List of Opioids from Strongest to Weakest

By Dr. Vilma Ruddock

Natural opiates and synthetic or semisynthetic opioid drugs are frequently misused for both their euphoric and sedative effects. The drugs differ in their potency and therefore the dose of each that will relieve the same level of acute or chronic pain will differ. Careful opioid selection and management can provide effective pain relief, while helping to decrease the current epidemic of opioid abuse, dependence, addiction, overdose, and death.

Comparing the Potency of Opioids

Morphine, the predominant alkaloid in the opium poppy plant seed, is the most potent natural opiate. The potency of all other opioids is estimated against that of 30 milligrams (mg) of morphine - the estimated morphine milligram equivalent (MME). The MME or potency of an opioid is its dose in mg that provides about the same level of pain relief as 30 mg of morphine taken by mouth.

You can calculate the MME for an opioid by dividing 30 mg by the drug's morphine equivalent conversion factor from a Centers for Disease Control and Prevention (CDC) chart:

The conversion factor for an oxycodone, such as OxyContin, is 1.5.
The estimated MME for OxyContin is therefore 20 mg - equivalent to 30 mg of morphine.

Mistakenly taking a high milligram dose of a potent opioid equal to that of a less potent opioid can lead to serious adverse outcomes, including overdose and death.

A Comparison Chart of Commonly Prescribed Opioids

The chart below compares aspects of the most frequently prescribed opioids in decreasing order of potency as calculated from their morphine equivalent conversion factors. Included are the drugs' generic and brand names, and the type and level of pain they are usually prescribed for. To read the chart, the following information is also helpful:

Doses:
- mg = milligrams
- mcg = micrograms
Onset of action:
- IR = immediate-release - the opioid dose is released into the blood at once
- ER = extended-release - the opioid is released over a time period
Usual dosing = how often a dose is taken
Type of pain treated:
- Acute = short-term pain
- Chronic = long-term, ongoing pain
- Pain severity: mild, moderate, moderately severe, severe

List of Opioids in Order of Potency

Brand Name	Generic Name	Onset of Action	MME	Doses	Usual Dosing	Type of Pain Treated
Duragesic	fentanyl	ER	2.5 mg	12-100 mcg/hour transdermal patches	72 hours	Chronic Severe Round-the-clock dosing needed Other opioids ineffective
Dilaudid	hydromorphone hydrochloride	IR	7.5 mg	2-4 mg tablets	4-6 hours	Acute Chronic Severe
Opana	oxymorphone hydrchloride	IR	10 mg	10 -20 mg tablets	4-6 hours	Acute Chronic Moderate Severe
Methadone	Methadone hydrochloride	IR	10mg	2.5-10 mg	3-4 hours	Moderate pain Severe pain
Methadone	Methadone hydrochloride	IR	10mg	60-80 mg	daily	Addiction treatment
Roxicodone	oxycodone hydrochloride	IR	20 mg	5-15 mg tablets	4-6 hours	Acute Chronic Moderate Severe
OxyContin	oxycodone, slow release	ER	20 mg	10 mg tablets	12 hours	Chronic Moderate Severe Round-the-clock dosing Other opioids ineffective
Percocet	oxycodone plus 325 mg acetaminophen	IR	20 mg	5-10 mg tablets	3-6 hours	Acute Chronic Moderate Severe
Morphine Sulfate	morphine sulfate	IR	30 mg	15-30 mg tablets	3-4 hours	Scute Chronic Moderate Severe
MS Contin	morphine sulfate	ER	30 mg	15 mg tablets	8-12 hours	Chronic Severe Round-the-clock dosing Other opioids ineffective
Vicodin	hydrocodone bitartrate plus 300 mg acetaminophen	IR	30 mg	5 -10 mg tablets	4-6 hours	Acute Chronic Moderate Moderately severe
Codeine Sulfate	codeine sulfate	IR	200 mg	15-60 mg tablets	3-4 hours	Acute Mild Moderate moderately severe
Demerol	meperidine hydrochloride	IR	300 mg	50-150 mg tablets	3-4 hours	Acute Moderate Severe
Ultram	tramadol hydrochloride	IR	300 mg	25-100 mg tablets	4-6 hours	Acute Moderate Moderately severe

Some brands listed here as immediate release, such as Opana, also come in extended release formulations. In addition to tablets, several of the opioids are also available in forms for intravenous, intramuscular, and other routes of administration.

CDC Recommended Opioid Prescribing

The use of an opioid is based on the level of pain, whether the pain is acute or chronic, as well as a person's other individual factors. Doctors rely on various sources of opioid prescribing guidelines to ensure the safe use of opioids, including the most recent, the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

In summary, when using opioids for treatment of pain, the CDC recommends doctors should:

Start with an immediate-release opioid at the lowest effective dose for the level of pain, then proceed from there.
For acute, short-term pain, treat for a short duration of three days or less and avoid treating more than seven days.
For chronic, long-term pain, prescribe an extended-release opioid only if an immediate-release option is ineffective.

According to other CDC data, using increasingly higher doses of an opioid does not translate to better pain relief and carries more risks, including overdose.

Potency and Risks

All opioids have similar side effects, as well as the risk of tolerance, abuse, dependence, and the irreversible changes of opioid addiction, based on the dose and the frequency and duration of use. Be aware that if you misuse or abuse opioids, the more potent the drug, the greater the risks of overdose and death.