1. Key dosing points: Begin a bowel regimen when opioid therapy is initiated (senna + docusate). For CHRONIC pain, use a scheduled medication regimen. ( ex: Morphine ER 30 mg by mouth q8h around-the-clock) For ACUTE or BREAKTHROUGH pain, use immediate release formulations on a prn basis. ( ex: Morphine IR 15 mg by mouth q2h prn pain) For prn doses, use 10-20% of the total 24-hour scheduled dose. Prn doses can be safely redosed if pain persists and no sedation is observed after peak opioid effects are reached. Oral = 1 hour, SC = 20-30 min, IV = 10- 20 min (fentanyl IV=6-10 min). Switching opioids: Use equianalgesic doses (See Table 1). Reduce the calculated dose 25-50% to account for lack of tolerance to the new opioid and interpatient variability. Adjusting scheduled and/or prn opioids for inadequate pain relief: There are 3 options: 1) Add or increase a scheduled dose, 2) Increase the prn dose, 3) Increase both the prn and scheduled dose. Dose increases less than 25% do not improve analgesia. For mild to moderate pain, increase the dose by 25-50%. For moderate to severe pain, increase the dose 50-100%. Opioid Dosing and Conversions Table 1: Equianalgesic Conversion of Opioids DrugSQ/IV DoseOral Dose Morphine1030 Hydromorphone1.56-7.5 Oxycodone------20-30 Oxymorphone------10 Hydrocodone ^ ------30 Codeine120200 Fentanyl0.1 mg (100 mcg)Not established ^ Only available as a combination product. Naloxone (Narcan®): Reverses sedation, respiratory depression, and ANALGESIA. Careful titration permits reversal of side effects without complete reversal of analgesia. Onset of effect is ~1-2 minutes. Duration of effect is 20-60 min. Dilute one vial (0.4 mg) with 9 mL NS. Give IVP as 1-2 mL doses every 60 seconds, based on patient response. Excess naloxone can cause seizures, tachycardia, hypertension, and withdrawal. For malignant pain or end-of-life care, consider consulting Pain/Palliative Medicine. Phone: 293-2957, Fax: 688-3700 Please refer to the pharmacy intranet for references and further information.

2. Methadone: Adverse events experienced with methadone use are generally related to: Inadvertent overdose due to a lack of knowledge with initiation/titration Due to methadone’s long half-life, accumulation occurs over 5-7 days. Monitor for sedation and/or respiratory depression, which may occur for up to 7 days after initiation or dose increases. Do not increase the methadone dose more often than every 72 hours. Drug interactions Methadone is metabolized primarily by CYP3A4 & CYP2D6. Cardiac arrhythmias (QT prolongation → Torsades de Pointes) Use caution in patients with baseline QT prolongation (QTc > 450 ms) or concomitant QT prolonging medications. Monitoring should include an EKG at the start of therapy, within 30 days of initiation or dose increases, and annually thereafter. * Ratios should only be used to convert TO methadone. Conversion ratios should NOT be used to convert FROM methadone TO morphine or other opioids. Consult an experienced prescriber. ** Use caution when converting very high doses of opioids (> 800 oral morphine equivalents) to methadone. Consult an experienced prescriber. Table 2: Equianalgesic Conversion to Methadone* Oral Morphine EquivalentMorphine: Methadone Ratio < 90 mg/day4:1 90 - 300 mg/day8:1 > 300 mg/day**12:1 Oral methadone: IV methadone ratio= 2:1 1 Patients with persistent, moderate to severe chronic pain who have been taking an around-the-clock opioid for longer than a week and are considered opioid-tolerant. 2 Significant interpatient and intrapatient variability exists in absorption from transdermal fentanyl. Example: patients with diffuse edema or cachexia have lower than anticipated fentanyl absorption. External heat increases absorption from fentanyl patches. Table 3: Equianalgesic Conversion to Transdermal Fentanyl Oral Morphine EquivalentTransdermal Fentanyl Dose 2 30 mg/day12 mcg 60 mg/day25 mcg 120 mg/day50 mcg 180 mg/day75 mcg 240 mg/day100 mcg Fentanyl Transdermal System (Duragesic®): Fentanyl patches should only be prescribed for CHRONIC PAIN in OPIOID TOLERANT patients. 1 Transdermal fentanyl can take 12-24 hours to begin working and does not peak for up to 72 hours. Do not titrate patch doses more frequently than every 72 hrs. This information has been developed by the authors and department listed above at The Ohio State University Medical Center and is intended for use only within the institution. The information is not meant to be applied rigidly and followed in all cases. Professional judgment must remain central to the application of this information. All rights reserved, including right of reproduction, in whole or in part, in any form without permission from The Ohio State University Medical Center. Copyright: © 2009 The Ohio State University Medical Center. Author(s): Hartman, Gustin; Department: Pharmacy; Date Originated: May 2009; Committee(s) Approved: P&T/MUE Executive Committee