Etiology: often divided into bone, neuropathic (burning vs. shooting) and visceral

Treatment:

• Mild Pain (non-opioid +/- adjuvant )

• Acetaminophen 325-650mg q4h, regularly
• ASA 325-650mg q4h, regularly
• NSAIDS (ie., ibuprofen 400-600mg qid, regularly; naproxen 250-500mg bid, regularly; indomethacin 25-50mg tid, regularly)

• Moderate Pain (mild opioid + non-opioid +/- adjuvant )

• Acetaminophen/caffeine/codeine(60mg) po q4h, regularly
• ASA/caffeine/codeine(60mg) po q4h, regularly
• Acetaminophen/oxycodone(5-10mg) q4h regularly
• ASA/oxycodone(5-10 mg) q4h regularly

• Severe Pain (strong opioid + non-opioid +/-adjuvant)

• Morphine po/sc

• po dose increments to provide pain-free 4h intervals: 5, 10, 15, 20, 25, 30, 40, 60, 80, 100, 120mg. Increments of 30-50mg until 400mg, then by 100mg

• sc dose equivalent to half of po dose

• Hydromorphone po/sc/pr

• 2-4mg po to start; increase dose to provide pain-free 4h intervals

• sc dose equivalent to half po dose
• 3mg suppositories pr to start; increase dose to provide pain-free 4h intervals

• Fentanyl transdermal (continuous release for 72 hours)

• 25mcg/h to start; increase every 2-3 days to max 300mcg/hr

• change patch every 3 days

• calculate oral morphine (mg/day) equivalency and apply appropriate dose of patch (mcg/hr)�see table in CPS

• Breakthough Pain

• 50% of regular dose given q2h prn
• if using transdermal fentanyl, use morphine or hydromorphone

• Adjuvant Analgesia (to be added to regular regimen)

1. Bone Pain (aching, localized)

• NSAIDs (ibuprofen 400-600 mg qid, regularly; naproxen 250-500mg bid, regularly; indomethacin 25-50mg tid, regularly) + cytoprotective agent (misoprostol 200 mcg po bid-qid)

• Consider radiotherapy, splinting, surgical fixation

2. Neuropathic Pain (burning or shooting pain)

• Consider TENS, Anesthesia consult (nerve block, epidural)

• Dexamethasone 4mg po/sc/iv od-qid

• Dysesthetic, burning, continuous pain:

• TCA (amitriptyline 10-25mg hs, titrate to 150mg hs; imipramine 10-25mg hs, titrate to 150mg hs)

• Capsaicin 0.025%-0.075% cream applied topically qid (requires 6 weeks for benefit)

• Lancinating, shooting pain:

• Carbamazapine start 100mg po bid, increase to 600-800mg divided bid-tid; monitor plasma levels)

• Clonazepam 0.25mg po q12h (can increase up to 3mg po q8h)

• Phenytoin 300mg hs

• Valproic acid 250mg hs (increase to max 1g/day single hs dose, or divided bid)

3. Visceral Pain (deep, poorly localized)

• Dexamethaxone 4-8mg po/sc/iv od-qid

• NSAIDs (ibuprofen 400-600 mg qid, regularly; naproxen 250-500mg bid, regularly; indomethacin 25-50mg tid, regularly) + cytoprotective agent (misoprostol 200 mcg po bid-qid)