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=== WHO 3-step Ladder for Pain Control ===
===Opioid Epidemic===
*Consider that with a 10-day supply of an initial opioid prescription, the odds of still being on opioids a year later is ~20%<ref>Rech MA, et al. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med. 2022 Aug;58:57-65. PMID 35636044</ref>
*Consider [[opioid free]] regimens
[[File:Opioid_abuse_graph.png|thumb|Continued Opioid Use After First Prescription]]
 
===WHO 3-step Ladder for Pain Control===
{| class="wikitable"
{| class="wikitable"
|-
|-
Línea 6: Línea 11:
! scope="col" | Parenteral
! scope="col" | Parenteral
|-
|-
| colspan="2" | '''Step1. Mild Pain, Nonopiod, +/- Adjuvant'''  
| colspan="2" | '''Step1. Mild Pain, Nonopioid, +/- Adjuvant'''  
|  
|  
|-
|-
| [[Acetaminophen]]  
| [[Acetaminophen]]  
| 650mg q4-q6h prn or 1000mg q6h prn
| 650mg q4-q6h PRN or 1000mg q6h PRN
| -
| -
|-
|-
| [[Aspirin]]  
| [[Aspirin]]  
| 650mg q4-6h prn or 1000mg q6h prn
| 650mg q4-6h PRN or 1000mg q6h PRN
| -
| -
|-
|-
| [[Ibuprofen]]<span class="Apple-tab-span" style="white-space:pre"> </span>  
| [[Ibuprofen]]<span class="Apple-tab-span" style="white-space:pre"> </span>  
| 400-800mg q6-8h prn
| 400-800mg q6-8h PRN
| -
| -
|-
|-
Línea 25: Línea 30:
| -
| -
|-
|-
| colspan="2" | '''Step2. Mod Pain, [[Opiod]] for mild/mod pain, +/-nonopiod, +/-Adjuvant'''  
| colspan="2" | '''Step2. Mod Pain, [[Opioid]] for mild/mod pain, +/-nonopioid, +/-Adjuvant'''  
|  
|  
|-
|-
| [[Hydrocodone]] (5mg/[[Acetaminophen]] 325mg)  
| [[Hydrocodone]] (5mg/[[Acetaminophen]] 325mg)  
| 1-2 tabs PO q4-6h prn
| 1-2 tabs PO q4-6h PRN
| -
| -
|-
|-
| [[Oxycodone]] (5mg/A[[cetaminophen]] 325mg)  
| [[Oxycodone]] (5mg/[[Acetaminophen]] 325mg)  
| 1-2 tabs PO q4h prn
| 1-2 tabs PO q4h PRN
| -
| -
|-
|-
Línea 44: Línea 49:
| -
| -
|-
|-
| colspan="2" | '''Step3. Severe Pain, Opiod for mod/sev pain, +/- nonopiod, +/-Adjuvant'''  
| colspan="2" | '''Step3. Severe Pain, Opioid for mod/sev pain, +/- nonopioid, +/-Adjuvant'''  
|  
|  
|-
|-
| [[Morphine]]  
| [[Morphine]]  
| 10-30mg q3-4h  
| 10-30mg q3-4h  
| 0.1-0.2 mg/kg(up to 15mg q4h)
| 0.1-0.2mg/kg(up to 15mg q4h)
|-
|-
| [[Morphine]] (controlled release)  
| [[Morphine]] (controlled release)  
| Start 30mg q8-12h , increase prn to 90-120mg q12h  
| Start 30mg q8-12h , increase PRN to 90-120mg q12h  
| -
| -
|-
|-
Línea 73: Línea 78:


