®(tablets): 5/325mg, 5/500mg, 7.5/325mg, 7.5/650mg, 10/660mg.  Co-Gesic®: 5/500mg.  Lorcet ®: 10/650mg. Lorcet® Plus: 7.5/650mg.  Maxidone®: 10/750mg.  Norco®: 5/325mg,  7.5/325mg,10/325mg.  Vicodin®: 5/500mg. Vicodin ES ®: 7.5/750mg.  Vicoden® HP: 10/660mg.  Zydone®: 5/400mg,  7.5/400mg, 10/400mg. ]
Hydromorphone Dilaudid ® Give 2 to 4 mg orally every 4 to 6 hours as needed.  
1-4 mg IM/SC/IV every 4 to 6 hours as needed.  
3 mg rectally every 6 to 8 hours as needed.

(Higher doses/more frequent administration may be required in opiate tolerant patients).
Oral: (opiate naive) Start 2-4 mg q3-4h prn. Usual range: 2-8 mg q3-4h prn.
IV: (opiate naive) Start: 0.2 - 0.6 mg q2-3h prn.  Pain, acute: 1-2 mg IV (slow - over 2-3 min) q3h prn.
Mechanically-ventilated pts: 0.7 - 2 mg q1-2h prn or start infusion: 0.5 - 1 mg/hr.
PCA: Usual concentration: 0.2 mg/ml.  Demand dose (usual): 0.1 - 0.2 mg (range: 0.05 - 0.5mg).  Lockout: 5-15 min. 4 hour limit: 4-6 mg.
Epidural: Bolus: 1-1.5 mg. Infusion conc: 0.05 - 0.075 mg/ml. Infusion rate: 0.04 - 0.4 mg/hr. Demand dose: 0.15mg. Lockout: 30 minutes.
IM/SC: (opiate naive) Start: 0.8 - 1 mg q4-6h prn. Usual range: 1-2 mg q3-6h prn. Acute pain: 1-2 mg IM/SC q4-6h prn.
Rectal: 3 - 6mg q3-8h prn.

[Supplied
Powder for injection
(hydromorphone HCl): 250mg.
Injection (HCl):  1 mg/ml (1 ml); 2 mg/ml (1, 20ml); 4 mg/ml (1 ml).  Dilaudid-HP®: 10mg/ml (1, 5, 50ml).
Oral liquid (hydromorphone HCl): 1 mg/ml (480 ml).
Suppository (rectal): 3 mg.
Tablet: 2, 4, 8mg. ]

Levorphanol Levo-Dromoran ® 2 mg orally or SC every 6 to 8 hours as needed.
Meperidine  
Demerol ®
25-150 mg IM/SC/IV/orally every 3 to 4 hours  as needed.

Analgesic: Oral, IM, IV, SC: 50-150 mg q3-4h prn. Oral therapy is discouraged.   Oral dose: 50% effectiveness of IV route. 25-150 mg IM/SC/IV/orally every 3 to 4 hours  as needed.

[Supplied: infusion: 10mg/ml (30ml).   
Injection (meperidine HCl): Multidose vial: 50mg/ml (30ml); 100mg/ml (20ml). Single dose:  25 mg(1 ml); 50mg/ml (1 ml); 75 mg(1 ml); 100mg (1 ml);  Syrup: 50mg/5ml (500ml).  Tablet: 50, 100mg ]

Methadone Dolophine ® Severe pain: 2.5 to 10mg IM/SC/orally every 3 to 4 hours as needed. Detox: 15-40mg orally once daily to start.

Important Note: Methadone accumulates with repeated doses and dosage may need to be adjusted downward after 3-5 days to prevent toxic effects. Some patients may benefit from q8-12h dosing intervals.  

Analgesia: Oral, IM, SC: 2.5 - 10 mg q3-8h prn up to 5-20mg q6-8h.  Detoxification: Oral: 15-40mg qd. Should not exceed 21 days and may not be repeated earlier than 4 weeks after completion. Maintenance of opiate dependence: 20-120mg qd. 

[Supplied: Injection: 10 mg/ml (20 ml).
Oral solution: 5 mg/ml (5, 500ml); 10 mg/5 ml (500ml).
Solution - oral concentrate: 10 mg/ml (30ml).
Tablet: 5, 10 mg. Tablet-dispersable: 40mg disket ]

 

 

Morphine sulfate:

(Regular release): 10-30mg orally every 4 hours. 
(MS Contin): 15-60mg orally every 8 to 12 hours. 
(Oral soln-Roxanol): 10-30 mg orally every 4 hours. (Injection): usual range: 2-15 mg IM/SC/IV every 4 hours as needed.

