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PAIN MANAGEMENT in the AGED PAIN MANAGEMENT 1) Ask about pain: function & level (0-10) 2) Guiding principles; 1st --Nonpharmacologic 2nd--scheduled dosing 3rd--limit side effects 3) Acute pain1st--Nonpharmacologic, 2nd--acetaminophen scheduled 3rd--narcs.--prn,1/4 usual dose (See back side) sedation?---> ritalin 2.5 mg bid 4) Chronic pain -evaluate cause (inflammatory vs neuropathic) - level (0-10), function, depression? -therapy: (for acute pain see narcotics) remember:- rehab. - educate - team concept 5) Meds. General therapy: -acetaminophen 1000mg qid or 650mg XL 2 tid –Narcotics (add prn & sustained release: (reverse side) (If needed >1 week use extended release primarily) If inflammatory/mechanical--ADD: --salicylates 500 mg bid->1500 mg bid (follow (asa) levels) other nsaid’s ½ usual dose. Avoid in renal/CHF/GI dz. If neuropathic---ADD: -capsaicin-0.025%-->0.075% qid "Burn is good" -neurontin 100 mg q hs, advance q 3 d. To bid--tid Max dose 300 mg qid -pregabalin 50 mg p.o. tid Max dose 100 mg tid -duloxetine start 20 mg q d, increase to bid max dose 60 mg q d -nortriptyline 10 mg q hs ,max 25 mg q hs Use levels to guide higher doses -lamotrigine 25 mg q d, increase by 50 mg q 2 wks, max 400 mg q d P-A-I-N P hysical A nxiety I interpersonal/social problems N on-acceptance/spiritual distress P hysical (Pain) - (make sure of diagnosis (when you can) Mech/ Inflammatory Drug vs. neuropathic vs. bone APAP* + + + NSAIDS + -- + Dexamethasone* * + -- + Opiates~ + +/- + Anti-depressants -- + -- Anti-convulsants -- + -- Radiation/chemo -- -- + *APAP: scheduled dose and add PRN narcotics (write p.o. or p.r.) **dexamethasone: 4-10 mg per dose ~Opiates po/pr* sc/iv size liquid morphine 5mg q 4h*. 2mg q 2 hr 15mg 10,20, 100mg/5ml oxycodone 2.5mg q 4h*. --- 5 mg 5 mg/5 ml. MS Contin 15mg q 12 h*. --- 15,30,60, 100,200 mg ---- --- 10, 20, 40, 80,160 mg ---- --- 25,50,75, 100mcg/h Oxycontin 10 mg q 12 h.* Duragesic p 25 mcg/h. q 3 d* Tramadol 50-100 mg q 46 hrs prn pain * (these are starting doses-titrate to pain control and tolerance) A nxiety (pain) (counsel, reassurance, family friends, pastor) Medication po im/iv size liquid lorazepam 0.5-2 mg t.i.d. 0.5-2 mg q 4h 0.5, 1& 2 mg 2mg/ml 0.5-2 mg q 4h 1-2 mg q 4 h. (not IV) haldol I nterpersonal/spiritual-->counseling, family/friends, pastors N on-acceptance-------------->counseling, family/friends, pastors 2mg/ml