Download 2011 Pain Pocket Guide FINAL

GENERIC NAME (BRAND NAME)
ADULT
DOSE (MG)
Non-Opioid Analgesics
Acetaminophen (=APAP) (Tylenol) 160, 325, 500mg
Ibuprofen (Advil, Motrin) 200, 400, 600, 800mg
Naproxen (Naprosyn, Aleve) 250, 375, 500mg
Naproxen sodium (Anaprox, Naprelan) 220, 275, 412.5, 550, 825mg
Salsalate (Disalcid) 500, 750mg
Sulindac (Clinoril) 150, 250mg
Celecoxib (Celebrex) 100, 200, 400mg
Opioids - Short Acting
Codeine/APAP (Tylenol # 3, # 4) 30/300, 60/300mg
Hydrocodone/APAP* (Norco) 5/325, 7.5/325, 10/325mg (see footnote
650 -1000 q4-6h
MAX
AVG.
COMMENTS / ADVERSE EFFECTS
DOSE/24HRS COST /
(MG)
MO.
Note: have a ceiling effect to analgesia but do not produce tolerance and/or dependence
4,000
400-800 q6-8h
3,200
15
Expressed as
base: 500 x1, then
250 po q6-8h
1000-1500 q12h
1,000 (Day 1
1250)
15
3,000
45
200 q12h
400
20
100-200 q12h
400
Tapentadol (Nucynta) 50, 75, 100 mg
Fentanyl (Onsolis) 200, 400, 600, 800, 1200 mcg buccal soluble film
130
1-2 tab q4-6h
1-2 tab q4-6h
4,000 APAP
4,000 APAP
1 tab q4-6h
4,000 APAP
5-15 q4-6h
10-30 q3-4h
2-8 q3-4h
10-20 q4-6h
_
_
_
_
50-100 q4-6h
200-1200mcg 4
times per day
600
1 dose/
episode, 4
doses/day
30
30
Combination products are not appropriate for chronic conditions. Reserve combination agents for treatment of
acute pain or combined with a longer acting agent for breakthrough pain.
Maximum dose of APAP < 4gm/day (<2.6 gm/day if child under 12, hepatic impairment or ethanol use).
35
(See panel (to the right) for a list of opioid related side-effects)
50
25
Best for dose titration & breakthrough pain in malignant pain syndromes
For breakthrough pain in malignant pain syndromes
For relief of moderate to severe acute pain only. Should be taken on an empty stomach at least 1 hour prior to eating or 2
hours after
For relief of moderate to severe acute pain only. Not for chronic use.
Indicated only for the management of breakthrough pain in pts w/ cancer, 18yo and older, who are already receiving and
who are tolerant to opioid therapy for their underlying persistent cancer pain.
350
350
Opioids - Long Acting
Note: Opiates have no ceiling/maximum dose, appropriate doses relieve pain through dosing interval without unmanageable side effects
30-100 q8-12h
NOT for opioid naïve patients. Do Not Crush Tablets.
_
Morphine SO4 ER (MS Contin, Oramorph, Kadian, Avinza )
70+
Consider generic morphine sulfate ER (MS Contin) as a first line oral therapy unless contraindicated.
15, 30, 60, 100mg
1 tab q12h or daily
Generally requires prior authorization and is used for patients with existing abuse problems (alcohol, drugs, etc.)
_
Morphine + Naltrexone (Embeda) 20/0.8, 30/1.2, 50/2, 60/2.4, 80/3.2,
100/4mg
10-40 bid
NOT for opioid naive patients. Do Not Crush Tablets.
_
Oxycodone (Oxycontin) SR 10, 15, 20, 30, 40, 60, 80mg
570
Fentanyl (Duragesic) 25, 50, 75, 100mcg/hr transdermal patch
Buprenorphine (Butrans) 5, 10, 20 mcg/hr transdermal patch
Hydromorphone ER (Exalgo) 8, 12, 16mg
Oxymorphone (Opana ER) 5, 7.5, 10, 15, 20, 30, 40mg
Apply new
patch q2-3d
Apply new
patch q7d
8-64 daily
5-40 daily
2.5-20 q3-8h
Methadone*** (Dolophine, Methadose)
5 or 10mg
*** For Use by Experienced Prescribers Only***
_
220
20mcg/ hr
_
_
440
650
_
25
Should not dose more frequently than q8h.
