Opioid pain medications

Opioid equivalence doses

Opioid	PO	SC/IV
Morphine	10mg	5mg
Codeine	100mg	—
Hydromorphone	2mg	1mg
Oxycodone	5-7.5mg	—
Methadone	1mg	—
Fentanyl	—	50mcg

• Conversions are mostly done to and from oral Morphine milligram equivalents (MME)

Starting doses

• Codeine: 15mg po q4h + 15mg po q1-2h prn
• Morphine: 5mg po q4h + 5mg po q1-2h prn
• Hydromorphone: 1mg po q4h + 1mg po q1-2h prn
• Start lower with severe frailty, COPD, and CHF
• Start with short-acting and stabilize pain before transitioning to long-acting
• Also consider:
  • Senna, lactulose, and PEG (but not docusate) for constipation
  • Metoclopramide or domperidone for nausea

Breakthrough dosing

• Rule out end-of-dose failure
• Use short-acting formulation of background opioid
• Start as 10% of total daily dose, then titrate 5-20%