Intern Survival Guide Topic

Multimodal pain control.

Inpatient pain control for the new intern: multimodal opioid-sparing first, a CDC-anchored equianalgesic conversion table, a worked IV-hydromorphone-to-oral-oxycodone conversion, and the 25–50% dose reduction for incomplete cross-tolerance. Never for the fentanyl patch, methadone, or buprenorphine.

Reviewed June 2026 · verify against current guidelines

Multimodal First

Build From the Bottom Up

Schedule non-opioids around the clock. Every one is opioid-sparing: less sedation, constipation, and respiratory depression. Reserve opioids for breakthrough and severe pain.

The scheduled foundation

Acetaminophen	1000 mg PO or IV q6h. Max 4 g/day; 3 g/day if prolonged use or elderly; 2 g/day in cirrhosis.
NSAID	Ketorolac 15 mg IV q6h (analgesic ceiling), max 5 days. Or ibuprofen 400-600 mg PO q6h.
Gabapentinoid	For neuropathic pain. Sedation and fall risk; dose for renal function.
Opioid	Breakthrough and severe pain only. Lowest effective dose.

Match the agent to the patient: limit acetaminophen in liver disease; avoid NSAIDs in kidney disease, GI bleeding, or heart failure; watch sedation and falls with gabapentinoids.

NSAID non-steroidal anti-inflammatory drug

Non-Drug Options

Tools Without a Dose

Use alongside every regimen

Move	Early mobilization, physical therapy, positioning, splinting.
Temperature	Ice for acute injury or swelling; heat for muscle spasm.
Mind-body	Slow breathing, guided imagery, music, distraction.
Procedural	TENS, acupuncture, or massage where available.
Environment	Treat anxiety, protect sleep, reduce nighttime noise.
Educate	Set expectations; reassurance lowers perceived pain.

Non-drug measures are opioid-sparing and have no ceiling. Order them on day one, not as a last resort.

TENS transcutaneous electrical nerve stimulation

Opioid Conversion

Convert Opioids Safely

Approximate equianalgesic dose

Opioid	IV	Oral
Morphine	10 mg	30 mg
Oxycodone	PO only	20 mg
Hydromorphone	1.5 mg	7.5 mg
Fentanyl	100 mcg	poor PO

Worked example: 3 mg/day IV hydromorphone

1.5 mg IV hydromorphone ≈ 30 mg oral morphine; 3 mg → 60 mg.
Oral morphine to oxycodone: 60 / 1.5 = 40 mg/day.
Cross-tolerance cut 25-50%: 20-30 mg/day.
Write: oxycodone 5 mg PO q6h, reassess.

Estimates only. Never use this table for the fentanyl patch, methadone, or buprenorphine.

PO by mouthmcg micrograms

Don't Get Burned

Where Conversions Kill

High-risk errors

Forgetting the cross-tolerance reduction when switching drugs.
Routine basal PCA infusions in opioid-naive patients.
Using this table for the fentanyl patch or methadone.
Morphine in renal failure: active metabolites accumulate.
No bowel regimen with a scheduled opioid.
Skipping an antiemetic for opioid-related nausea.

Order naloxone and monitor sedation and respiratory rate after any opioid change.

PCA patient-controlled analgesia

Sources

Verify against current guidelines and local protocol before acting.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 2022 (oral MME conversion factors).
Arnold R, Weissman DE. Calculating Opioid Dose Conversions. PCNOW Fast Fact #36, 2024.
Bhatnagar M, Pruskowski J. Opioid Equivalency. StatPearls, 2024.
McPherson ML. Demystifying Opioid Conversion Calculations. 2nd ed. ASHP, 2018.
Forestell B, Sabbineni M, Sharif S, et al. Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain. Ann Emerg Med. 2023;82:615-623.
Acetaminophen ceiling per FDA prescribing information.

Downloads

Every card for this topic — carousels and tables, print-ready for the wards or for sharing.

Carousel6 slides