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PAIN MANAGEMENT GUIDELINES
1. Use a multi-modal drug approach. Combine opioids with non-opioids and adjuvant analgesics as
indicated.
2. Base administration schedule on the analgesic's duration of effect. Best to use sustained release
opioids for scheduled dosing and always use immediate release opioids for rescue or breakthrough
dosing. Do not crush or chew extended-release preparations.
3. In opioid naïve patients start with low dose, short acting opioids and titrate for effect.
4. Avoid meperidine (Demerol) and the mixed agonist-antagonist opioids (e.g. Stadol, Nubain, and Talwin).
5. Acetaminophen (APAP): Do not exceed 2000-4000 mg in 24 hours, check current guidelines.
6. Non-invasive routes preferred. For severe pain or rapidly escalating pain, it may be necessary to provide
intravenous analgesics until the pain is managed. If oral, rectal, or transdermal dosing is no longer
practical or appropriate, continuous subcutaneous or intravenous infusions are indicated.
7. Mild Pain (rating 1-3) Start with simple analgesics; acetaminophen (APAP) or NSAIDs, with adjuvant
analgesics as appropriate.
8. Moderate to Severe Pain (rating 4-10) When pain does not respond to non-opioid analgesics and
adjuvants, consider adding an opioid. Drugs with APAP, ASA or NSAIDs in combination with opioids
limit flexibility of dosing and should be used for mild to moderate pain only.
9. Titration: Increase by 25 to 50% for moderate pain; increase by 50 to 100% for severe pain. Calculate
amount of opioid taken in last 24 hours (add breakthrough + maintenance doses) and administer as new
24-hour maintenance dose; calculate new breakthrough dose.
10. Breakthrough Pain Dosing: Scheduled dosing will maintain stable serum drug levels and provide
consistent relief. Patients on long acting opioids or continuous parenteral infusions must have an order
for breakthrough pain medication. Frequent breakthrough dosing requires a change in the scheduled
sustained release drug dose. Oral breakthrough dose is ≈ 10-20% of the oral 24 hour baseline dose.
Peak effect of immediate-release opioid is ≈ one hour; may repeat dose every one hour if patient is not
overly sedated. IV/SubQ breakthrough dose is ≈ 50 to 100% of the hourly IV/SubQ rate. Peak effect of IV
opioids is ≈ 10-15 minutes; may repeat dose every 15 minutes if patient not overly sedated. Peak effect
of SubQ opioids is ≈ 30 minutes; may repeat dose every 30 minutes if patient not overly sedated. IM
dosing not recommended.
11. When changing drug or route of administration, use equianalgesic doses. See drug chart on other side.
If changing from one drug to another, the new drug may be more effective, because of differences in
potency or drug bioavailability. Start at 1/4 to 1/2 of the amount calculated using the equianalgesic
tables. Make sure breakthrough medication is available and titrate dose according to individual patient
response. Consult pain or palliative specialist when switching to and from methadone.
12. Manage opioid side effects aggressively. Patients never become tolerant to the constipating effects of
opioids. Always start stimulant laxative/softener combination with opioids.
13. To discontinue opioids taper gradually to patient response to avoid withdrawal symptoms.
14. Always educate patients and caregivers about pain medications, side effect management and safe
storage.
Pain Sources
Pain Character
Drug Class/Examples
Myofascial
- Acetaminophen/NSAIDs: Celecoxib (Celebrex), Somatic Pain
Ibuprofen, (Motrin, Advil, Caldolor), Naproxen (Aleve) - Opioids Visceral Pain
Bone Pain
- NSAIDs: Celecoxib (Celebrex), Ibuprofen, (Motrin, Advil, Caldolor), Naproxen (Aleve), Ketorolac (Toradol), and others - Corticosteroids/Bisphosphonates - Radiation Therapy, Radionuclides - Opioids Neuropathic
- Anticonvulsants: Gabapentin (Neurontin), Nerve Damage
Dysesthesia
-Tricyclic Antidepressants: Nortriptyline (Pamelor), Desipramine (Norpramin) - SNRI Antidepressants: Duloxetine (Cymbalta), Venlafaxine (Effexor) - Corticosteroids - Topical Anesthetic, Lidocaine Patch 5% (Lidoderm) - Opioids SIDE EFFECT
OPIOID SIDE EFFECT MANAGEMENT
Constipation
Tolerance to opioid related constipation does not occur. Start with combined senna as stimulant
and docusate (Colace) as softener. May increase to 4 tabs bid. If no BM in 2 days add a
laxative (Dulcolax, Lactulose, Milk of Magnesia, polyethylene glycol). Increase fluids, activity,
adjust to effect.
