![]() |
|
Taxonomy of pain:
Nociceptive Somatic Visceral Neuropathic Psychogenic Idiopathic |
Obtain history of prior therapies, recent analgesics including doses
Place Amount Intensifiers Nullifiers Effects Description |
WHO Step therapy
Severe 3 Strong Opioid Non Opioid Adjuvant Moderate 2 Weak Opioid Non Opioid Adjuvant Mild 1 Non Opioid Adjuvant |
Cognitive behavioral
Massage / PT Acupuncture Cutaneous techniques |
Radiation Tx
Surgery Interventional Procedure Anesthetic Techniques |
Non Opioids
NSAIDs Cox 1 Cox 2 (better GI safety-Celebrex) Cox 3 Acetaminophen |
Opioids
Codeine Hydromorphone Morphine Oxycodone Fentanyl Levorphanol Methadone Oxymorphine |
Adjuvants
Anticonvulsants Gabapentin Pregabalin Antidepressants Tricyclic SSRI SNRI (neuropathic pain) Local Anesthetic Lidoderm Viscous Xylocaine EMLA 0.1 % morphine intrasite gel Doxepin cream Diclofenac cream / patch GABA agonists NMDA agonists Corticosteroids Tapentadol (Nucynta) |
Rapid titration IV pain control (Inpatient)
IV MS 2 mg q 2 min 'til initial analg or severe adverse effect (Same dose regardless of previous meds) Total dose assumed to last 4 hours, convert to 24 hr dose PO (e.g. 6 mg = 36mg/24hr = 108mg PO) Choose SR dosing for oral daily need, keep IV dose (6 mg in example) for breakthrough q 4 hrs for the fist 24 hrs Based upon study: http://onlinelibrary.wiley.com/doi/10.1002/cncr.10636/pdf |
Rapid titration PO pain control (Outpatient)
PO MS 5-10 mg, reassess pain in 1 hr (peak onset) If pain unchanged double dose, reassess & repeat until pain down 50%, then calculate dose as 4 hr need and administer 24 hr dosing Convert 24 hour dose to long acting equivalent to 75-100% of 24 hr dose, include prn (breakthrough) at 10-15% of 24 hr dose (use short acting) |