Mini Cases: Pain Management
Do the following conversions:
• 90 mg morphine PO =
• 45 mg hydromorphone IV =
• 120 mg oxymorphone PO =
• 100 mg morphine PO/day =
• 100 mg morphine PO/day =
mg Hydromorphone PO
mg Oxycodone PO
mg Morphine IV
mcg/hr Fentanyl TD patch
mcg/hr Fentanyl IV
Case 1:
You get a call from a physician resident on a general medicine service. He says, “I need to know what dose
of Duragesic® to start for this patient. She has been using Percocet® 5 mg, about 12 tablets a day for the
last week while she was here. She is going home tomorrow. What dose should I write?”
Case 2:
One of the hospitalists working at your hospital is calling for your help with an IV to PO conversion for JJ.
For the last 6 days, JJ has been receiving hydromorphone IV 1.5 mg/hr continuously with 2 mg q15
minutes prn.
What questions do you have for the physician before you can help?
What dose of Oxycodone SR (OxyContin®) would you recommend?
What would you recommend for breakthrough pain?
Case 3:
AN is a 26 yr old female with chronic pain related to Sickle Cell disease. She has a PCP that writes for
Morphine SR (MSContin®) 60 mg TID and oxycodone IR 15 mg TID prn. She presents to the ED today
complaining of increasing pain (9/10) consistent with her typical crisis pain. Thirty minutes after receiving
hydromorphone IV (Dilaudid®) 1 mg, the patient still rates her pain at 9/10.
The RN wants to know if it is okay to give her more pain medication at this time.
What dose do you recommend?
AN has been in the hospital for 7 days, and is preparing for discharge. In the last 24 hours, she has used
Morphine SR (MSContin®) 60 mg TID, hydromorphone 4 mg IVP x 2 doses, and oxycodone IR 60 mg x 4
doses. What dose of Morphine SR (MSContin®) should she be discharged on?
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Quick Points: Pain Management
Questions to ask:
 What is the source of pain?
o Is this acute pain?
o Has the pain changed recently/ will the pain change soon?
 Is this dose controlling pain? (i.e. what is the pain score?)
 Are there side effects? (most importantly, sedation or respiratory depression)
Scheduled Opioids:
o Options for scheduled opioids include, sustained release oral or transdermal formulations, aroundthe-clock immediate release formulations, continuous opioid infusions.
o Reserve scheduled opioids for chronic, persistent pain.
Breakthrough dosing:
 10-20% of the schedule daily dose of opioids
o Example: For a patient using Morphine SR 100 mg po q8h, the appropriate dose for
breakthrough pain would be Morphine IR 30-60 mg po prn pain.
 For acute or breakthrough pain, opioids can be safely redosed after they reach peak effect.
Titration:
 For uncontrolled pain:
o Increase 25-50% for mild to moderate pain
o Increase 50-100% for moderate to severe pain
o EXCEPTION: Generally, do not recommend more than a 50% increase in methadone at
any one time.
For patients with opioid-induced sedation or neurotoxicity:
 Decrease dose 25-50%
Switching opioids:
 Use equianalgesic doses.
 Reduce calculated dose 0-50% to account for incomplete cross tolerance and variations in
individual responses.
o General guideline for reduction of calculated dose:
 0%- continues to have moderate to severe pain, no sedation present
 25%- continues to have mild to moderate pain, no sedation present
 50%- has no pain to mild pain OR sedation present with any pain score
IMPORTANT NOTE: All opioid dose changes should be made on a percentage basis, not mg. It is more
dangerous to increase a patient’s dose from Morphine IV 1 mg/hr to Morphine IV 3 mg/hr (200% increase)
than to increase from Morphine IV 30 mg/hr to Morphine IV 60 mg/hr (100% increase).
Opioids Analgesic Classes
• Phenanthranes
– Morphine
– Codeine
– Hydromorphone
– Oxycodone
– Hydrocodone
• Phenylpiperidines
– Meperidine
– Fentanyl
• Diphenylheptanes
– Methadone
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