{{General opioid chart}}
{{General opioid chart}}
===[[Opioid]] Analgesics Chart===
{| class="wikitable"
|-
|
'''DRUG'''
|
'''TYPICAL ADULT DOSE'''
|
'''PHARMACOKINETICS'''
|
'''COMMENTS'''
|-
|
[[Morphine]]
|
0.1 mg/kg IV
10mg IM
0.3 mg/kg PO
|
Onset: 1-2 min (IV), 10-15 min (IM/SC)
Peak effect: 3-5 min (IV), 15-30 min (IM)
Duration: 1-2 h (IV), 3-4 h (IM/SC)
|
*Histamine release may produce transient hypotension or nausea and emesis,
**neither require routine adjunctive treatment
|-
|
[[Hydromorphone ]]
(Dilaudid)
|
0.015 mg/kg IV
1-2 mg IM
|
Onset: 3-5 min (IV)
Peak effect: 7-10 min (IV)
Duration: 2-4 h (IV)
|
|-
|
[[Fentanyl]]
|
1.0 mcg/kg IV
|
Onset: &lt;1 min (IV)
Peak effect: 2-5 min (IV)
Duration: 30-60 min (IV)
|
*High doses can cause chest wall rigidity (&gt;5 mcg/kg IV)
|-
|
[[Meperidine ]]
(Demerol)
|
1.0-1.5 mg/kg IV/IM
|
Onset: 5 min (IV)
Peak effect: 5-10 min (IV)
Duraction 2-3 h (IV)
|
*Contraindicated when patient taking a MAOI
*Neurotoxicity occur when multiple doses given in the presence of renal failure
|-
|
[[Oxycodone]]
|
5-10 mg PO
30 mg PR
|
Onset: 10-15 min (PO)
Duration 3-6 h (PO)
|
*Possible inadvertent acetaminophen overdose with combination agents
|-
|
[[Hydrocodone]]
|
5-10 mg PO
|
Onset: 30-60 min (PO)
Duraction 4-6 h (PO)
|
*Lower incidence of nausea
*Possible inadvertent acetaminophen overdose with combination agents
|-
|
[[Codeine]]
|
30-60 mg PO
30-100 mg IM
|
Onset: 30-60 min (PO)


Duraction: 4-6 h (PO)
===Non-Opioid Analgesics Chart===
 
|
*High incidence of GI side effects
*Some patients cannot convert to codeine-6-glucuronide and morphine
*Possible inadvertent acetaminophen overdose with combination agents
 
|-
|
[[Tramadol ]]
 
(Ultram)
 
|
50-100 mg PO
 
|
Onset: 10-15 min (PO)
 
Duration: 4-6 h (PO)
 
|
*Central nervous system side effects
 
|}
 
=== Non-Opioid Analgesics Chart ===


{| class="wikitable"
{| class="wikitable"
Línea 247: Línea 89:
| [[Acetaminophen]]
| [[Acetaminophen]]
|  
|  
650-1000 mg PO q4h  
650-1000mg PO q4h  


1-2 g PO q4h
1-2 g PO q4h
Línea 255: Línea 97:
|-
|-
| [[Aspirin]]
| [[Aspirin]]
| 650-1000 mg PO q4h
| 650-1000mg PO q4h
|  
|  
*Reye syndrome in children, tinnitus, central nervous system toxicity, metabolic acidosis
*Reye syndrome in children, tinnitus, central nervous system toxicity, metabolic acidosis
|-
|-
| [[Ibuprofen]]  
| [[Ibuprofen]]  
| 400-800 mg PO q4-6h
| 400-800mg PO q4-6h
|  
|  
*GI upset, platelet dysfunction, renal dysfunction, bronchospasm
*GI upset, platelet dysfunction, renal dysfunction, bronchospasm
Línea 266: Línea 108:
| [[Naproxen]]  
| [[Naproxen]]  
|  
|  
250 mg PO q6-8h  
250mg PO q6-8h  


