Natural derivatives: Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS)
Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS)
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
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
Titrate 2-5 mg increments q5-10 min
Peak analgesia in 10-20 min
Average: 10 mg q3-4h
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)
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)
Titrate 0.5-1.0 mg increments
Peak analgesia in 5-15 min
Average: 1.5 mg q3-4h
Butorphanol
(Stadol)
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
Opioids
Benzodiazepines
Synthetic cannabinoids
Amphetamines
Antihistamines
Antipsychotics
Laxatives
Antivirals