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PAIN MEDICATIONS

Opioids
  Principles
  Specific medications
Nonsteroidal Anti-inflammatory
Other
Nociceptors
Painful
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  Neuropathies

Also see
  Itch
  Muscle Pain
    Principles
  Pain: General principles
From Roxane Institute

NOTE
  1. Dosages are general guidelines only.
  2. Classes of medications have different advantages and disadvantages
  3. Before using any of the medications listed here: Recheck and become familiar with
OPIOIDS 3
PRINCIPLES 2
  • Utilization
    • Opioids are drugs of choice for severe, refractory pain
    • Non-opioid medications should be tried first for chronic pain
  • Dosing
    • No analgesic ceiling effect for pure agonists
    • Dose can be titrated to achieve maximum pain relief
    • Oral route preferred: In appropriate doses as effective as parenteral
    • Other noninvasive routes
      • Rectal: Avoid when local lesions are present
      • Transdermal: Fentanyl
      • Parenteral routes: Use when others not available
        • Intramuscular and Subcutaneous: Avoid with repetitive dosing
          • Painful
          • Absorption unreliable
          • Contraindications: Children; Edema; Thrombocytopenia
        • IV: Risk of respiratory suppression
        • Epidural and Intrathecal
          • Risk of respiratory depression: Acute or delayed
          • Need preservative-free drug formulations
    • Modify dose: Renal or Hepatic disease
  • Side effects
    • Constipation
      • Very common
      • Use prophylactic stimulant laxatives when possible
    • Sedation
      • Frequent with initial opioid use
      • Tolerance develops rapidly in most patients
    • Respiratory depression: Rare, except with
      • Opioid naive patients
      • Significant pulmonary disease
    • Hypersensitivity reactions: Rare; When present change to different opioid class
      • Phenanthrene derivatives: Morphine, Codeine, Hydromorphone, Oxycodone
      • Phenylpiperidine derivatives: Meperidine, Fentanyl
      • Diphenylheptane derivative: Methadone 4
    • Cardiac: Especially methadone
    • Opioid use disorder
    • Avoid: concurrent opioids & benzodiazepines
  • Advantages
    • Can generally be titrated up to an effective dose
    • Sedative and anxiolytic properties also useful in pain control
    • Some opioids are inexpensive
    • Long acting, controlled-release forms available
    • Multiple choices of drugs & routes of administration
  • Problems & Considerations
    • Side effects may limit analgesic effectiveness
    • Prescription is tightly regulated
    • Antagonists: Naloxone; Naltrexone
      • Cause immediate reversal of all opioid effects including analgesia
        • Results in acute withdrawal
        • May be complicated by severe pain or seizure
      • Not used to reverse non-life-threatening effects: Confusion or sedation
      • If used to reverse life-threatening respiratory depression or hypotension: Administer cautiously
    • Methadone
      • Cardiac disorders: QT prolongation; At higher doses
      • Long half-life: Difficult to titrate
      • Dose equivalents to other opioids: Complex
      • Not useful for acute pain
      • Inexpensive
    • Meperidine
      • Short (2-3 hour) duration
      • Repeated administration may lead to CNS toxicity: Tremor, confusion, or seizures
    • Opioid agonist-antagonists: Pentazocine; Butorphanol; Nalbuphine
      • Risk of precipitating withdrawal in opioid-dependent patient
      • Analgesic ceiling
      • Possible production of unpleasant psychotomimetic effects (e.g., dysphoria)
    • Partial agonist: Buprenorphine
      • Analgesic ceiling
      • Can precipitate withdrawal
SHORT-ACTING OPIOIDS A LONG-ACTING OPIOIDSA
Drug (MME) Equivalent Doses Drug Equivalent Doses
OralParenteralOralParenteral
Morphine (1) 30 mg q 3-4 h 10 mg q 3-4 h MS-Contin 90 - 120 mg q 12 h .
Hydromorphone (4) 7.5 mg q 3-4 h 1.5 mg q 3-4 h Levorphanol 4 mg q 6-8 h 2 mg q 6-8 h
Codeine (0.15) 200 mg q 3-4 h . Methadone (4-10) 20 mg q 6-8 h 10 mg q 3-6 h
Hydrocodone (1) 30 mg q 3-4 h . Propoxyphene . .
Oxycodone (1.5) 30 mg q 3-4 h . Oramorph SR 90 - 120 mg q 12 h .
Meperidine 300 mg q 2-3 h 100 mg q 3 h Oxymorphone (3) . 1 mg q 3-4 h
Fentanyl (2.4) IM or IV Fentanyl Transdermal: 25 μg patch @
45 -135 mg Morphine p.o. over 24 h
Opioid-naive adults and children > 50 kg body weight
MME = Morphene milligram equivalents


NON-STEROIDAL ANTI-INFLAMMATORY
Salicylates Phenylalkanoic Acid Derivatives
Drug Typical dose Drug Typical dose
Aspirin 650 mg q 4-8 h Ibuprofen 400 mg q 6 h
Diflunisal 500 mg q 12 h Naproxen 500 mg q 12 h
Salsalate 1 g q 8 h Fenoprofen 300 mg q 6 h
Trilisate 750 mg q 6-8 h Ketoprofen 50 mg q 6-8 h
Indoles Flurbiprofen 100 mg q 8 h
Drug Typical dose Oxaprozin .
Indomethacin 50 mg q 8 h Napthylalkanone
Sulindac 200 mg q 12 h Drug Typical dose
Indole Acetic Acids Nabumetone 1 g qd
Drug Typical dose Fenamates
Tolmetin 400 mg q 8 h Drug Typical dose
Ketorolac 30 mg IM/IVq 6 h Meclofenamate 50 mg q 4-6 h
Pyranocarboxylic Acid Mefenamic acid 250 mg q 6 h
Drug Typical dose Diclofenac 50 mg q 8 h
Etodolac 400 mg q 12 h Oxicam
Drug Typical dose
Piroxicam 20 mg qd


OTHER MEDICATIONS FOR PAIN
Antidepressants Anticonvulsants
Bedtime dose helps sleep & pain Especially for lancinating pain
Drug Typical dose Drug Typical dose
Amitriptyline 25 to 100 mg qhs Carbamazepine 200 mg q 8 h
Desipramine 75 mg qhs Valproic acid 250 mg q 8 h
Nortriptyline 75 mg qhs Phenytoin 100 mg q 8 h
Fluoxetine 20 mg qd Clonazepam 0.5 mg q 8 h
Venlafaxine ER 37.5 - 225 mg/d Gabapentin 600 mg q 8 h
Paroxetine 20 to 40mg qd Lamotrigine1 25 mg bid
Analgesics Local Anesthetics
Drug Typical dose Drug Typical dose
Acetaminophen 650 mg q 4-6 h Mexiletine 225 mg q 8 h
Tramadol 100 mg q 4-12 h Flecainide 150 mg q 12 h
Steroids Lidocaine 1.5 mg/kg IV
Drug Typical dose Topical
Prednisone 20-80 mg qd Drug Typical dose
Dexamethasone 4-16 mg qd Capsaicin Topical qid
Pain medications: Mechanisms
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References
1. Diabet Med 2007 Feb 28
2. StatPearls 2020: Dec 5, StatPearls 2020 Nov
3. LiverTox 2020 Nov
4. J Pain 2020 Jun 26:S1526, CNS Drugs 2020;34:827-839

9/13/2022