Pain Management
Acute Pain - Drugs and dosages for managing pain:
Mild Pain (Step 1):
- Suggested Agent: Acetaminophen po
- Dose: 500 mg-1g q6-8h
- Cautions: Liver disease/elderly
- Adverse effects: Negligible at therapeutic doses
- Suggested Agent: Ibuprofen po
- Dose: 200-400 mg q8h
- Cautions: Platelet dysfunction (not COX-2), asthma or COPD, severe cardiac disease, hypertension, renal disease or history of peptic ulceration. COX-2 may be gastroprotective
- Adverse effects: See cautions above.
- Suggested Agent: Celecoxib po
- Dose: 100-200 mg q12h
- Cautions: Platelet dysfunction (not COX-2), asthma or COPD, severe cardiac disease, hypertension, renal disease or history of peptic ulceration. COX-2 may be gastroprotective
- Adverse effects: See cautions above.
Moderate Pain (Step 2):
- Suggested Agent: Acetaminophen 500mg/Codeine 30mg po
- Dose: 1-2 tablets q4h
- Cautions: Liver disease in elderly and history of allergy to opioid analgesics
- Adverse effects: Gastric irritation with codeine
- Suggested Agent: Acetaminophen 500mg/Oxycodone 5mg po +/- local anesthetic
- Dose: 1-2 tablets q4h
- Cautions: Relies on patient’s ability to metabolize to active form.
- Adverse effects: Constipation, itching, nausea, sedation, respiratory depression, especially at higher doses with both medications
Severe Pain (Step 3):
- Suggested Agent: I.V. Morphine
- Dose: 0.1-0.15 mg/kg
- Cautions: Reduce dose in elderly and supervise closely until pain controlled
- Adverse effects: Constipation, itching, nausea, sedation, respiratory depression, especially at higher doses with both medications.
- Suggested Agent: I.V. Hydromorphone
- Dose: 0.02-0.03 mg/kg
- Cautions: Reduce dose in elderly and supervise closely until pain controlled
- Adverse effects: Constipation, itching, nausea, sedation, respiratory depression, especially at higher doses with both medications.
- Call Acute Pain Service: Consider local anesthetic techniques
Neuropathic Pain (Step 4):
- Suggested Agent: Amitriptyline po
- Dose: 10-50mg qhs
- Cautions: Cardiac Disease (TCA)
- Adverse effects: Anticholinergic effects (TCA) and sedation, especially at higher doses.
- Suggested Agent: Gabapentin po
- Dose: 100-300mg q8h
- Cautions: Elderly more prone to sedation.
- Adverse effects: Anticholinergic effects (TCA) and sedation, especially at higher doses.
Next page: Acute pain - Treating opioid-related adverse effects