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A. Classes of Agents [1,2]

  1. Acute Pain
    1. Aspirin, Acetaminophen, and NSAIDS
    2. Codeine, Oxycodone (shorter acting opiates)
    3. Ketorolac (Toradol®) - a strong NSAID (near narcotic strength), parenteral available
    4. Tramadol (Ultram®) - atypical opioid analgestic
    5. Morphine (IR or elixer), Meperidine (Demerol®), Hydromorphone (Dilaudid®, Palladone®)
  2. Chronic Pain
    1. Tricyclic Antidepressants (Amitriptyline, Nortriptyline, Imipramine)
    2. Anticonvulsants: Carbamazepine, valproate, gabapentin [63], pregabalin [21], others [40]
    3. Lidocaine, mexilitine, other anti-arrhythmic agents
    4. Narcotics - typical and atypical
    5. Capsaicin Cream 0.025% (Zostrix®, Heet®, others) - depletes substance P; apply tid-qid
    6. NSAIDs and/or Acetaminophen (Tylenol®) - many are now over the counter
    7. Acetaminophen maximum dose is 4000mg/d, reduce with liver disease [51]
    8. Acetaminophen extended release now available 1300mg po q8 hours
    9. Long term NSAID therapy should consider COX2 selective/specific agents [42]
    10. Combination therapies are often synergistic
  3. Phantom Limb Pain
    1. Difficult management problem
    2. Currently, only ? therapy is 3 IU/kg salmon calcitonin iv or sc qd or 3X/week
  4. Post-Transplant Pain
    1. Cyclosporine can cause a severe bone pain syndrome in many patients
    2. Probably due to vasoconstrictive properties of this agent
    3. Osteonecrosis has been reported as well (probably increased risk with glucocorticoids)
    4. Aching bone pain, very deep, usually lower extremities; worse with recumbency
    5. Calcium channel blockers (nifedipine, felodipine, isradipine) very effective for pain
  5. Cancer Pain
    1. Opiates in combinations with other therapies are usually required
    2. Chronic pain mediations described above may be helpful
    3. Bone pain represents a substantial problem
    4. Detailed discussion in separate outline
  6. Post-Operative Pain
    1. Opioids are usually required
    2. Patient controlled analgesia (PCA) is often preferred
    3. PCA with intravenous morphine, dilaudid or transdermal fentanyl is effective [62]
    4. NSAIDs, particularly COX2 selective, can reduce opioid doses and speed some recovery [57]
    5. Epidural anesthesia is generally superior to parenteral opioids [58]