NOT for opioid naïve patients. Less constipation and itching.
Elevated body temp >40ºC may ! rate of fentanyl release/absorption.
Do NOT exceed one 20mcg/hr Butrans patch due to the risk of QTc interval prolongation. Use caution when prescribing
to opioid-experienced patients requiring high doses of opioids (more than 80mg/day of oral morphine equivalents).
NOT for opioid naïve patients. Do Not Crush Tablets.
Do Not Crush Tablets. Patients must not consume anything with alcohol. Co-ingestion of alcohol with Opana ER may
result in a potentially fatal overdose of oxymorphone.
Prescribing information presented is for treatment of pain (analgesia), not for addiction /detoxification.
Titrate dose slowly. Risk of accumulation due to long half life (15-30 hrs). Not first drug of choice in elderly.
Cardiac toxicity in overdose. Inform the patient of arrhythmia risk. Measure QTc before treatment begins, after 30
days, and annually during treatment (monitor more often if daily dose>100mg or if unexplained syncope or seizures
develop). Discuss risks and benefits and repeat monitoring more often if 450 ms<QTc<500 ms. Consider
discontinuation or dose reduction or eliminate concomitant arrhythmia risks (e.g. medications that cause kypokalemia)
when QTc exceeds 500 ms.
Neuropathic Agents /Adjuvants
Desipramine (Norpramin) 10, 25, 50, 75, 100, 150mg
Amitriptylline (Elavil)
Venlafaxine (Effexor) IR 25, 37.5, 50, 75, 100mg; XR 37.5, 75, 150,
225mg
Duloxetine (Cymbalta) 20,30, 60mg
Gabapentin (Neurontin) 100, 300, 400, 600mg
Pregabalin (Lyrica) 25, 50, 75, 150, 200, 225, 300mg
Tramadol (Ultram) 50mg
(Ultram ER) 100, 200, 300mg
Equivalent doses are approximate and should coincide with detailed
assessment. Patient’s age, weight, previous opioid exposure must be
considered. Start with lowest dose and titrate upward as necessary. Titrate
by increasing the dose as a % of Total Daily Dose. An increase of 25-50%
is generally safe. Frequent reassessment is recommended.
Maximum dose of APAP < 4gm/day (<2.6 gm/day if child under 12, hepatic impairment or ethanol use). May not be
appropriate for daily use for extended periods of time. Risk of hepatic / renal toxicity with chronic overdose.
For NSAIDs / Salicylates / COX-2s:
!
Use caution in patients with CHF, HTN, CrCl<30, liver disease, hx GI bleed, aspirin/NSAID allergy, or bleeding
disorder.
!
Salsalate has fewer GI side effects relative to other NSAIDs.
!
Salsalate, sulindac: Not for pts <16 yrs.
!
COX-2’s do not provide greater pain relief vs traditional NSAIDs. Celebrex contraindicated in sulfa allergy. Use
cautiously in elderly.
!
COX-2s & diclofenac have highest CV risk. Naproxen is lowest..
!
Piroxicam & ketorolac have highest GI risk. Ibuprofen & celecoxib are lowest.
Analgesic
Parenteral
(mg)
Oral
(mg)
Comments
Morphine SO4
(MS)
10
30
Hydromorphone
1.5
7.5
Active metabolite may
accumulate in renal
failure
No evidence of active
metabolite, useful
alternative to MS
When given
repeatedly, long t½
may lead to
accumulation/toxicity
Note: Codeine/APAP & Hydrocodone /APAP are C-III controlled substances. All others listed below are C-II controlled substances
regarding 500mg APAP combination products being phased out by the FDA)
Oxycodone/APAP * (Percocet) 10/325, 2.5/325, 5/325, 7.5/325mg
APAP, (Roxicet) 5/325mg APAP
Oxycodone IR 5, 15, 30; (Roxicodone) Soln 1/1ml, 20/ml
Morphine SO4 10/5ml, 20/1ml soln; MS IR 15, 30mg
Hydromorphone (Dilaudid) 2, 4, 8 mg
Oxymorphone (Opana) 5, 10mg
5
EQUIANALGESIC OPIOID CONVERSION CHART
10-50 qhs
25 – 100 qhs
150
75 – 225 daily
225
60 daily
120
70
15
115
175
100-600 tid
50 tid
3600
300
85
155
Methadone
Fentanyl
Oxycodone
___
Hydrocodone
___
30
Codeine
120
200
Useful in patient
itching from
phananthrenes (e.g.