500-1000 mg PR q6-8h
500-1000mg PR q6-8h


|  
|  
*GI upset, platelet dysfunction, renal dysfunction, bronchospasm plus interacts with protein-bound drugs<br>
*GI upset, platelet dysfunction, renal dysfunction, bronchospasm plus interacts with protein-bound drugs<br>
|-
|-
| Indomethacin  
| [[Indomethacin]]
|  
|  
25-50 mg PO q12h  
25-50mg PO q12h  


100 mg PR q24h
100mg PR q24h


|  
|  
Línea 284: Línea 126:
| [[Ketorolac]]
| [[Ketorolac]]
|  
|  
15-30 mg IV q6h  
15-30mg IV q6h  


30-60 mg IM
30-60mg IM


|  
|  
Línea 294: Línea 136:


{{Parenteral opioids chart}}
{{Parenteral opioids chart}}
=== Dosing Guidelines for Parenteral Opioids===
{{Oral opioid chart}}
{| class="wikitable"
|-
| '''DRUG'''
| '''ROUTE'''
| '''DOSAGE'''
| '''COMMENTS'''
|-
| [[Morphine]]
| IV or IM
|
Titrate 2-5 mg increments q5-10 min


Peak analgesia in 10-20 min
Average: 10 mg q3-4h
| Preferred first-line agent in most situations<br>
|-
| [[Fentanyl ]]
| IV or IM
|
Titrate 25-50 mcg increments q2-3 min
Peak analgesia in 3-5 min
Duration 30-60 min
|
Ideal for short procedures
No histamine release
Typically not suitable for the ED
|-
|
[[Meperidine ]]
(Demerol)
| IV
|
Titrate 12.5-50 mg increments
Peak analgesia in 5-10 min
Average: 100 mg q2-3h
|
Risk of unique CNS toxicity with repeated dosing
IM injection is very irritating to tissue
|-
|
[[Hydromorphone]]
(Dilaudid)
| IV
|
Titrate 0.5-1.0 mg increments
Peak analgesia in 5-15 min
Average: 1.5 mg q3-4h
|
|-
|
[[Butorphanol ]]
(Stadol)
| IV
|
Titrate 0.5-2.0 mg increments
Peak analgesia in 4-5 min
Average: 2 mg q3-4h
|
Mixed agonist-antagonist
May be preferred in biliary colic
|}
{{Oral opioid chart}}
=== Oral Opioid Dosing Chart===
{| class="wikitable"
|-
| '''DRUG'''
| '''ANALGESIC EQUIVALENCE'''
| '''USUAL STARTING DOSE'''
| '''USUAL INTERVAL'''
|-
| [[Morphine]] (MSIR, Roxanol, others)
| 30 mg
| 15-30 mg
| 3-4 h
|-
| [[Morphine]]: sustained release (MS Contin, Oramorph-SR)
| 30 mg
| 30 mg
| 8-12 h
|-
| [[Meperidine]] (Demerol)
| 300 mg
| 50-100 mg
| 2-3 h
|-
| [[Codeine]] (in Tylenol #3, others)
| 200 mg
| 30-60 mg
| 3-4 h
|-
| [[Oxycodone]] (Roxicodone, also in Percocet, Percodan, Tylox, others)
| 20-30 mg
| 5-10 mg
| 3-6 h
|-
| [[Hydrocodone]] (in Lorcet, Lortab, Vicodin, others)
| 30 mg
| 5-10 mg
| 3-6 h
|-
| [[Hydromorphone]] (Dilaudid)
| 7.5 mg
| 4-8 mg
| 2-3 h
|-
| [[Tramadol]] (Ultram)
| N/A
| 25-50 mg
| 4-6 h
|}