B. Non-Steroidal Anti-Inflammatory Agents [2,42]

  1. Agents block prostaglandin (PG) synthesis by inhibiting cyclooxygenase (COX)
    1. Most current agents block both COX1 and COX2 about equally
    2. COX1 is responsible for basal PG synthesis (stomach, intestine, vasculature)
    3. COX2 is induced in inflammatory conditions and is mainly responsible for pain
    4. COX2 is not expressed on gastrointestinal (GI) mucosa or on platelets
    5. Nonselective and COX2 specific agents have equal efficacy on pain [10,11,38]
    6. COX2 specific inhibitors have minimal GI effects do not increase bleeding [38,49]
    7. Adding proton pump inhibitor (PPI) to COX1/2 inhibitor reduces PUD risk to that of COX specific NSAIDs with chronic use (6 months) [52]
    8. Switching to COX-2 selective NSAIDs will prevent most GI ulceration and reduces the need for adjunctive GI medications in osteoarthritis [56]
  2. Prescription and Over The Counter (OTC) Agents
    1. Ibuprofen (Motrin®, Advil®): 200-800mg q4-6 hrs prn
    2. Naproxen (Naprosyn®, Anaprox®, Napralan®, Aleve®): bid- tid oral or suspension; qd forms
    3. Ketoprofen (Orudis®): qd, potent agent
  3. Acute Pain Control
    1. When OTC agents fail, consider the following:
    2. Diclofenac (Voltaren®, Cataflam®): 50-75 po bid - tid; ER and XL forms 100mg qd also [68]
    3. Diclofenac + omperazole (Prilosec®) has very low risk of peptic ulcer [52]
    4. Indomethacin (Indocin®): strong, used for pericarditis, gout; poor GI tolerance
    5. Ketorolac (see below)
    6. Rofecoxib (Vioxx®), COX2 specific, his been withdrawn due to increased cardiac risks [4,5,9,11]
    7. Celecoxib (Celebrex®), COX2 specific, does not show increase in cardiac risk and has been protective versus no NSAID or non-selective NSAIDs in various studies [4,5]
    8. COX2 specific agents do not increase bleeding risk and can be used perioperatively [49,57]
    9. Topical NSAIDs also show some activity and are very safe [12]
    10. Diclofenac 1.3% Patch (Flector®) - mild efficacy for acute minor muscle pains, strains [3]
    11. Diclofenac (Voltaren® Gel 1%) 2-4gm qid applied locally provides modest pain relief [68]
  4. Ketorolac (Toradol®)
    1. Very potent NSAID may be given intravenous, intramuscular, oral
    2. Typically given 15-30mg iv q6 hours
    3. Fewer mental status and respiratory depressive effects than narcotics
    4. Slightly increased risk of bleeding in GI tract and operative site
    5. Limit to <5 days of use, particularly in elderly
  5. Longer Acting for Chronic Conditions [10]
    1. Celecoxib (Celebrex®): COX2 specific, 200mg qd-bid, sulfur moiety [10,36]
    2. Meloxicam (Mobic®): COX2 selective, 7.5-15mg qd, may have improved gastric safety
    3. Nabumetone (Relafen®): some COX2 selectivity, 500-750mg po bid or 1000mg qd
    4. Oxaprozin (Daypror): good pain control, 1200-1800mg po qd
    5. Diclofenac (Voltaren XR® and generic ER): good pain control, 100mg qd (XR form) [68]
    6. Flurbiprofen (Ansaid®): 100-200mg po qd-bid
    7. Sulindac (Clinoril®): relatively poor pain control [39]
  6. Side Effects of NSAIDS
    1. Chronic dyspepsia, gastritis and peptic ulceration may be significant with nonselective but not COX2 selective agents [10]
    2. COX2 selective agents do not cause GI problems over 12-52 weeks [10,11,38,42,48,56]
    3. COX2 selective agents do not block platelet function and can be used perioperatively [49]
    4. Renal insufficiency - reduced glomerular filtration, peripheral edema, hypertension
    5. May interfere with antihypertensive action of blood pressure lowering drugs
    6. Inhibition of platelet coagulation function by blocking thromboxane release
    7. Should not be taken in 3rd trimester due to inhibition of prostaglandin functions
    8. Topical NSAIDs do not appear to have these problems due to low systemic levels [12]
    9. Helicobacter (H.) pylori infection synergizes with NSAIDs to increase ulcer risk [45]
    10. Eradication of H. pylori prior to initiation of NSAIDs reduces risk of developing ulcer [46]
    11. Rofecoxib but not celecoxib or valdecoxib have increased cardiovascular (CV) risk [4,5,11]
    12. Non-selective NSAIDs including ibuprofen and naproxen have shown 0-10% increased CV risk versus no NSAIDs [4,5,6]
  7. Risk Factors for NSAID-Associated Gastroduodenal Ulcers [14]
    1. Advanced age (linear increase)
    2. History of ulcer
    3. Concomitant use of glucocorticoids
    4. Higher doses of NSAIDs / use of >1 NSAID at a time
    5. Concomitant administration of warfarin or other anticoagulants
    6. Serious underlying systemic disorder, especially liver disease
    7. Concomitant infection with H. pylori is a risk factor (see above)
    8. Cigarette smoking and alcohol consumption may be risk factors