Oral (Regular release): 5-30mg q4h prn. 
Controlled release MS Contin®: 15-60mg orally every 8 to 12 hours.  
Sustained release (Kadian®): See below.    
Extended release (Avinza®)
: 30 - 120mg qd.   The daily dose must be limited to a maximum of 1600 mg/day. Doses  over 1600 mg/day contain a quantity of fumaric acid that has not been demonstrated to be safe, and which may result in serious renal toxicity. Patients receiving other oral morphine formulations may be converted to Avinza® by administering the patient's total daily oral morphine dose as Avinza® once-daily. Should not be given more frequently than every 24 hours.
Rectal: 10-30 mg PR q4h prn.  
IM, IV, SC:  2.5 to 20 mg q2-6h prn. Usual: 10mg q4h prn.
IV/SC continuous infusion: 0.8 - 10 mg/hr. Titrate to response. Usual range: up to 80mg/hr.
Epidural: Start 5 mg in lumbar region. If inadequate relief c/in 1 hr, give 1-2 mg. Max: 10 mg/24 hours.
Intrathecal (1/10th epidural dose): 0.2 - 1 mg. Repeat doses are not recommended. 

[Supplied
Capsule - immediate release (MSIR®): 15, 30mg.
Capsule - extended release (Avinza®): 30, 60, 90, 120mg.
Capsule - sustained release (Kadian®): 20,30, 50, 60, 100mg.
Infusion (premixed in D5W): 0.2 mg/ml (250, 500ml); 1 mg/ml (100, 250, 500ml)
Injection: 0.5 mg/ml (10 ml); 1 mg/ml (10, 30, 50 ml); 2 mg/ml (1 ml); 4 mg/ml (1 ml); 5 mg/ml (1, 30, 50 ml); 8 mg/ml (1 ml); 10 mg/ml (1, 2, 10 ml);  15 mg/ml (1 , 20 ml); 25 mg/ml (4, 10, 20, 40, 50ml);  50 mg/ml (10, 20, 40, 50ml).
Preservative free (Inj) Astramorph®: 0.5 mg/ml (2, 10ml);  1 mg/ml (2, 10 ml).  Infumorph®: 10 mg/ml (20 ml); 25 mg/ml (20ml).  Duramorph®: 0.5 and1 mg/ml  (10 ml)
Oral solution: 10 mg/5ml (5, 100, 500 ml);  20 mg/ml(30, 120, 240ml);  20mg/5ml(30, 120 ml).  Roxanol®: 20 mg/ml(30, 120 ml).  Roxanol 100®: 100mg/5ml (240 ml).
Suppository: 5, 10, 20, 30mg.  
Tablet (MSIR®): 15, 30mg.
Tablet - Controlled release (MS Contin®): 15, 30, 60, 100, 200mg. (Oramorph®): 15, 30, 60, 100mg. ]

Kadian®  Conversion from Other Oral Morphine Formulations to Kadian®  Patients on other oral morphine formulations may be converted to Kadian®  by administering one-half of the patient's total daily oral morphine dose as Kadian®  capsules every 12 hours (twice-a-day) or by administering the total daily oral morphine dose as Kadian® capsules every 24 hours (once-a-day). Kadian® should not be given more frequently than every 12 hours. 
[Supplied: capsule: 20, 30, 50, 60, 100mg]

Oxycodone (Roxicodone): 5 mg orally every 6 hours as needed. [5 mg tab] 
(OxyContin- Extended release): 10-40 mg orally every 12 hours. [10, 20, 40, 80, 160mg ]

Pain: (Regular release)- 2.5 - 5 mg po q6h prn.  (Controlled release): 10 - 40 mg po q12h (Much higher doses possible in opiate tolerant patients).

[Supplied: (oxycodone hydrochloride)
Capsule - immediate release: OxyIR®: 5 mg.
Oral solution (Roxicodone®): 5 mg/5ml (5 ml, 500ml).
Oral solution concentrate (Oxydose®, Oxyfast®, Roxicodone Intensol®): 20mg/ml (30ml)
Tablet: Precolone®: 5 mg.  Roxicodone®: 5, 15, 30mg.
Tablet - controlled release (Oxycontin®): 10, 20, 40, 80, 160mg ]


Combinations: 
Initial dose based on oxycodone content. Max dose based on APAP content.   Dosing: 1 tab q4-6h prn.

[Supplied: Caplet: (Roxicet®): 5/500mg.
Capsule: Tylox®: 5/500mg
Oral Solution: Roxicet®:  5 mg-325mg/5 ml (5ml, 500ml).
Tablet: Endocet®: 5/325 mg.   Perocet®: 2.5/325mg, 5/325mg,  7.5/325mg, 7.5/500mg,  10/325mg, 10/650mg.  Roxicet®: 5/325mg.   Percodan: 5/325mg - 1 tab q6h prn.

Propoxyphene Darvon ® 65 mg orally every 4 hours as needed. [65mg]

Pain: Propoxyphene HCL: 65 mg po q3-4h prn.

Non-Narcotic analgesics:
Fioricet (apap 325mg + butalbital 50mg + caffeine 40mg):  1-2 tabs orally every 4 hours (Maximum of 6 tablets/day)
Fiorinal (ASA 325mg + butalbital 50mg + caffeine 40mg):  1-2 tabs orally every 4 hours. (Maximum of 6 tablets/day)
Soma compound (carisprodol 200mg + ASA 325mg): 1-2 tabs orally four times daily.
Tramadol (Ultram): 50-100 mg orally every 4 to 6 hours as needed.  Max 400 mg/day.