MS, hydromorphone)
20
Not preferred due to
variation in conversion
to active metabolite.
Oxymorphone
1
10
Active metabolite of
oxycodone.
*Avoid use of meperidine for analgesia when possible. If must use, avoid in
renal impairment, > 48hrs or > 600mg/24hrs.
** Fentanyl patch dosing should be started at conservative levels due to some
variability with calculating dose equivalency from parenteral.
COMMON OPIOID SIDE EFFECTS
!
!
!
!
!
!
Sedation, anti-cholinergic SE (dry mouth, constipation, blurred vision), hypotension. Avoid if cardiac conduction
disorder, seizure or concomitant SSRI.
Nausea, hypertension, dizziness, sexual dysfunction. Avoid with hx of seizure disorder.
!
Drowsiness, dizziness, HA, GI upset; linked to severe liver damage; not recommended in chronic liver disease, CrCl
<30ml/min, ESRD, alcohol use; contraindicated in narrow angle glaucoma. Doses up to 120 mg/day in clinical trials
offered no additional benefit and were less well tolerated than 60 mg/day.
Dizziness, N/V, ataxia, weight gain, palpitations, somnolence, blurred vision, lower extremity edema, and tremor.
!
Sedation or activation, nausea, dizziness. Avoid in patients with seizure disorder (doses > 400 mg/day) or taking SSRI.
50-100 q4-6h
400
20
100 daily
300
250
*FDA to restrict the strength of acetaminophen in prescription drug products, predominantly combinations of acetaminophen and opioids, to 325 mg per tablet, capsule, or other dosage unit (FDA News Release)
*see NCCN Adult
Cancer Pain page 24
for more information
http://www.nccn.org/
professionals/physici
an_gls/pdf/pain.pdf
0.1 -0.2
50-100
IM**
mcg/hr
(patch)
Constipation: Start bowel regimen for ALL patients. Daily stool
softener (docusate sodium) + fiber + senna; or bisacodyl stimulant
laxative as needed, 3-4 times/week. Encourage fluids. Will not develop
tolerance over time.
Somnolence: Use with caution when operating a motor vehicle or
heavy machinery. Avoid consumption with alcohol. Tolerance usually
develops to sedative and cognitive effects over time.
Nausea: Take with food. Tolerance usually develops over time.
Headache, sweating, dry mouth, amenorrhea, sexual dysfunction,
urinary retention, itching: Contact doctor if symptom is severe or
persists. High dose opioids may " testosterone levels.
Myoclonus, respiratory depression, dyspnea: Notify doctor at once.
Tolerance (physical dependence): An expected diminution of drug
effect over time, a result of chronic opioid treatment. Tolerance to
sedation and nausea is common. Tolerance to constipation or pain
relief is uncommon. Physical withdrawl can occur with abrupt
discontinuation of therapy.
Pseudoaddiction: Drug seeking behavior due to inadequate pain
control and should not be mistaken for true addictive behavior.
Addiction (psychological dependence): Impaired control over drug
use, continued use despite harm, compulsive preoccupation with
obtaining and using the substance. Patients with evidence of addiction
should be referred to a pain specialist.
Chronic Pain Conditions Commonly Seen in the Primary Care Setting 2, 3
TYPE OF PAIN
SYMPTOMS
TREATMENT
Non-Pharmacologic
Persistent Low
Back Pain
Back pain, numbness,
weakness in legs, bladder or
bowel dysfunction
Osteoporosis Pain
Persistent back pain, may
intensify w/ sitting or
standing, relieved by bed
rest, exacerbated by sudden
movements (coughing,
sneezing, turning quickly)
Exercise to prevent muscle
deconditioning & "
activity, Physical therapy
(PT), cognitive behavioral
therapy (CBT)
PT, exercise to strengthen
back muscles, supportive
pillows, ice massage,
patient education, social
support
COMMENTS
Pharmacologic
st
1 line: APAPor NSAIDs, opioids,
adjuvant analgesics (tricyclic
antidepressants [TCAs], muscle relaxants
[skeletal muscle relaxants,
benzodiazepines])
Preventing bone loss & reducing
fracture risk: Calcium & vitamin D,
hormone replacement therapy (HRT),
parathyroid hormone (PTH), raloxifene,
biphosphonates, calcitonin, denosumab
Pain: NSAIDs, celecoxib, tramadol or
tapentadol, opioids w/ APAP
!
