Opioid Analgesics 

Drug

Adult Dose*

Pediatric Dose†

Comments

Opioid agonists in combination products‡ for moderate pain

Oral: 30–60 mg every 4–6 hours as needed

Oral: 5–10 mg every 4–6 hours as needed

Opioid agonists for moderate-to-severe pain

Transdermal: 12 or 25 mcg/hour every 3 days

Transmucosal: 100–200 mcg every 2–4 hours

Intranasal: 100–200 mcg every 2–4 hours

Parenteral: 25–100 mcg every 30–60 minutes IV or as patient-controlled analgesia

Parenteral: 1–2 mcg/kg/dose IV; may be repeated in 2–4 hours as needed

May trigger less histamine release and thus may cause less hypotension than other opioids

Transdermal: When used in cachectic patients, may result in erratic absorption and blood levels

Supplemental analgesia required at first because peak analgesia does not occur until 18–24 hours after application

May take many hours for adverse effects to resolve after removing patch

Short-acting transmucosal and intranasal forms: Used for breakthrough pain in opioid-tolerant adults and for conscious sedation in children

IV form: Sometimes used for procedural sedation

Oral immediate release: 2–4 mg every 4–6 hours

Oral extended-release: 8–32 mg every 24 hours

Oral liquid: 2.5–10 mg every 4–6 hours

Parenteral: 0.2–1 mg every 4–6 hours or as patient-controlled analgesia

Rectal: 3 mg every 6–8 hours

Short half-life

Rectal form: Used at bedtime

Oral: 2 mg every 6–8 hours

Parenteral: 1–2 mg IM or subcutaneously every 6–8 hours; 1 mg IV every 3–6 hours

Long half-life

Oral: 50–300 mg every 4 hours

Parenteral: 50–150 mg IV or IM every 4 hours as needed

Not preferred because its active metabolite (normeperidine) causes dysphoria and central nervous system excitation (eg, myoclonus, tremulousness, seizures) and accumulates for days after dosing is begun, particularly in patients with renal failure

Oral: 2.5–10 mg every 8–12 hours

Parenteral: 2.5–10 mg IM or IV every 8–12 hours

Used for treatment of heroin withdrawal, long-term maintenance treatment of opioid use disorder, and analgesia for chronic pain

Establishment of a safe, effective dose for analgesia complicated by its long half-life (usually much longer than duration of analgesia)

Requires close monitoring for several days or more after amount or frequency of dose is increased because serious toxicity can occur as the plasma level rises to steady state

Risk of QT-interval prolongation; ECG monitoring recommended

Oral immediate-release: 5–30 mg every 4 hours

Oral controlled-release: 15 mg every 12 hours

Oral sustained-release: 30 mg every 24 hours

Parenteral: 2–5 mg IV or IM every 2–4 hours as needed

> 6 months old and < 50 kg:

  • Oral immediate-release tablet or oral solution: 0.2–0.5 mg/kg/dose every 3–4 hours as needed (usual initial maximum dose 15–20 mg/dose)

  • IV (preferred), subcutaneous, IM (IM not recommended): 0.05 mg/kg/dose every 2–4 hours as needed (initial maximum dose 1–2 mg/dose)

> 6 months old and ≥ 50 kg:

  • Oral immediate-release tablets or oral solution: 15–20 mg every 3–4 hours as needed.

  • Parenteral (IV, subcutaneous, or IM): 2–5 mg/dose every 2–4 hours as needed

Standard of comparison

Triggers histamine release more often than other opioids, causing itching

Oral: 5–10 mg every 6 hours

Oral controlled-release: 10–20 mg every 12 hours

Oral: 5 mg every 4 hours

Oral controlled-release: 5–10 mg every 12 hours

IM : 1–1.5 mg every 4 hours

IV: 0.5 mg every 4 hours

Rectal: 5 mg every 4–6 hours

May trigger less histamine release than other opioids

Opioid agonist-antagonists§

IV or IM: 0.3 mg every 6 hours

Sublingual: 75 mcg once a day or, if tolerated, every 12 hours for ≥ 4 days, then increased to 150 mcg every 12 hours

Transdermal patch: initially 5mcg/hour applied once a week; may be titrated to 20 mcg/hour once a week

Use only in patients > 13 years (same as adult dose)

Psychotomimetic effects (eg, delirium, sedation) less prominent than those of other agonist-antagonists, but other effects similar

Higher affinity for mu receptors than traditional analgesics

May induce acute withdrawal if added to long-term opioid therapy

chronic pain

May be used as agonist therapy in opioid use disorder but requires special licensure

IV: Initially 1 mg, may be repeated every 3–4 hours as needed; usual range: 0.52 mg every 3–4 hours as needed

IM: Initially 2 mg, may be repeated every 3–4 hours as needed; usual range: 1–4 mg every 3–4 hours as needed.

Nasal: Initially1 mg (1 spray in one nostril); if adequate relief is not achieved, may be repeated in 60–90 minutes; after the second dose, may be repeated every 3–4 hours as needed

Not recommended

Parenteral: 10 mg IM, IV, subcutaneous every 3–6 hours

Not recommended

Pentazocine

Oral: 50–100 mg every 3–4 hours

Parenteral: 30 mg IV, IM, every 3–4 hours (not to exceed 360 mg/day)

Not recommended

Usefulness limited by the following:

  • Ceiling effect for analgesia at higher doses

  • Potential for opioid withdrawal in patients physically dependent on opioid agonists

  • Risk of psychotomimetic effects, especially for nontolerant, nonphysically dependent patients with acute pain

Can cause confusion and anxiety, especially in older patients

Oral immediate-release: 50–100 mg every 4–6 hours, a second dose ≥ 1 hour later (≤ 700 mg total dose on 1st day); after 1st day, 50–100 mg every 4–6 hours (≤ 600 mg total daily dose)

Oral extended-release: 50 mg every 12 hours (usual therapeutic dose of 100–250 mg every 12 hours; maximum 500 mg/day)

Used to treat neuropathic pain due to diabetes, moderate to severe acute pain, and moderate to severe chronic pain

Reported to have fewer frequent adverse effects (eg, constipation) than other opioids,

Oral immediate-release: 50–100 mg every 4–6 hours; maximum 400 mg/day

Oral extended-release: 100 mg once a day; increase by ≤ 100 mg/day every 5 days to a dose of ≤ 300 mg total daily dose

Not recommended

Less potential for abuse than with other opioids

Not as potent as other opioid analgesics

* Starting doses are for opioid-naive patients. Patients with opioid tolerance or severe pain may require higher doses.

† Not all drugs are appropriate for analgesia in children.

§ Opioid agonist-antagonists are not usually used for chronic pain and are rarely drugs of choice for older patients.

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