Pain Management at the End of Life

APPENDIX A: TYPES OF PAIN (GRID)

ACUTE

CHRONIC

SOMATIC VISCERAL

Pain Management

APPENDIX B: DOSING INFORMATION NON-OPIOIDS ANALGESIA DOSING INFORMATION*

Medication Name Route Usual Dosing Recommended Maximum Dose

Acetaminophen (Tylenol®, plain and extra strength)

PO, PR 325-650 mg q 4 hr or PRN 650mg q 4 hr 4000mg/24 hr

Aspirin Products Acetylsalicylic acid (ASA) (salicylic acid derivative); various brands of aspirin

PO, PR 325-650 mg q 4 hr routinely or PRN 650 mg q 4 hr 5000 mg/24 hr

Celecoxib (Celebrex®)), cox-2 selective PO 100-200 mg BID 200 mg BID 400 mg/24 hr

Chlorine Magnesium Trisalicylate (Trilisate®), salicylic acid derivative

PO 1000-1500 mg q 12 hr or 500 – 1000 mg q 8 hr

1500 mg q 8 hr 4500 mg/24 hr

PO, PR IR IR: 50-75 q6-8 hr

50 mg q 6 hr

Diclofenac (Cataflam®, Voltaren®), acetic acid derivative

PO SR SR: 75-100 mg q 8-12 hr 75 mg PO q 8 hr 225mg/24 hr

Diflunisal (salicylic acid derivative) Dolobid® PO 250-500 mg q 8-12 hr 500 mg q h 1500 mg/24hr

PO IR 200-500 mg q 6-12 hr 1200 mg/24 hr Etodolac (Lodine®), acetic acid derivative PO SR 400-600 mg q 12 hr 1200 mg/24 hr

Flurbiprofen (various trade names), propionic acid derivative

PO 50-100 mg q 12 hr 200-300 mg/24 hr

Ibuprofen (Motrin®, Advil®), propionic acid derivative

PO 200-800 mg q 6-8 hr 800 mg q 6 hr 3200 mg/24 hr

PO IR 25-75 mg q 8-12 hr 50 mg q 6 hr PO SR 75 mg q 12-24 hr 200 mg/24 hr

Indomethacin (Indocin®), indole

PR 50 mg q 6 hr 200 mg/24 hr Ketoprofen (Orudis®), propionic acid derivative PO 25-50 mg q 6-8 hr 150 mg/24 hr

PO 20 mg initially followed by 10 mg QID

PO: 40 mg/24 hr (Not to exceed 5 days combined PO/IM/IV)

IM single dose 60 mg or 30 mg q 6 hr IM: 120 mg/24 hr

Ketorolac (Toradol®), acetic acid derivative

IV single dose 30 mg or 15 mg q 6 hr IV: 120 mg/24 hr Nabumetone (Relafen®) PO 1000-2000 mg q 12-24 hr 1000 mg q 12 hr

2000 mg/24 hr Naproxen (Naprosyn®) propionic acid derivative PO 250-500 mg q 8-12 hr 500 mg q 8 hr

1500 mg/24 hr Piroxicam (Feldene®), oxicam PO 10-20 mg q 12-24 hr 20 mg q 12 hr

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Pain Management

NON-OPIOIDS ANALGESIA DOSING INFORMATION* Medication Name Route Usual Dosing Recommended

Maximum Dose 40 mg/24 hrs

Salsalate (Disalcid®), salicylic acid derivative PO 1000-1500 mg BID 3000 mg/24 hr Sulindac (Clinoril ®), indole PO 150 mg q 12 hr 200 mg q 12 hr

400 mg/24 hr * Dosing information reflects common medications and is not intended to be all inclusive.

OPIOIDS DOSING INFORMATION* Medication Name Route Usual Starting

Dose Onset (Minutes)

Peak (Minutes)

Duration (Hours)

Half Life Recommended Maximum Dose (RMD)

PO/SL 15-30 mg q 4 hr; 2.5-5 mg q 4 hr for elderly

30-60 60-120 3-6

Controlled release

15-30 mg q 4 hr 30-60 8-12

Rectal 10-20 mg q 4 hr 30-60 20-60 4-5 IV 2.5-15 mg q 4 hr 5-10 20 3-4 SC 10 mg q 4 hr 10-20 50-90 3-4

Morphine

IM 10 mg q 4 hr 10-20 30-60 3-4

Half life = 2-4 hrs RMD = No ceiling- based on patient report of pain control or presentation of unmanageable side effects

Morphine extended release (Avinza®, Kadian®)

PO 30 mg q 4 hr - - 24 RMD = 1600 mg/day due to potentially serious renal toxicity associated with funaric acid

PO 30-60 mg q 4 hr 30-60 60-90 3-4 SC 15-60 mg q 4 hr 10-20 Unknown 3-4 IM 15-60 mg q 4 hr 10-20 30-60 3-4

Codeine

Combination medication

1-2 tablets PO q 4 hr ATC or PRN

Half life = 2-4 hrs RMD = 600 mg/24 hrs; in combination medications, limited to 12 tables per 24 hrs (4 g acetaminophen per 24 hrs)