!
!
!
Exercise, weight loss (if
overweight), PT, assistive
devices, local heat
1st line: APAP, non-selective NSAIDs +
PPI or misoprostol, topical NSAIDs or
capsaicin, COX-2 inhibitors, tramadol or
tapentadol, intra-articular injections w/
corticosteroids of hyaluraonate, Opioids
for moderate to severe refractory pain;
glucosamine and chondroitin.
!
CBT, hypnotherapy,
biofeedback, relaxation
therapy, stress management,
aerobic exercise, PT,
strength training, heat
massage
SNRIs (venlafaxine, duloxetine,
milnacipran), TCAs, SSRIs (fluoxetine,
paroxetine), NSAIDs, gabapentin,
pregabalin, pramipexole, tramadol.
!
Mild to severe deep aching
pain associated with trigger
points, often localized to a
single muscle, commonly
following muscle overload
Release trigger points “taut
bands” by stretching
affected muscle, spray
(vapo-coolant) & stretch
(muscle), massage
TCAs, analgesics, antidepressants some
benefit, trigger point injections w/ local
anesthetic (0.5% lidocaine, 0.5%
bupivicaine) w/ or w/o corticosteroid dry
needle manipulation
!
Chronic Daily
Headache
(Transformed
Migraine)
( Chronic TensionType Headache
(CTTH) w/
intermittent attacks
of migraine occurring
> 15 days/ month for
#$ 4 hours x 6
months)
Predominance of one
HA type, CTTH or
migraine occurs over
time
!
Relaxation training, stress
management, address
psychosocial/ co-morbid
conditions (e.g. depression,
anxiety, sleep disorders)
Treat analgesic medication overuse by
tapering short-acting “prn” meds 10% /
wk to % withdrawal, replace w/ long
acting prophylactic Tx. Migraine
predominance: anticonvulsants
(divalproex ER, topiramate,) beta blockers
(propranolol LA), TCA (amitriptyline),
calcium channel blockers
CTTH predominance: No FDA
approved agents but TCAs usually
warranted for most patients
!
Painful Diabetic
Neuropathy
Loss/reduction in sensation,
pain, weakness, numbness,
tingling in feet, hands, legs;
allodynia, hyperalgesia
1st line: gabapentin, pregabalin, analgesic
antidepressants (nortriptyline,
desipramine, venlafaxine, duloxetine,
citalopram, paroxetine); adjuvant
analgesics (e.g. clonidine, baclofen),
topical agents (e.g. lidocaine 5% patch);
opioids (not long term); optimizing
glycemic control also shown to reduce
pain.
!
Osteoarthritis (OA)
Pain
Fibromyalgia
Syndrome
Myofascial Pain
Syndrome
Deep aching poorly
localized pain involving
distal, proximal
interphalangeal joints, first
metacarpal joint of hand,
lumbar cervical spine, wt.
bearing joints (knees, hips,
ankles)
Widespread
musculoskeletal pain,
stiffness, paresthesia,
nonrestorative sleep, easy
fatigability, multiple tender
points widely &
symmetrically distributed
!
!
Daily headache (HA),
one or both sides of
head, neck, or face
depending on
predominance of HA
type
Usual symptoms of
migraine (e.g. nausea,
sensitivity to light,
sound) often fade as
HA becomes chronic
Physical, emotional
trauma, major life
changes, surgery,
hormonal #s may be
triggers
PT, psychological, &
behavioral interventions
!
!
!
!
!
PAIN EVALUATION & MANAGEMENT
Initial History
!
No obvious etiology in 85%
of isolated back pain cases
"d risk in postmenopausal
! & pts on glucocorticoids
Vertebral compression
fractures = most common
complication
Use opioids cautiously as
may "risk of fall/fracture
Loss of cartilage contributes
to pain
No specific labs are
diagnostic for OA, diagnosis
usually based on clinical &
radiologic findings.
!
!
!
!
!
!
Obtain history, including description of pain
(location, time, duration and intensity)
Physical function
Identify exacerbating or relieving factors
contributing to pain
Psychosocial function over past 2 weeks
Substance abuse history
History of prior pain treatment
Co-morbid conditions
Physical Examination
!
!
!