<div style="display:none">
<!-- SMW MedicationDose annotations for all medications on this page -->
<!-- Step 1: Mild Pain (Non-opioid) -->
{{MedicationDose|drug=Acetaminophen|dose=650 mg PO q4-6h PRN or 1000 mg PO q6h PRN|route=PO|context=Step 1 - Mild pain (non-opioid)|indication=Acute pain management|max_dose=4 g/day|notes=Risk of liver dysfunction and necrosis}}
{{MedicationDose|drug=Aspirin|dose=650 mg PO q4-6h PRN or 1000 mg PO q6h PRN|route=PO|context=Step 1 - Mild pain (non-opioid)|indication=Acute pain management|notes=Reye syndrome in children; tinnitus, metabolic acidosis}}
{{MedicationDose|drug=Ibuprofen|dose=400-800 mg PO q6-8h PRN|route=PO|context=Step 1 - Mild pain (NSAID)|indication=Acute pain management|max_dose=3200 mg/day|notes=GI upset, platelet dysfunction, renal dysfunction}}
{{MedicationDose|drug=Gabapentin|dose=300 mg PO qhs (starting dose)|route=PO|context=Neuropathic pain adjuvant|indication=Acute pain management}}
{{MedicationDose|drug=Naproxen|dose=250 mg PO q6-8h or 500-1000 mg PR q6-8h|route=PO/PR|context=Non-opioid analgesic (NSAID)|indication=Acute pain management|notes=GI upset, platelet dysfunction, renal dysfunction}}
{{MedicationDose|drug=Indomethacin|dose=25-50 mg PO q12h or 100 mg PR q24h|route=PO/PR|context=Non-opioid analgesic (NSAID)|indication=Acute pain management|notes=GI upset, platelet dysfunction, renal dysfunction}}
{{MedicationDose|drug=Ketorolac|dose=15-30 mg IV q6h or 30-60 mg IM|route=IV/IM|context=Non-opioid analgesic (NSAID, parenteral)|indication=Acute pain management|notes=Greater GI bleeding risk than ibuprofen; limit to 3 days IV, 5 days PO}}
<!-- Step 2: Moderate Pain (Mild Opioids) -->
{{MedicationDose|drug=Hydrocodone|dose=5-10 mg PO q4-6h PRN (with acetaminophen 325 mg)|route=PO|context=Step 2 - Moderate pain (mild opioid)|indication=Acute pain management}}
{{MedicationDose|drug=Oxycodone|dose=5-10 mg PO q4-6h PRN|route=PO|context=Step 2 - Moderate pain (mild opioid)|indication=Acute pain management}}
{{MedicationDose|drug=Codeine|dose=30-60 mg PO q3-4h|route=PO|context=Step 2 - Moderate pain (mild opioid)|indication=Acute pain management|notes=Some patients cannot convert to active metabolite}}
{{MedicationDose|drug=Tramadol|dose=50-100 mg PO q4-6h|route=PO|context=Step 2 - Moderate pain (mild opioid)|indication=Acute pain management|onset=10-15 min|duration=4-6 hours|notes=CNS side effects; display=Tramadol (Ultram)}}
<!-- Step 3: Severe Pain (Strong Opioids) -->
{{MedicationDose|drug=Morphine|dose=0.1 mg/kg IV or 10 mg IM or 0.3 mg/kg PO; titrate 2-5 mg IV q5-10min|route=IV/IM/PO|context=Step 3 - Severe pain (1st line opioid)|indication=Acute pain management|onset=1-2 min (IV), 10-15 min (IM)|duration=1-2 hours (IV), 3-4 hours (IM)|notes=Histamine release may cause transient hypotension or nausea}}
{{MedicationDose|drug=Hydromorphone|dose=0.015 mg/kg IV or 1-2 mg IM; titrate 0.5-1.0 mg IV increments|route=IV/IM|context=Step 3 - Severe pain (opioid)|indication=Acute pain management|onset=3-5 min (IV)|duration=2-4 hours (IV)|display=Hydromorphone (Dilaudid)}}
{{MedicationDose|drug=Fentanyl|dose=1.0 mcg/kg IV; titrate 25-50 mcg IV q2-3min|route=IV|context=Step 3 - Severe pain (opioid, short-acting)|indication=Acute pain management|onset=<1 min (IV)|duration=30-60 min (IV)|notes=High doses (>5 mcg/kg) can cause chest wall rigidity}}
{{MedicationDose|drug=Meperidine|dose=1.0-1.5 mg/kg IV/IM; titrate 12.5-50 mg IV increments|route=IV/IM|context=Step 3 - Severe pain (opioid, avoid if possible)|indication=Acute pain management|display=Meperidine (Demerol)|notes=Contraindicated with MAOIs; neurotoxic metabolite with repeated dosing}}
{{MedicationDose|drug=Butorphanol|dose=0.5-2.0 mg IV; average 2 mg q3-4h|route=IV|context=Step 3 - Severe pain (mixed agonist-antagonist)|indication=Acute pain management|display=Butorphanol (Stadol)|notes=Mixed agonist-antagonist; may cause withdrawal in opioid-dependent patients}}
</div>
==See Also==
==See Also==
*[[Opiod Overdose]]
*[[Opioid overdose]]
*[[Opioid Withdrawal]]
*[[Opioid withdrawal]]
*[[Analgesics_and_Sedatives_(Peds)|Analgesics and Sedatives (Pediatrics)]]
*[[Analgesics_and_Sedatives_(Peds)|Analgesics and Sedatives (Pediatrics)]]
*[[Complex regional pain syndrome]]


