Table 9. Common Opioids for Chronic Pain Management continued Medication Available Oral Strengths Dosage
Clinical Considerations
Tapentadol, extended-release tablets • Nucynta ER
Tablets: 50 mg 100 mg 150 mg 200 mg 250 mg
Conversion from immediate release tapentadol: • Calculate total daily tapentadol dose • Divide into two equal doses and give orally every 12 hours • Titrate by no more than 100 mg/ day every three days Conversion from a different opiate agonist to Duragesic: • Convert the previous 24-hour opioid analgesic requirement to an equianalgesic morphine dose • Use conversion chart to determine Duragesic initial dosage • Change the patch every 72 hours • May titrate ate initial dosage after three days (72 hours) • Subsequent dose titrations should be made no more frequently than every six days Monitor patients closely for respiratory depression the first 24 to 72 hours after initiating therapy or dose escalation Supplemental doses may be required
No established dosage ratios exist for direct conversion from other opioids to tapentadol. Generally, recommended to start at 50 mg PO twice daily and titrate by no more than 100 mg/day every three days. The maximum dose of tapentadol extended-release is 500 mg/day (250 mg PO twice daily). Recommended initial Duragesic based on daily morphine dose: • Morphine 60 to 134 mg/day PO: Fentanyl transdermal patch 25 mcg/ hour • Morphine 135 to 224 mg/day PO: Fentanyl, transdermal patch 50 mcg/ hour • Morphine 225 to 314 mg/day PO: Fentanyl transdermal patch 75 mcg/ hour • Morphine 315 to 404 mg/day PO: Fentanyl transdermal patch 100 mcg/ hour • Morphine 405 to 494 mg/day PO: Fentanyl transdermal patch 125 mcg/ hour • Morphine 495 to 584 mg/day PO: Fentanyl transdermal patch 150 mcg/ hour • Morphine 585 to 674 mg/day PO: Fentanyl transdermal patch 175 mcg/ hour • Morphine 675 to 764 mg/day PO: Fentanyl transdermal patch 200 mcg/ hour • Morphine 765 to 854 mg/day PO: Fentanyl transdermal patch 225 mcg/ hour • Morphine 855 to 944 mg/day PO: Fentanyl transdermal patch 250 mcg/ hour • Morphine 945 to 1034 mg/day PO: Fentanyl transdermal patch 275 mcg/ hour • Morphine 1035 to 1124 mg/day PO: Fentanyl transdermal patch 300 mcg/ hour Do not use to convert fentanyl transdermal patches to other opioids, as this will result in overestimation and possible fatal overdose. During treatment with extended- release formulations, immediate-release formulations may be required for breakthrough pain. Due to the unique properties of methadone, dosage ratios for direct conversion to methadone are variable and can be inconsistent between patients. The duration of action of methadone is 4 to 8 hours, while the elimination half-life ranges from eight to 59 hours. Increased monitoring for delayed adverse effects (i.e., respiratory depression) is required, especially during the first 24 to 72 hours after initiation or dose increase. The potency of methadone increases with repeated dosing. Immediate-release opioids may be required for breakthrough pain.
Fentanyl, transdermal patch (72-hour) • Duragesic
Patch Strength 12 mcg/hour 25 mcg/ hour 37.5 mcg/hour 50 mcg/hour 62.5 mcg/hour 75 mcg/hour 87.5 mcg/hour 100 mcg/hour
Methadone, immediate release • Dolophine • Methadose
Tablets: 5 mg 10 mg
Conversion from a different opiate agonist to methadone: • 30 to 40 mg/day (divided into two to three doses) • Titrated every five to seven days in doses of 5 to 10 mg/day
Oral solution: 5 mg/5 mL 10 mg/5mL
*Note: While many ER/LA opioid analgesics are FDA-approved (at specific dosages) for opioid-naïve or non-opioid-tolerant patients, current guide - lines for chronic pain management do not recommend these products to patients (Dowell et al., 2016); therefore, those doses are not provided pre - viously. It is recommended to stop all other around-the-clock opioid drugs upon initiating a new ER/LA product.
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Book Code: AUS3024
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