C. Narcotics [28,29]

  1. Mainly work centrally, though peripheral opiate receptors are well described
    1. Central activities result in drowsiness, respiratory and cardiovascular depression
    2. Very good for severe pain (cancer, others) and trauma, surgery
    3. Equivocal evidence for efficacy in neuropathic (nonmalignant) pain [15]
    4. Peripherally acting agents without central effects are under development
  2. All of these agents are controlled substances and most require written prescriptions
  3. Most patients with chronic pain not associated with terminal illness can achieve good pain control with a stable dose of opioids with minimal addiction risk [28]
  4. Side Effects
    1. Side effects of each agent may be somewhat different, likely due to the patient's particular metabolism or susceptibilities
    2. Respiratory suppression is the most concerning side effect
    3. Constipation is the most common and potentially disabling side effect
    4. Stool softeners or laxatives should usually be given with chronic opioids
    5. There is very little addiction potential in patients with true chronic pain taking opiates [29]
    6. Reccomendations for treating acute pain with opioids in patients on opioid agonists (drug abusers) have been made [8]
  5. Equianalgesic doses of opiates are attainable for most of the agents, whether they belong to the less potent or more potent groups [29]
  6. Equianalgesic Doses [50]
    1. Morphine: 10mg parenteral, 30-60mg oral
    2. Codeine: 120mg parenteral, 200mg oral
    3. Oxycodone: not available parenteral, 15-20mg oral
    4. Methadone: 10mg parenteral, 10-20mg oral (caution, can produce delayed sedation)
    5. Fentanyl: 0.1mg (100µg) parenteral, not available oral
    6. Hydromorphone: 1.5-2.0mg parenteral, 6-8mg oral
    7. Meperidine: 75-100mg parenteral, 300mg oral (caution, metabolite can cause seizures)
  7. Less Potent Agents [44]
    1. Codeine - dose is 15-30mg po q3-6 hrs; high nausea rate, good cough suppressant
    2. Tylenol + Codeine - usually Tylenol #3; 1-2 tablets q4-6 hrs (prescription may be phoned)
    3. Oxycodone - 5-10mg po q4-6 hours or 10-80mg q12 hour. Better tolerated than codeine
    4. Oxycodone + Acetaminophen (Tylox®, Percocet®, Roxicet®) - 1-2 tablets q4-6 hours
    5. Oxycodone + Aspirin (Percodan®) - 5mg oxycodone + 325mg aspirin; 1-2 tabs q4-6 hours
    6. Oxycodone + ibuprofen (Combunox®) - 5mg oxycodone + 400mg ibuprofen [67]
    7. Oxycodone controlled release (OxyContin®) - 10, 20, 40, 80mg q12 hours only
    8. Hydrocodone + Acetaminophen (Vicodin®) - 1-2 tablets q4-6 hours (Rx may be phoned)
    9. Propoxyphene (Darvon®) - probably weaker than oxycodone
    10. Dihydrocodeine + ASA or acetaminophen (Synalgos-DC®, DHCplus®)
  8. More Potent Agents
    1. Meperidine (Demerol®): iv, im (with Vistaril®), or po; 50-100mg, 2-4 hour im duration
    2. Caution with meperidine, as metabolite can accumulate long term and cause seizures
    3. Fentanyl (Sublimaze®): short acting iv form with <1 hour duration after one dose
    4. Fentanyl Patch (Duragesic®): for chronic pain (usually cancer pain); patch over 72
    5. Morphine (various formulations, see below)
    6. Hydromorphone (Dilaudid®): initially 2-4mg po q4-6 hours; suppositories, injection also
    7. Levorphanol (Levo-Dromoran®): 1.5-2.5mg im dose q3-6 hours; oral 2-4mg
  9. Morphine Sulfate (MS)
    1. Main side effects are nausea, constipation, respiratory depression
    2. Elixir
    3. Immediate release (IR)
    4. Sustained release: MS Contin® (q12 hour), Avinza® (q24 hour)
  10. Butorphanol (Stadol®) [7,30]
    1. Available as im/iv and nasal spray (Stadol NS®)
    2. Mixed agonist/antagonist
    3. Moderate to severe pain
    4. Dose 1.5-2.5mg per spray
    5. Very expensive
  11. Methadone (Dolophene® and others)
    1. Good pain relief, long acting opiate agonist with reduced withdrawal potential
    2. Should be given qid for pain relief (typically 5-10mg po qid)
    3. Addiction is much decreased compared with agonist agents
    4. Good for chronic intravenous drug abusers (IVDA) who need pain control
    5. Methadone may still be abused and must be monitored closely, particularly in IVDA
    6. Caution with chronic dosing for pain: can accumulate and cause increased sedation
  12. Pentazosine
    1. Mixed agonist/antagonist
    2. Talacen®: pentazosine 25mg with acetaminophen 650mg (1 tab q4 hours po)
    3. TalwinNx®: pentazosine 50mg with naloxone 0.5mg (to prevent iv abuse); 1-2 tab q4-6hr
    4. Indicated for moderate to severe pain, orally active
    5. Typical combination opiates with mild to moderate nausea potential
  13. Other Mixed Agonist/Antagonist Drugs
    1. Buprenorphine (Buprenex® and others) - 0.4mg IM q3-6 hours
    2. Nalbuphine (Nubain® and others) - 12mg IM q3-6 hours
    3. Dezocine (Dalgan®) - 10mg im q3-6 hours
  14. Neuropathic Pain
    1. Intravenous fentanyl has effects on neuropathic (and cancer) pain, independent of its sedative properties [16]
    2. There are no clinical characteristics of neuropathic pain which predict opiate responses
    3. In chronic neuropathic pain Higher doses of opioids more effective on pain control but not sleep or activity levels compared with lower doses [53]
    4. Responses in neuropathic pain are suboptimal with considerable side effects [53]
  15. Avoid mixed-agents in patients on pure agonists (may cause withdrawal)
  16. Adjunctive Agents
    1. Hydroxyzine (Vistaril®, Atarax®) - 50-100mg IM adds to analgesic effects of opiods [1]
    2. Addition of NSAIDs or acetaminophen to opiates reduces opiate requirements ~30% [49]
  17. Prescribing Opioids for Pain [28]
    1. Confirm inadequacy of non-opioid analgesics
    2. Explain benefits and risks and clinic's monitoring policies
    3. Establish treatment goals
    4. Strongly consider written consent or contract (inform on toxicology screening also)
    5. Initiate therapy at low standard dose and increase as tolerated up to 8 weeks
    6. Constipation prophylaxis is critically important and often overlooked
    7. Maintain stable, moderate, effective dose with monthly refills
    8. Prescriptions should ALWAYS be picked up by patient IN PERSON
    9. Toxicology screening as needed
    10. Comprehensive followup at least once annually
    11. If treatment is failing, slow weaning is critical to prevent acute withdrawal
    12. Dose escalation should be accompanied by careful evaluation of disease progression
    13. If dose escalation fails, opioid rotation may be effective (start new drug at lower dose)
    14. Can also wean and discontinue therapy, restart opioid after abstinence if needed

