Opioid

Usual starting dose

Frail persons, very elderly persons, patients with advanced heart and lung disease

Codeine

15 mg PO every 4 h

+ 15 mg PO every 2 h as neededa

7.5 mg PO every 6 h

+ 7.5 mg PO every 2 h as neededa

Tramadol

37.5 mg or 50 mg PO every 8 h

+ 37.5 mg or 50 mg PO every 4 h as neededb

37.5 mg PO bid

+ 37.5 mg PO every 4 h as neededb

Morphine

5 mg PO every 4 h

+ 5 mg PO every 1 h as needed

1 mg or 2.5 mg PO every 6 or 8 h

+ 1 mg PO every 2 h as needed (select a dose; range provided here only to individualize dose to frailty level)

Hydromorphone

1 mg PO every 4 h

+ 1 mg PO every 2 h as needed

0.2 mg PO or 0.5 mg PO every 6 or 8 h (select a dose; range provided here only to individualize dose to frailty level)

+ 0.5 mg PO every 2 h as needed

Oxycodone

2.5 mg or 5 mg PO every 4 h

+ 5 mg PO every 2 h as needed

This tables serves only as a general guideline; doses may sometimes need to be individualized.

Avoid prescribing ranges of doses; choose one dose and assess its impact. If not effective, titrate up. Ranges are confusing for patients, caregivers, and care providers.

In monitored settings, as-needed dosing can be done every 1 hour (as needed). Where there are concerns of inappropriate use of breakthrough doses, consider increasing the interval to every 3 or even 4 hours.

a The maximum daily dose of codeine is ~300 mg PO in 24 h.

b The maximum daily dose of tramadol is 400 mg PO in 24 h.