Rule out reversible causes, e.g. constipation. Prochlorperazine (Compazine) 10 mg PO q 6 hr Vomiting
PRN or 25 mg suppository PR q 6 hr PRN. May add Lorazepam (Ativan) 0.5 mg q 6 hr PO/SL, PRN or Metoclopramide (Reglan) (also helpful for early satiety and constipation) 10 mg PO QID. Scopolamine TD (Transderm-Scop) patch 1.5 mg q 3 days is effective for movement related nausea q 72 hrs. Haloperidol (Haldol) 0.5 - 4 mg PO or IV/SQ q 6 hrs. Respiratory
Rare - closely monitor in opioid-naïve patients. Increased risk with obstructive sleep apnea, Depression
obesity, on benzodiazepines, or in those with respiratory compromise. Tolerance develops. SCCPI CANCER PAIN MANAGEMENT REFERENCE CARD
Southern California Cancer Pain Initiative
c/o City of Hope • 1500 E. Duarte Road
Duarte, California 91010
626.256.4673 Ext. 63202
Fax: 626.301.8941
Email: sccpi@coh.org
Download or Order Laminated Card on SCCPI website
http://sccpi.coh.org
SCCPI Mission: To promote optimum pain relief for all people with cancer.
EQUIANALGESIC TABLE GUIDELINES
Dosing is always dependent on individual patient characteristics and response.
Verify dosing for pediatric and geriatric patients.
APPROXIMATE EQUIVALENCE
DOSAGE FORM/STRENGTHS
IV/SubQ ORAL
Morphine
Immediate Release Tablets
Morphine Sulfate Immediate Release - 15, 30 mg Sustained Release Tablets
MS Contin – 15, 30, 60, 100, 200 mg q 8 or 12 hrs Oramorph SR - 15, 30, 60, 100 mg q 8 or 12 hrs Avinza – 30, 45, 60, 75, 90, 120 mg q 24 hrs
Kadian –10, 20, 30, 50, 60, 80, 100, 200 mg q 12-24 hrs
Generics – Oral Liquid
Morphine Sulfate Immediate Release
Solution – 2 mg/ml, 4 mg/ml, 20 mg/ml
Suppository
Rectal Morphine Sulfate (RMS) – 5, 10, 20, 30 mg
Hydromorphone
Injection – 1, 2, 4 mg/ml
Suppository
Extended Release (Exalgo*) – 8,12,16 mg q 24 hrs
Oxycodone
Immediate Release Tablets
Oxycodone/Acetaminophen Tablets*
Percocet – 2.5/325, 5/325, 7.5/325, 7.5/500, 10/325 mg
Roxicet – 5/325, 5/500 mg, 10/650
Sustained Release Tablets
Oxycontin – 10, 15, 20, 30, 40, 60, 80 mg
Liquid
Oxycodone – 20 mg/ml
Roxicet Oxycodone HCL 5mg/325 APAP/5ml
* Do not exceed 2000-4000 mg Acetaminophen q 24 hrs Oxymorphone Tablets
Opana ER – 5, 10, 20, 30, 40 mg q 12 hrs Hydrocodone
Hydrocodone/Acetaminophen* Tablets
Examples: Vicodin – 5/500 mg; Vicodin ES – 7.5/750 mg Lortab – 2.5/500 mg, 5/500 mg 7.5/500 mg, 10/500 mg Norco – 5/325 mg, 7.5/325 mg, 10/325 mg Hydrocodone/Ibuprofen Tablets
* Do not exceed 2000-4000 mg Acetaminophen q 24 hrs Dual Action
Tramadol Hydrochloride** Tablets
Analgesics
Morphine ≈
Ultracet – 37.5/325 mg (Acetaminophen*) * Do not exceed 2000-4000 mg Acetaminophen q 24 hrs Extended Release*
Tapentadol Tablets
Fentanyl
Skin Patch
Transdermal
Fentanyl ≈
≈ 200 mg oral
Fentanyl
Transmucosal-Buccal Oral Lozenge
Breakthrough
Actiq – 200, 400, 600, 800, 1200, 1600 mcg Fentanyl Buccal Strip
Sublingual
Abstral Fentanyl SL –100, 200, 300, 400, 600, 800 mcg
Fentanyl Nasal Spray
Lazanda –100, 200, 400, 800 mcg
Methadone
Equivalency ratios for methadone are complex because of its long half-life, potency, and individual variations in pharmacokinetics. Consult American Pain Society References:
American Pain Society. (2008). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain.
6th Edition. www.ampainsoc.org.
Pasero, C. & McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. MO: Elsevier Mosby.
For more resources, see the City of Hope Pain & Palliative Care Resource Center at http://prc.coh.org.
**Davis, M., Glare, P., & Hardy, J. (2005). Opioids in Cancer Pain. NY: Oxford University Press.
Pain Scale
0 1 2 3 4 5 6 7 8 9 10
NO PAIN WORST PAIN

Source: http://sccpi.coh.org/PC-12.pdf