== Sources ==
==References==
Adapted from Tintinalli and Harwood &amp; Nuss, World Health Organization 3-Step Analgesia Ladder for Cancer &amp; Washington Manual Intership Survival Guide, 2008  
Adapted from Tintinalli and Harwood &amp; Nuss, World Health Organization 3-Step Analgesia Ladder for Cancer &amp; Washington Manual Intership Survival Guide, 2008  


[[Category:Misc/General]]  
[[Category:Misc/General]]  
[[Category:Drugs]]
[[Category:Pharmacology]]
[[Category:Palliative Medicine]]
 
==References==
<references/>
 
[[Category:Symptoms]]

Revisión actual - 10:56 22 mar 2026

Opioid Epidemic

  • Consider that with a 10-day supply of an initial opioid prescription, the odds of still being on opioids a year later is ~20%[1]
  • Consider opioid free regimens
Continued Opioid Use After First Prescription

WHO 3-step Ladder for Pain Control

Agent Oral Parenteral
Step1. Mild Pain, Nonopioid, +/- Adjuvant
Acetaminophen 650mg q4-q6h PRN or 1000mg q6h PRN -
Aspirin 650mg q4-6h PRN or 1000mg q6h PRN -
Ibuprofen 400-800mg q6-8h PRN -
Gabapentin (neuropathic Pain) Start 300mg qhs -
Step2. Mod Pain, Opioid for mild/mod pain, +/-nonopioid, +/-Adjuvant
Hydrocodone (5mg/Acetaminophen 325mg) 1-2 tabs PO q4-6h PRN -
Oxycodone (5mg/Acetaminophen 325mg) 1-2 tabs PO q4h PRN -
Oxycodone (Oxycontin) 5mg q4-6h -
Tramadol 50-100mg q4-6h (max 400mg/day) -
Step3. Severe Pain, Opioid for mod/sev pain, +/- nonopioid, +/-Adjuvant
Morphine 10-30mg q3-4h 0.1-0.2mg/kg(up to 15mg q4h)
Morphine (controlled release) Start 30mg q8-12h , increase PRN to 90-120mg q12h -
Fentanyl - mcg/kg q1-3h
Hydromorphone (Dilaudid) 2-4mg q4-6h 1-4mg q4-6h
Levorphanol 2mg q6-8h

2mg q6-8h

^In elders, use a bulk laxative and give instructions regarding activity, hydration and close follow-up

General Opioid Analgesics Chart

DRUG

TYPICAL ADULT DOSE

PHARMACOKINETICS

COMMENTS

Morphine

0.1 mg/kg IV

10mg IM

0.3 mg/kg PO

Onset: 1-2 min (IV), 10-15 min (IM/SC)