D. Tramadol (Ultram®) [17]

  1. Atypical opioid analgesic with serotonin and neurepinephrine reuptake blocking activity
  2. Little addictive potential and minimal withdrawal signs when discontinued
  3. Approximately as potent as codeine + acetaminophen (more expensive, however)
  4. Utility
    1. Neuropathic pain
    2. Fibromyalgia [54]
    3. Chronic pain of many types
  5. Drug Interactions
    1. Avoid concommitant use with opioids, tricyclics, and MAO inhibitors
    2. Quinidine (and probably MAO inhibitors) raise drug levels of Tramadol
    3. Carbamazepine (Tegretol®) lowers levels
    4. Can be used with NSAIDs, tylenol, some chronic pain agents (see below)
    5. Seizures have been reported with high doses in susceptible patients
  6. Dosing
    1. Start at 50mg initial dose, add another 50mg per dose if no response
    2. Standard dosing is 50-150mg po tid-qid (prn)
    3. Decrease dose or increase dosing interval for liver and renal failure
    4. Tramadol 37.5mg +acetaminophen 325mg (Ultracet®) also available
  7. Does not require DEA number
  8. May be particularly useful in drug abusers and in elderly

E. Post-Surgical (Post-Traumatic) Pain [49]

  1. Combinations of analgesics used perioperatively are most effective
    1. Local anesthetics
    2. Nonopioid analgesics: acetaminophen, classical NSAIDs, COX2 specific agents
    3. Opioid analgesics
  2. Stepped Approach
    1. Local anesthetics + nonopioid analgesics used for mild postoperative pain (Step 1)
    2. Intermittent use of opioids added to Step 1 regimen for moderate postoperative pain (2)
    3. Sustained release opioids added and/or local anesthetic peripheral nerve blockade to Step 2 regimen for severe pain (Step 3)
  3. Post-Operative Specific Considerations
    1. Preemptive (preoperative) epidural pain control reduces post-surgical pain [7]
    2. Opioids for parenteral use include meperidine or morphine (others) delivered by patient controlled analgesia (PCA)
    3. Meperidine (Demerol® 50-75mg IM) + hydroxyzine (Vistaril® q3-4 hrs) typically for up to 48 hours
    4. An oral opiate is usually given for ~5d with taper (such as hydrocodone, oxycodone, or hydromorphone)
    5. Ketorolac, a parenteral/oral NSAID, is potent but can increase bleeding risk (see below)
    6. COX2 specific NSAIDs do not increase bleeding risk and can reduce opiates required
    7. Acetaminophen up to 4000mg/d in patients with normal liver function may be very beneficial and can be added to opioids and/or NSAIDs
    8. Episodic use of pain medications - incisions often cause most pain at night
    9. For most surgery, pain medications rarely required after 2 weeks
    10. Nonabsorbable opioid antagonist given post-operatively improves bowel function and reduces hospital stay [43]
  4. Local Anesthetics [49]
    1. Local injections provide up to 4 hours of analgesia
    2. For longer durations, placement of small catheter at surgical wound or near local innervation with continuous infusions have been used
    3. Lidocaine (0.5-1.0%) typically used but has short duration of action
    4. Bupivicaine (0.25%) is longer acting but can cause serious cardiovascular and central nervous system side effects
    5. Ropivacaine (0.25-0.5%) - long acting anesthesia with good safety
    6. Levobupivocaine (0.25%) provides long acting with good safety
    7. Epinephrine 1:200,000 added prolongs duration of analgesia and reduces systemic uptake