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Pain Management

OPIOIDS DOSING INFORMATION* Medication Name Route Usual Starting

Dose Onset (Minutes)

Peak (Minutes)

Duration (Hours)

Half Life Recommended Maximum Dose (RMD)

Transdermal patch

(Duragesic Patch®)

Therapy initiated with the 25 mcg/hr system, dosage adjusted as needed and tolerated. Each system may be worn for 72 hrs

12-16h 24 hours 48-72

Transmucosal (Actiq®)

200 mcg 15 45 1

IV 2 mcg 1h 1-5 3-5 0.5-4

Fentanyl

IM 50-100 mcg q 4 hr 7-15 10-20 0.5-4

Half life = 13-24 hrs RMD = limited only by need and adverse effects

Hydrocodone (Vicodin® - various combinations with acetaminophen)

PO 1-2 tabs q 4-6 h or prn

30-60 60-90 4-6 Half life = 4 hrs RMD = limited to 4 g acetaminphen/24 hrs

PO 1 mg titrate as needed q 4 hr ATC q 1 hr prn

15-30 30-90 3-4

SC 1 mg q 3 h ATC; q 30 min prn

10-20 30-90 3-4

IM 1 mg q 3 hr ATC; 30 min prn

10-20 30-90 3-4

IV via infusion 1mg q 1 hr + breakthrough q 30 min prn

5 10-20 3-4

Hydromorphone (Dilaudid®)

Rectal 15-30 30-90 3-4

Half life = 2-3 hr RMD = limited only by need and adverse effects

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Pain Management

OPIOIDS DOSING INFORMATION* Medication Name Route Usual Starting

Dose Onset (Minutes)

Peak (Minutes)

Duration (Hours)

Half Life Recommended Maximum Dose (RMD)

PO 5 mg q 8 hr; can be dependent on conversion from another drug; titrate dose q 7 days due to delayed clearance

30-60 60-120 4-8

SC 2.5-10 mg q 4 hr 10-20 60-120 4-8

Methadone

IM 2.5-10 mg q 4 hr 10-20 60-120 4-8

Half life = 12-190 hr RMD = limited only by need and adverse effects

IR PO 2.5-5 q 4 hr ATC q 1 hr prn

30-60 60-90 3-4

CR PO 10 mg q 12 hr 30-60 90-180 8-12

Oxycodone

PR (not available in US)

5-↑ q 4 h ATC q 1 h prn

30-60 30-60 3-6

Half life = 2-4 PO, 4.5 CR RMD = limited only by need and adverse effects

Propoxyphene hydrochloride (Darvon®)

PO 65 mg q 4 hr (intermittent dosing recommended)

30-60 60-90 4-6 Half life = 6-12 hr RMD = 390 mg/24 hr; Darvocet N 100 contains acetaminophen and has RMD of 4 g/24 hr; Not recommended in chronic pain, in the elderly or end-of-life care

* Dosing information reflects common medications and is not intended to be all inclusive.

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Pain Management

MIXED AGONIST-ANTAGONISTS DOSING INFORMATION* Medication Name Route Usual Starting Dose Onset

(Minutes) Peak (Minutes)

Duration (Hours)

Half Life Recommended Maximum Dose (RMD)

SL 5 30-60 Unknown IV 5 10-20 3-4

Buprenorphine (Buprenex®)

IM

0.3 mg q 6 hr

10-20 30-60 3-6

Half life = 2-3 hr RMD = 0.3 mg q 4 hr, IM only 0.6 mg q 6 hr

IV 5 10-20 3-4 IM 10-20 30-60 3-4

Nasal spray

2 mg q 3-4 hr

5-15 60-90 3-4

Butorphanol (Stadol®)

Half life = 3-4 RMD = ceiling for respiratory depression is reached at 30-60 µg/kg

IV 5 10-20 3-4 SC < 15 Unknown 3-4 IM < 15 30-60 3-4

Nalbuphine (Nubain®)

10 mg q 3-4 hr

Half life = 5 hr RMD = respiratory ceiling and analgesia ceiling reached at 30 mg

Pentazocine (Talwin®)

PO 50-100 mg 1 3-4 hr 15-30 60-80 3-4 Half life = 2-3 hr RMD = 600 mg/24 hr of little value in pain management; should not be considered for end-of-life care

* Dosing information reflects common medications and is not intended to be all inclusive.

TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION*

Medication Name

Route Usual Starting Dose

Usual Effective Dose Range

Dosing Schedule Uses

Amitriptyline (Elavil®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Migraines and other headaches, arthritis, chronic low back pain, fibromyalgia, painful diabetic polyneuropathy, chronic facial pain

Imipramine (Tofranil®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Arthritis, headache, painful diabetic polyneuropathy

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Pain Management

TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION* Medication Name

Route Usual Starting Dose

Usual Effective Dose Range

Dosing Schedule Uses

Doxepin (Sinequan®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Co-existent pain and depression, headache, low back pain

Clomipramine (Anafranil®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Varied neuropathic pains, idiopathic pain

Desipramine (Norpramine®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Post-herpetic neuralgia, painful diabetic neuropathy

Nortriptyline (Aventyl®, Pamelor®)

PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses (e.g., q 8 h); titrate every 3-4 days to the effective dose

Mixed neuropathic pains

* Dosing information reflects common medications and is not intended to be all inclusive.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) ANTIDEPRESSANTS DOSING INFORMATION*

Medication Name Route Usual Starting Dose Usual Effective Dose Range

Dosing Schedule Uses

Fluoxetine (Prozac®)

PO 10-20 mg/day 20-40 mg/day QID

Paroxetine (Paxil®) PO 20 mg/day 20-40 mg/day QID Diabetic neuropathy Sertraline (Zoloft®) PO 50 mg/day 150-200 mg/day QID or BID * Dosing information reflects common medications and is not intended to be all inclusive.

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Pain Management

ANTICONVULSANTS DOSING INFORMATION*

Medication Name Route Usual Starting Dose Usual Effective Dose Range

Dosing Schedule Uses

Carbamazepine (Tegretol®)

PO 200 mg/day 600-1200 mg/day; titrate weekly to desired effect; do not increase because the 200 mg is ineffective – increase because carbamazepine autoinduces it’s own metabolism

q 6-8 hr Trigeminal neuralgia, post-herpetic neuralgia, painful diabetic neuropathies, glossopharyngeal neuralgia, paraxysmal pain in Multiple Sclerosis, stabbing pains after laminectomy, lancinating pains from cancer, phantom limb pain

PO 200 mg/day in divided doses; loading dose may be used (e.g., 500 mg x 2)

200-400 mg/day in divided doses

q 8 hr; q 24 if extended preparation such as Kapseals

Phenytoin (Dilantin®)

IV 500-1000 mg/day Variable and unknown Variable and unknown

Painful diabetic neuropathies, trigeminal neuralgia, paroxysmal pan in post-herpetic neuralgia,

Gabapentin (Neurontin®)

PO 100-300 mg/day Dose may be increased daily

300-3600 mg/day q 8 hr All types of neuropathic pain, reflexive sypathetic dystrophy, HIV-related neuropathy, post-herpetic neuralgia

Clonazepam (Klonopin®)

PO 0.5 mg/day 0.5 mg/day q 8 hr Trigeminal neuralgia, paroxysmal post-laminectomy pain, post-traumatic neuralgia, lancinating phantom limb pain,

PO: Divalproex sodium

(Depakote®)

250 mg/day 1500-300 mg/day q 8 hr Valproic Acid (Depakene®)

IV: Valproate sodium

(Depacon®)

Max 20 mg/kg over 5 min.

Variable and unknown Variable and unknown

Trigeminal neuralgia, post-herpetic neuralgia

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Pain Management

ANTICONVULSANTS DOSING INFORMATION* Medication Name Route Usual Starting Dose Usual Effective Dose

Range Dosing Schedule Uses

Baclofen (Lioresal®) PO 5 mg q 8 hr 30-200 mg/day q 8 hr Spasticity, lancinating pain, shooting pain, paroxysmal neuropathic pain, trigeminal neuralgia

* Dosing information reflects common medications and is not intended to be all inclusive.

CORTICOSTEROIDS DOSING INFORMATION* Medication Name USUAL STARTING DOSE Dose equivalents Dexamethasone (Decadron®)

0.75-9 mg PO QD divided BID, TID or QID, higher doses based on situation 2 mg

Methylprednisolone 8 mg Prednisone 10 mg * Dosing information reflects common medications and is not intended to be all inclusive.

LOCAL ANESTHETIC AGENTS DOSING INFORMATION*

Medication Name

ROUTE USUAL STARTING DOSE – Based on 4 hr dosing

USUAL EFFECTIVE DOSE RANGE

DOSING SCHEDULE ONSET

Mexiletine (Mexitil®)

PO 150 mg/day Can increase dose every 3 days as tolerated

900-1200 mg/day Every 8 hrs

Tocainide (Tonocard®)

PO 400 mg/day 1200-1600 mg/day Q 8 h

IV brief infusion 2-5 mg/kg over 20-30 min - - 15-30 min Lidocaine® IV or SC

continuous infusion

1 mg/kg/h - -

* Dosing information reflects common medications and is not intended to be all inclusive.

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Pain Management

PSYCHOSTIMULANTS DOSING INFORMATION*

Medication Name ROUTE USUAL STARTING DOSE – Based on 4 hr dosing

USUAL EFFECTIVE DOSE RANGE

DOSING SCHEDULE

Caffeine PO 50-150 mg/day per dose of opioid or NSAID

Dextroamphetamine (Dexadrine®)

PO 2.5 mg/day after breakfast 10-30 mg/day BID, avoid evening dosing, may increase titration by 50% per day to achieve desired effects

Methylphenidate (Ritalin®)

PO 2.5 mg/24 hr 10-30 mg/24 hr BID – one tablet at breakfast and one tablet at lunch, avoid evening dosing, may increase titration by 50% per day to achieve desired effects; also available SR

* Dosing information reflects common medications and is not intended to be all inclusive.

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