& Mental status
Musculoskeletal exam
Neurological assessment
Treatment Plan
!
Dx may be complicated by
rheumatoid arthritis or
spondylarthopathies
!
!
!
!
Associated w/ depression
Opioids not proven to be
effective
Osteopathic manipulation,
heat or ice, ultrasound,
exercise, transcutaneous
electrical nerve stimulation
(TENS) may be effective
Depression, anxiety,
fibromyalgia may also
perpetuate HA
Analgesic overuse is
common & may perpetuate
daily HA and rebound
HAs.
May take weeks, months
after stopping daily meds
before HA becomes
episodic again; then may
be managed acutely w/
analgesics (NTE 2-3 days
/wk to avoid recurrence of
overuse HA) and/or
migraine meds (e.g.
triptans, ergotamine) &
prophylactic treatment
NSAIDS, acetaminophen
are generally ineffective
Note: The above information in not inclusive and is provided as a general overview. Additional references & info are available upon request.
1. Pain Management (Module 2) Overview of Management Options. AMA CME for Primary Care Physician Feb. 2010. www.ama-cmeonline.com,/pain_mgmt (& select module)
2. Pain Management Assessing and Treating Persistent Nonmalignant Pain, Common Persistent Pain Conditions (Module 8). AMA CME Program for Primary Care Physicians, Feb. 2010.
3. Assessing and Treating Neuropathic Pain (Module 9) AMA CME for Primary Care Physicians, Feb. 2010.
4. Krantz MJ et al. QTc interval screening in methadone treatment. Ann Intern Med 2009 Jan 20; [e-pub ahead of print]. (http://www.annals.org/cgi/content/full/0000605-200903170-00103v1)
CHRONIC NON-MALIGNANT PAIN
MANAGEMENT
QUICK REFERENCE
January 2011
!
Set Goals of Therapy
% Pain, "function/activities
Non-pharmacologic treatment
Analgesia – NSAIDs, opioids, adjuvants
Discuss Risk /Benefit
Obtain Patient Consent and/or have patient
sign Pain Management Agreement*
Set Exit Plan if treatment goals not achieved
or patient non-compliant (referral)
Evaluate Treatment Outcomes “4As”
Evaluate patient outcomes every 1-6 months
! Analgesia
! Activities of daily living
! Adverse effects
! Assess for aberrant drug- taking behaviors!
o Early refill requests, lost or stolen Rxs
o Manipulative behavior
o Missed appointments
o Doctor shopping
o "d dose without authorization
o Purposeful over sedation
o Alcohol abuse, illicit drug use
o Periodic urine toxicity screenings
Modify Therapy Accordingly
*Sample Pain Management Agreement available at
http://www.painedu.org/Downloads/NIPC/Patient_Medication_Managem
ent_Agreement.pdf
!
Patient Activity Reports (PARs) identify patient’s narcotic prescription
filling activities. PAR forms are available from the “CURES” statewide
narcotic monitoring program at http://ag.ca.gov/bne/trips.htm or 916-3199062
Pearls for Pain Management1
!
!
!
!
Individualize treatment
Initiate a comprehensive evaluation and
management plan that includes both pharmacologic
and non-pharmacologic therapies.
Select appropriate analgesic, route, lowest effective
dose with around the clock (ATC) dosing to
optimize treatment. Select generic over brand drugs
when possible.
Anticipate and manage side effects.
When opioid analgesics are indicated:
!
Long-acting agents are preferred. Pain relief is more
consistent and adherence is enhanced.
!
Use short-acting opioids for dose titration,
breakthrough pain
!
Initiate bowel program.
!
Proactively address risk of misuse, abuse and/or
addiction. Use a Pain Management Agreement /
Contract when appropriate.
!
Differentiate physical dependence (tolerance) and
psychological dependence (addiction).
!
Monitor for aberrant drug-taking behaviors.
Recent CDC data show that visits to the Emergency
Department due to the “nonmedical use” of opioid
analgesics increased 111 percent during 2004–2008 (from
144,600 to 305,900 visits).1 Estimated ED visits due to
the nonmedical use of benzodiazepines increased 89
percent during that same time (from 143,500 to 271,700
visits). Cai R, Crane E, Poneleit K, et al. Emergency
department visits involving nonmedical use of selected
prescription drugs — United States, 2004-2008. MMWR.
2010;59(23):705-709.