II. Precautions

  1. Prescribe the lowest effective dose for the shortest appropriate course
  2. Adjust for Chronic Opioid Analgesic Therapy (COAT)
    1. Work with COAT provider on acute and subacute dosing

III. Preparations: Morphine Equivalent Opioid Doses (MME)

  1. IMPORTANT: Doses are for comparison only - do not use these doses
  2. Most potent agents (compared with Morphine)
    1. Fentanyl (Sublimaze) 20 mcg per hour IV or 2.4 MME
    2. Fentanyl transdermal (mcg patch) or 7.2 MME
    3. Hydromorphone (Dilaudid) 1.5 mg IV (7.5 mg orally) or 4 MME
    4. Methadone 2.5 mg IV (5 mg orally)
      1. See Methadone for conversion ratios
      2. Conversion ratio to Morphine is variable per dose
        1. Low Dose (<=20 mg/day): 7.5 mg or 4 MME
        2. Moderate Dose (20-60 mg/day): 3.75 to 3 mg or 8-10 MME
        3. Very High Dose (>60 mg/day): 2.5 mg or 12 MME
    5. Oxymorphone 10 mg orally or 3 MME
    6. Nalbuphine (Nubain) 10 mg IV or 1 MME
  3. Morphine (comparison)
    1. Morphine 10 mg IV (30 mg orally) or 1 MME (by definition of Morphine Milligram Equivalent)
  4. Less potent agents (compared with Morphine)
    1. Oxycodone 20 mg orally or 1.5 MME
    2. Hydrocodone 30 mg orally or 1 MME
    3. Meperidine (Demerol) 75 mg IV (300 mg orally) or 0.1 MME
    4. Codeine 120 mg IV (200 mg orally) or 0.15 MME
    5. Tramadol (900 mg orally) or 0.1 MME

IV. Preparations: Acute prescriptions (typical)

  1. See Acute Pain Management
  2. Limit to 4 days of Opioid and 100 Morphine Milligram Equivalence (MME) for total course
  3. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 20 tabs per total course
  4. Oxycodone IR (5 mg tabs): Up to 13 tabs per total course
  5. Hydromorphone (2 mg tab): Up to 12 tabs per total course

V. Preparations: Acute prescriptions (major surgery or Trauma)

  1. Limit to 7 days of Opioid and 200 MME for total course
  2. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 40 tabs per total course
  3. Oxycodone IR (5 mg tabs): Up to 26 tabs per total course
  4. Hydromorphone (2 mg tab): Up to 25 tabs per total course

VI. Preparations: Post-Acute Pain (5 to 45 days after acute event)

  1. Prescribe in 7 day increments of no more than 200 MME per 7 days
  2. Avoid >700 cummulative MME
  3. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 40 tabs/week
  4. Oxycodone IR (5 mg tabs): Up to 26 tabs per week

VII. Preparations: Chronic Pain (>45 days)

  1. See Chronic Pain Management
  2. Limit to low dose (up to 50 MME/day) in most patients
    1. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin) 10 tabs/day (up to 50 mg/day)
    2. Oxycodone IR (5 mg tabs) 6 tabs/day (up to 33 mg/day)
    3. Oxycodone SR (15 mg, Oxycontin) 2 tabs/day (up to 33 mg/day)
    4. Methadone (5 mg) 2 tabs/day (up to 12 mg/day)
  3. Avoid high dose (up to 90 MME/day) in most cases
    1. Informed Consent regarding risk of Opioid Dependence and other adverse effects
    2. Attempt to taper to 50 MME/day
    3. Hydrocodone/Acetaminophen (10 mg/300 mg, Vicodin): 9 tabs/day (up to 90 mg/day)
    4. Oxycodone IR (10 mg tabs) 6 tabs/day (up to 60 mg/day)
    5. Oxycodone SR (30 mg, Oxycontin) 2 tabs/day (up to 60 mg/day)
    6. Methadone (5 mg) 4 tabs/day (up to 20 mg/day)

VIII. References

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