F. Chronic Pain Managament

  1. Classes of Chronic Pain
    1. Neuropathic - including post-traumatic, post-surgical, phantom-limb syndrome [2]
    2. Sympathetic
    3. Trigeminal Neuralgia
    4. Back Pain
    5. Cancer Pain
    6. Bone Pain (usually cancer pain)
    7. Visceral Pain
    8. Pain associated with AIDS
  2. Pharmacotherapy (in usual order of use)
    1. Acetaminophen
    2. NSAIDs (nonselective then COX2 selective)
    3. Capsaicin cream - topical; derived from pepper, depletes substance P
    4. Gabapentin (Neurontin®; see below) [63]
    5. Tricyclic Antidepressants
    6. Other Anticonvulsants [40] - valproate or carbamazepine
    7. Lidocaine cream (preferably urea base) or patch (Lidoderm®)
    8. Combination of tricyclic antidepressant and verapamil (calcium channel blocker)
    9. Mexilitine: anti-arrhythmic with lidocaine - like properties
    10. Opiates: Oxycodone, Dilaudid®, MS Contin
    11. Acupuncture may be effective in a variety of chronic conditions (see below) [18]
    12. Novel therapeutics
  3. Gabapentin (Neurontin®) [19,20,63]
    1. Structural analog of gamma-aminobutyric acid (GABA) affets glutamate release
    2. Does not bind GABA receptors or directly affect GABA metabolism
    3. Dose: 900-3600 mg qd divided (2-3 times)
    4. Generally well tolerated with relatively good efficacy in many pain syndromes
    5. Clear efficacy in post-herpetic neuralgia and painful diabetic neuropathy [13,40,63]
    6. Combined gabapentin + morphine is superior to either for severe neuropathic pain [13]
    7. May have efficacy in migraine prophylaxis
    8. Side effects: diziness, somnolence, confusion (all <8%)
  4. Pregabalin (Lyrica®) [21]
    1. Structural analog of GABA and gabapentin
    2. Approved for postherpetic neuralgia and diabetic peripheral neuropathic pain
    3. Also approved for epilepsy
    4. Initial dose is 150mg per day divided 2-3 times (bid or tid)
    5. May increase to maximum of 300mg per day for neuropathic pain, 600mg/d for epilepsy
    6. Adverse effects are dose related: dizziness, somnolence, blurred vision
    7. Associated with euphoria and Schedule V controlled substance by FDA
  5. Other Anticonvulsants [40]
    1. Carbamazepine (Tegretol®) is most commonly used, especially for trigeminal neuralgia
    2. Sodium valproate (Depokene®) is often used
    3. Effective in diabetic neuropathy
    4. Caution with long term side effects, particularly hepatic
    5. Gabapentin or pregabalin are usually better tolerated and as or more efficacious
  6. Tricyclic Antidepressants (TCAs)
    1. Major activity probably due to "nerve membrane stabilization"
    2. Inhibit reuptake of serotonin and norepinephrine
    3. Active for anxiety, migraines, and fibromyalgia syndrome
    4. Tertiary amine TCAs quite sedating but are most effective: amitriptyline, imipramine
    5. Amitriptyline was not effective for pain due to HIV peripheral neuropathy [22]
    6. Secondary amines better tolerated: nortriptyline (Pamelor®), desipramine (Norpramin®)
    7. Usually initiate 10-25mg po qhs (due to sedating side effects)
    8. Other side effects: dry mouth, orthostatic hypotension, constipation, prolonged QTc
    9. Contraindicated in prolonged QT syndromes and with drugs that prolong the QT
  7. Selective Serotonin Reuptake Inhibitors [23]
    1. May have slight improvement in tension type headaches but not migraines
    2. Most effective in mixed chronic pain types (may have anxiety component)
    3. Duloxetine (Cymbalta®), a mixed reuptake inhibitor, is approved for diabetic peripheral neuropathy [24]
