Stepped Care Drugs for Nociceptive Pain
(e.g., OA, not myofascial pain, fibromyalgia)
- Intra-articular corticosteroid/topical diclofenac/capsaicin: Diabetics should monitor glucose post-corticosteroid injection; prescribe assistive device. It is prudent to monitor Cr after topical NSAID initiated.
- Acetaminophen: 325-1,000 mg q4-6h, max 3 gm/d (ask about all OTCs with acetaminophen).
- Salsalate: 500-750 mg bid (max 3 gm/d) with food or milk (mild anti-inflammatory); does not interfere with platelet function; GI bleeding and nephrotoxicity rare, but Cr monitoring is prudent.
- Celecoxib: 100-200 mg bid – Not for long term use in elderly.
- Ibuprofen: 400 mg po q4-6h OR naproxen 250-500 mg bid with food or milk – Do not use long-term in older adults10; PPI/misoprostol if long term.
- Duloxetine: Consider for musculoskeletal pain; see dosing under Peripheral Neuropathy.
- Tramadol: Start 25 mg qd; increase by 25-50 mg in divided doses every 3-7 days to max dose of 100mg QID. Renal dosing (CRcl < 30ml/min) 100mg BID. Educate on s/sx of serotonin syndrome if other serotonergics.
- Hydrocodone/acetaminophen: 5/325 – 10/500 mg q4-6h; max acetaminophen dose 3gm/day.
- Oxycodone: 5-10 mg q4h OR morphine 2.5-5 mg q4h (not recommended if CLcr< 30); assess total needs after 7d on stable dose, then convert to long acting; if morphine needed, avoid long acting if renal insufficiency.
- Fentanyl and methadone safest of opioids if renal insufficiency; ALWAYS consult pain expert.
OPIOID PRECAUTIONS
- Start stimulant laxative at first sign of constipation.
- Always carefully calculate opioid conversions: Opioid Calculator
- Use extreme caution when prescribing opioids if mobility dysfunction or sleep apnea.
- All patients taking opioids should also be prescribed intranasal naloxone.