Opiate Combinations

Anexsia (hydrocodone/APAP 5/500, 7.5/650, 10/660):  1 tab orally every 4 to 6 hours as needed.
Darvocet N-100 (propoxyphene 100mg/APAP 650mg): 1 tab orally every 4 to 6 hours as needed (Maximum of 6 tabs/day).
Darvon Compound (propoxyphene 65mg + ASA 389mg + caffeine 32.4mg) 1 tab orally every 4 hours as needed.
Lorcet (hydrocodone/APAP 5/500):  1-2 tabs orally every 4 to 6 hours as needed. //  (7.5/650 & 10/650 ): 1 tab orally every 4 to 6 hours as needed.
Lortab (hydrocodone/APAP 2.5/500, 5/500):  1-2 tabs orally every 4 to 6 hours as needed.   //  (7.5/500, 10/500): 1 tab orally every 4 to 6 hours as needed.
Percocet (oxycodone 5 mg/APAP 325 mg): 1 tab orally every 6 hours as needed.
Percodan (Oxycodone 5 mg/ ASA 325mg):  1 tab orally every 6 hours as needed.
Roxicet (oxycodone/APAP 5/325, 5/500):  1 tablet orally every 6 hours as needed.
Tylenol with Codeine 
(APAP/codeine)
#2: 300/15, 
#3: 300/30mg, 
#4: 300/60 mg: 
1-2 tabs orally every 4 to 6 hours as needed.
Tylox (oxycodone 5mg /APAP 500mg):  1 tab orally every 6 hours as needed.
Vicodin (hydrocodone/APAP 5/500 or Vicodin ES (7.5/750): 1-2 tabs orally every 4 to 6 hours as needed. Max 8 tablets/day (Vicodin) or max 5 tablets/day (Vicodin ES).
 Wygesic (propoxyphene/APAP 65/650mg):  1 tablet orally every 4 hours as needed.
Agonist-Antagonists: 
Buprenorphene (Buprenex):  0.3 to 0.6 mg IV/IM every 6 to 8 hours as needed.
Butorphanol (Stadol):0.5 to 2 mg IV or 1-4 mg IM every 3 to 4 hours as needed. Nasal spray (Stadol NS): 1 spray every 3 to 4 hours as needed [1 mg/spray] 
Dezocine (Dalgan): 2.5 to 10 mg IV every 2 to 4 hours or 5-20mg IM every 3 to 6 hours as needed.
Nalbuphine (Nubain):  10-20mg IV/IM/SC every 3 to 6  hours as needed.
Pentazocine (Talwin): 30mg IV/IM every 3 to 4 hours as needed.
Antagonists
Nalmefene (Revex): opioid overdose: 0.5 mg/70kg IV with 1mg/70 kg 2 to 5 minutes later if needed. Post-op opoid reversal: 0.25 mcg/kg every 2 to 5 minutes as needed.
Naloxone (Narcan):  0.4 to 2 mg every 2 to 3 minutes as needed IV/IM/SC/ET.
Other
Suboxone ®

(Buprenorphine and naloxone)

Treatment of opioid dependence. Not recommended for use during the induction period. Initial treatment should begin using buprenorphine oral tablets. Patients should be switched to the combination product for maintenance and unsupervised therapy. Maintenance: Target dose (based on buprenorphine content): 16 mg/day -  range: 4-24 mg/day.

Supplied: sublingual tablet: Buprenorphine 2 mg and naloxone 0.5 mg; buprenorphine 8 mg and naloxone 2 mg.

Ziconotide
Prialt ®

Non-opioid analgesic for the treatment of severe chronic pain. 

CLINICAL PHARMACOLOGY
Mechanism of Action
Ziconotide binds to N-type calcium channels located on the primary nociceptive (A-delta and C) afferent nerves in the superficial layers (Rexed laminae I and II) of the dorsal horn in the spinal cord. Although the mechanism of action of ziconotide has not been established in humans, results in animals suggest that its binding blocks N-type calcium channels, which leads to a blockade of excitatory neurotransmitter release from the primary afferent nerve terminals and antinociception.


Dosage (adults): Initial dose: 2.4 mcg/day (0.1 mcg/hour) intrathecally. 
Dose may be titrated by less than 2.4 mcg/day (0.1 mcg/hour) at intervals no greater than 2-3 times/week to a maximum dose of 19.2 mcg/day (0.8 mcg/hour) by day 21. Average dose at day 21: 6.9 mcg/day (0.29 mcg/hour). A faster titration should be used only if the urgent need for analgesia outweighs the possible risk to patient safety. Effects are generally reversible within 2 weeks of discontinuation.

Supplied:  Injection (soln):  100 mcg/ml (1 ml, 2 ml, 5 ml).
 25 mcg/ml (20 ml).
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