  8. Other therapy
    1. Surgery ± neurectomy, spinal fusion, sympathectomy, nerve block
    2. Transcutaneous Electronic Nerve Stimulation ("TENS") device
    3. Ultrasound treatments
    4. Butorphanol nasal spray
    5. Tramadol (Ultram®; see above)
    6. Acupuncture (see below)
    7. Intrathecal treatment (including methylprednisolone, lidocaine, other agents)
  9. Synthetic Cannabanoids [55]
    1. Limited activity in acute pain, with common adverse events
    2. May have activity in neuropathic pain and for spasticity
    3. Dimethylheptyl-D8-tetrahydrocannabinol-11-oic acid (CT-3) has been studied
    4. CT-3 has analgesic and anti-inflammatory activities
    5. 10mg had significant reduction in neuropathic pain within 3 hours of dose
    6. Less effect on pain 8 hours after dose
    7. Only transient dry mouth and tiredness increased with CT-3 versus placebo
  10. N-Type Calcium Channel Blocker (CCB) [61]
    1. Ziconotide (SNX-111, Prialt®) is given intrathecally for severe pain
    2. Has shown good activity in cancer and AIDS associated pain
    3. Active in pain unresponsive to opioids or in patients with severe opioid side effects
    4. ~50% response to ziconotide versus 17% with placebo

G. Pain Management in Geriatric Patients

  1. High frequency of older patients with (chronic) pain conditions
    1. Arthritis and musculoskeletal problems
    2. Cancer pain
    3. Neuropathic pain: diabetic neuropathy, herpes zoster
    4. Leg cramps (usually nocturnal), claudication
  2. Increased sensitivity to medications
  3. Assessment and Evaluation of Pain
    1. Complaints by elderly persons must be taken seriously
    2. Depression and/or anxiety may be due to pain syndromes
    3. Focus physical exam of new complaints on neurologic and musculoskeletal systems
    4. Invasive and other diagnostics may be best carried out in hospitalized setting
    5. Pain is frequently undertreated in the elderly [25]
  4. Medical Therapy
    1. Acetaminophen is usually the first line treatment
    2. Mild increase in chronic renal failure with chronic acetaminophen use is concerning [26]
    3. NSAIDs are usually avoided due to high risk of GI and renal side effects
    4. However, NSAIDs may be very effective and synergistic with opiates
    5. Careful monitoring of GI (stool guaiac) and renal function (creatinine) should be done
    6. Opiate side effects including cognative dysfunction, constipation, and respiratory depression are more common in elderly than in younger patients
    7. Regular dosing of opiates is usually preferred over sporadic dosing in chronic pain
    8. Regular dosing leads to better pain control, reduced cognitive impairment
    9. Meperidine (Demerol®) should be avoided due to pro-seizure effects of metabolites
    10. Transdermal patches are usually too potent for most elderly patients
    11. Tramadol (Ultram®) may be an effective alternative to opiates
    12. Tricyclic antidepressants of the secondary amine class are preferred if used
    13. Capsaicin cream is effective and generally well tolerated
  5. Non-Drug Therapies
    1. Usually more desirable (fewer side effects) than medical therapy when effective
    2. Application of heat and cold can be effective
    3. Massage therapy
    4. Ultrasound therapy
    5. Swimming - water exercises are especially effective in musculoskeletal conditions
    6. Aerobics and weight lifting programs
    7. Transcutaneous nerve stimulation (TIMS) devises may be effective
    8. Acupuncture (see below)
    9. Biofeedback, relaxation, meditation, prayer and hypnosis should be considered

