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Commonly Used Non-Opioid Analgesics
Maximum Dose
Average Dose
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Side Effects
Maximum Dose
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Pocket Tool
Non Steroidal Anti-Inflammatory Drugs (NSAIDS) (use with extreme caution in the elderly)
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Principles of Pain Management
1. Ask the patient about the presence of pain 3. Perform a comprehensive pain assessment, including: What makes the pain better or worse n History/physical exam 4. Do not use I.M. route. Oral, I.V. or S.C. preferred.
5. Treat persistent pain with scheduled medications 6. Ordinarily two drugs of the same class (e.g., NSAIDs) should not be given concurrently; however, one long-acting and one short-acting opioid may be prescribed concomitantly Lower incidence of adverse Contraindicated in sulfonamide allergy. 7. Assess, anticipate and manage opioid side effects aggressively No platelet effects. Risk of cardiovascular 8. Most opioid agonists have no ceiling dose for analgesia; titrate to Dual Mechanism Analgesics
9. With older adults, start low, go slow, but go! 400 mg (300 mg
10. Discuss goals and plans with patient and family in the elderly)
12. Avoid meperidine.
13. Addiction occurs rarely unless there is a history of substance Management of Opioid Side Effec
a) compulsive use, b) loss of control, c) use despite harm Monitor for common adverse effects: GI ulceration and bleeding, decreased platelet aggregation, and renal toxicity.
Management of Opioid Side Effects
Management of Breakthrough Pain
Adverse Effect
Management Considerations
When using long-acting opioids around-the-clock for persistent pain, obtain order for a short-acting opioid (rescue) for breakthrough pain.
Begin bowel regimen when opioid therapy is initiated. Include a mild stimulant laxative (e.g., Senna, Cascara) + stool
softener (e.g., Colace) at hs, or in divided doses as routine prophylaxis
n The rescue dose is 10-15% of the 24h total daily dose.
n Oral rescue doses should be available every 1-2h; parenteral Tolerance typically develops. Hold sedatives/anxiolytics, dose reduction; consider CNS stimulants (e.g., increase caffeine intake, methylphenidate, dextroamphetamine or modafinil) n If patient is consistently using 3 or more rescue doses daily, Dose reduction, opioid rotation; consider metoclopramide, prochlorperazine, scopolamine patch consider increasing the around-the-clock dose.
n Whenever the around-the-clock dose is increased, the rescue Dose reduction, opioid rotation; consider an antihistamine such as diphenhydramine Dose reduction, opioid rotation, consider neuroleptics (haloperidol or risperidone) n Consider using the same drug for both scheduled and breakthrough doses when possible (e.g., long-acting morphine + Dose reduction, opioid rotation, neuroleptic therapy (haloperidol, risperidone) Dose reduction, opioid rotation, increase fluid intake; consider clonazepam, baclofen Examples:
Oral rescue dosing: Pt. is on MS Contin 200 mg q 12h.
Sedation precedes respiratory depression. Hold opioid. Give low dose naloxone - dilute 0.4 mg (1ml of a 0.4 mg/ml amp
1. Total daily dose (200 mg x 2 = 400 mg morphine/24h) of naloxone) in 9 ml normal saline for final concentration of 0.04 mg/ml 2. Calculate 10 to 15% of 24h dose for rescue dose. References
(10% = 40 mg, 15% = 60 mg short-acting morphine) 1) American Geriatric Society Clinical Practice Guidelines (2002, 2009). 3. Rescue dose = 40-60 mg of morphine q 1-2h.
2) American Pain Society (2008), Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition.
Parenteral Dosing: (based on continuous infusion)
3) American Pain Society (2005), Guideline for the Management of Cancer Pain in Adults and Children.
Calculate rescue dose based on 25-50% of hourly dose.
4) American Pain Society (2002), Guideline for the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis, 2nd ed., Glenview, IL: APS.
Printed through a grant from Tufts University School of Medicine, Master of Science in Pain Research, Education and Policy.
Switching From One Opioid To Another: (Examples)
Adjuvant Analgesic Drugs
1. Calculate the total 24h dose of pt’s opioid regimen.
Most commonly used drugs. Consideration should be given to comorbidities, hepatic and renal insufficiency, and age.
2. Locate new opioid on equianalgesic chart.
Starting Dose
Dose Range
Antidepressants (often use lower doses to treat pain than to treat depression)
Tricyclic Antidepressants
4. Divide the total daily dose of the new opioid by the number (10 mg or less for
drowsiness, dizziness, constipation, urinary elderly) Titrate dose
(45 mg divided by 6 doses = 7.5 mg q 4h) Obtain baseline EKG for history of cardiac 5. Reduce calculated dose of new opioid by 25% -50% for incomplete cross tolerance; titrate up as needed. Better side effect profile than amitriptyline. Use caution in opioid-naïve patient.
Duragesic patch 25 mg q 72h = 50 mg oral morphine q 24h. Better side effect profile than amitriptyline. Divided into 6 doses = 8.3 mg oral morphine or 2.8 mg IV morphine q 4h. These are approximate doses.
Selective Serotonin and Norepinephrine Reuptake Inhibitor (SSNRI) Antidepressant
*Opioid Equianalgesic Chart
(opioids with no ceiling dose)
lower starting dose for patients for whom Parenteral Oral
Starting Dose for Opioid
Titrate slowly to reduce risk of serious Corticosteroids
*Combination Opioid Drugs (have ceiling dose)
5-10 mg po daily or bid Minimal effective dose For cancer pain, continue treatment until side effects outweigh benefit. Also for joint Local Anesthetic
Patch may be cut to fit painful area(s). Other Adjuvant
*Equianalgesic doses are approximate. Individual patient response must be observed. Doses are titrated according to Disclaimer: The intent of this guide is to provide a brief summary of commonly used analgesics. It is not a complete pharmacological
patient’s response. Doses may be lower in frail & elderly.
review. All medications should be administered only with physician or licensed allied health provider orders.
No liability will be assumed for the use of this tool.


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