Peak effect: 3-5 min (IV), 15-30 min (IM)

Duration: 1-2 h (IV), 3-4 h (IM/SC)

  • Histamine release may produce transient hypotension or nausea and emesis,
    • neither require routine adjunctive treatment

Hydromorphone

(Dilaudid)

0.015 mg/kg IV

1-2 mg IM

Onset: 3-5 min (IV)

Peak effect: 7-10 min (IV)

Duration: 2-4 h (IV)

Fentanyl

1.0 mcg/kg IV

Onset: <1 min (IV)

Peak effect: 2-5 min (IV)

Duration: 30-60 min (IV)

  • High doses can cause chest wall rigidity (>5 mcg/kg IV)

Meperidine

(Demerol)

1.0-1.5 mg/kg IV/IM

Onset: 5 min (IV)

Peak effect: 5-10 min (IV)

Duraction 2-3 h (IV)

  • Contraindicated when patient taking a MAOI
  • Neurotoxicity occur when multiple doses given in the presence of renal failure

Oxycodone

5-10 mg PO

30 mg PR

Onset: 10-15 min (PO)

Duration 3-6 h (PO)

  • Possible inadvertent acetaminophen overdose with combination agents

Hydrocodone

5-10 mg PO

Onset: 30-60 min (PO)

Duraction 4-6 h (PO)

  • Lower incidence of nausea
  • Possible inadvertent acetaminophen overdose with combination agents

Codeine

30-60 mg PO

30-100 mg IM

Onset: 30-60 min (PO)

Duraction: 4-6 h (PO)

  • High incidence of GI side effects
  • Some patients cannot convert to codeine-6-glucuronide and morphine
  • Possible inadvertent acetaminophen overdose with combination agents

Tramadol

(Ultram)

50-100 mg PO

Onset: 10-15 min (PO)

Duration: 4-6 h (PO)

  • Central nervous system side effects

Non-Opioid Analgesics Chart

DRUG
TYPICAL ADULT DOSE
COMMENTS
Acetaminophen

650-1000mg PO q4h

1-2 g PO q4h

  • Liver dysfunction and necrosis
Aspirin 650-1000mg PO q4h
  • Reye syndrome in children, tinnitus, central nervous system toxicity, metabolic acidosis
Ibuprofen 400-800mg PO q4-6h
  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
Naproxen

250mg PO q6-8h

500-1000mg PR q6-8h

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm plus interacts with protein-bound drugs
Indomethacin

25-50mg PO q12h

100mg PR q24h

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
Ketorolac

15-30mg IV q6h

30-60mg IM

  • GI upset, platelet dysfunction, renal dysfunction, bronchospasm
  • Much greater risk of GI bleeding than ibuprofen; use limited to 3d IV and 5d PO

Parenteral Opioid Dosing Chart

DRUG ROUTE DOSAGE COMMENTS
Morphine IV or IM

Titrate 2-5 mg increments q5-10 min

Peak analgesia in 10-20 min

Average: 10 mg q3-4h

Preferred first-line agent in most situations
Fentanyl IV or IM

Titrate 25-50 mcg increments q2-3 min

Peak analgesia in 3-5 min

Duration 30-60 min

Ideal for short procedures

No histamine release

Typically not suitable for the ED

Meperidine

(Demerol)

IV

Titrate 12.5-50 mg increments

Peak analgesia in 5-10 min

Average: 100 mg q2-3h

Risk of unique CNS toxicity with repeated dosing

IM injection is very irritating to tissue

Hydromorphone

(Dilaudid)

IV

Titrate 0.5-1.0 mg increments

Peak analgesia in 5-15 min

Average: 1.5 mg q3-4h

Butorphanol

(Stadol)

IV

Titrate 0.5-2.0 mg increments

Peak analgesia in 4-5 min

Average: 2 mg q3-4h

Mixed agonist-antagonist

May be preferred in biliary colic

Oral Opioid Dosing Chart

DRUG ANALGESIC EQUIVALENCE USUAL STARTING DOSE USUAL INTERVAL
Morphine (MSIR, Roxanol, others) 30 mg 15-30 mg 3-4 h
Morphine: sustained release (MS Contin, Oramorph-SR) 30 mg 30 mg 8-12 h
Meperidine (Demerol) 300 mg 50-100 mg 2-3 h
Codeine (in Tylenol #3, others) 200 mg 30-60 mg 3-4 h
Oxycodone (Roxicodone, also in Percocet, Percodan, Tylox, others) 20-30 mg 5-10 mg 3-6 h
Hydrocodone (in Lorcet, Lortab, Vicodin, others) 30 mg 5-10 mg 3-6 h
Hydromorphone (Dilaudid) 7.5 mg 4-8 mg 2-3 h
Tramadol (Ultram) N/A 25-50 mg 4-6 h


Acetaminophen 650 mg PO q4-6h PRN or 1000 mg PO q6h PRN PO (max 4 g/day) — Risk of liver dysfunction and necrosis Aspirin 650 mg PO q4-6h PRN or 1000 mg PO q6h PRN PO — Reye syndrome in children; tinnitus, metabolic acidosis Ibuprofen 400-800 mg PO q6-8h PRN PO (max 3200 mg/day) — GI upset, platelet dysfunction, renal dysfunction Gabapentin 300 mg PO qhs (starting dose) PO Naproxen 250 mg PO q6-8h or 500-1000 mg PR q6-8h PO/PR — GI upset, platelet dysfunction, renal dysfunction Indomethacin 25-50 mg PO q12h or 100 mg PR q24h PO/PR — GI upset, platelet dysfunction, renal dysfunction Ketorolac 15-30 mg IV q6h or 30-60 mg IM IV/IM — Greater GI bleeding risk than ibuprofen; limit to 3 days IV, 5 days PO Hydrocodone 5-10 mg PO q4-6h PRN (with acetaminophen 325 mg) PO Oxycodone 5-10 mg PO q4-6h PRN PO Codeine 30-60 mg PO q3-4h PO — Some patients cannot convert to active metabolite Tramadol 50-100 mg PO q4-6h PO (onset 10-15 min, duration 4-6 hours) — CNS side effects; display=Tramadol (Ultram) Morphine 0.1 mg/kg IV or 10 mg IM or 0.3 mg/kg PO; titrate 2-5 mg IV q5-10min IV/IM/PO (onset 1-2 min (IV), 10-15 min (IM), duration 1-2 hours (IV), 3-4 hours (IM)) — Histamine release may cause transient hypotension or nausea Hydromorphone (Dilaudid) 0.015 mg/kg IV or 1-2 mg IM; titrate 0.5-1.0 mg IV increments IV/IM (onset 3-5 min (IV), duration 2-4 hours (IV)) Fentanyl 1.0 mcg/kg IV; titrate 25-50 mcg IV q2-3min IV (onset <1 min (IV), duration 30-60 min (IV)) — High doses (>5 mcg/kg) can cause chest wall rigidity Meperidine (Demerol) 1.0-1.5 mg/kg IV/IM; titrate 12.5-50 mg IV increments IV/IM — Contraindicated with MAOIs; neurotoxic metabolite with repeated dosing Butorphanol (Stadol) 0.5-2.0 mg IV; average 2 mg q3-4h IV — Mixed agonist-antagonist; may cause withdrawal in opioid-dependent patients

See Also

References

Adapted from Tintinalli and Harwood & Nuss, World Health Organization 3-Step Analgesia Ladder for Cancer & Washington Manual Intership Survival Guide, 2008

References

  1. ↑ Rech MA, et al. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med. 2022 Aug;58:57-65. PMID 35636044
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