H. Acupuncture [18,47]

  1. Clear Evidence of Efficacy
    1. Postoperative nausea and vomiting in adults (not effective in children)
    2. Chemotherapy-related nausea and vomiting
    3. Pregnancy-related nausea and vomiting
    4. Postoperative dental pain
  2. Some Evidence of Efficacy
    1. Menstrual Cramps
    2. Low Back Pain
    3. Myofascial Pain
    4. Knee osteoarthritis - 8 and 26 weeks, some decline in effect over time []
    5. Headache (including migraine)
    6. Postoperative Pain
    7. Temporomandibular Joint (TMJ) Disorder
    8. Addiction
    9. Carpal Tunnel Syndrome
    10. Epicondylitis
    11. Chronic obstructive pulmonary disease
  3. Conflicting Results
    1. Chronic pain
    2. Chronic neck with back pain
    3. Osteoarthritis
    4. Alcoholism
    5. Asthma
    6. Weight reduction
    7. Stroke Rehabilitation
  4. Ineffective
    1. Pain due to HIV peripheral neuropathy [22]
    2. Smoking cessation
    3. Tinnitus
    4. Fibromyalgia [64]
  5. Acupuncturists are now licensed and available for therapy
  6. Acupuncture Side Effects [41]
    1. Majority are mild
    2. Needle pain
    3. Fatigue
    4. Bleeding (minor)
  7. Given low rates of side effects, acupuncture should be considered in any of above areas
  8. Feelings of relaxation following acupuncture reported in >80% of patients [41]

J. Pain Management in Children [50,59]

  1. Children age >7 can usually use pain analogue scales similar to adults
  2. For patients >60kg, dosages are similar to that for adults
  3. Data derived from Tables 2 and 3 in Ref [50]
  4. Oral Dosages for Nonopioid Analgesics (Patients <60kg)
    1. Acetaminophen 10-15mg/kg (maximum 100mg/kg) q4 hours (hr)
    2. Ibuprofen 6-10mg/kg (max 40mg/kg) q6 hr
    3. Naproxen 5-6mg/kg (max 24mg/kg) q12 hr
    4. Aspirin is generally not recommended
  5. Opioids
    1. Codeine not recommended IV
    2. Codeine: Child <50kg: 0.5-1.0 mg/kg q4 hr / Child >50kg: 30-60mg q3-4 hr
    3. MS IV: Child <50kg: 0.1mg/kg q2-4 hr bolus / Child >50kg: 5-8mg q2-4 hr
    4. MS PO immediate release: Child <50kg: 0.3mg/kg q3-4hr / Child >50kg: 15-20mg q3-4hr
    5. MS PO sustained release: Child <20-35kg: 10-15 q8-12hr / Child >35-50kg: 15-30 q8-12hr / Child >50kg: 30-45mg q8-12hr
    6. Oxycodone PO: Child <50kg: 0.1-0.2mg/kg q 3-4hr / Child >50kg: 5-10mg q3-4hr
    7. Methadone PO: Child <50kg: 0.1-0.2mg/kg q 4-8hr / Child >50kg: 5-10mg q4-8hr
    8. Hydromorphone PO: Child <50kg: 0.04-0.08 mg/kg q3-4hr / Child >50kg: 2-4mg q3-4hr
    9. Meperidine PO: Child <50kg: 2-3mg/kg q3-4 hr / Child >50kg: 100-150mg q3-4 hr
    10. Fentanyl, hydromorphone, meperidine may also be used for bolus or infusion dosing
    11. Respiratory depression can be reversed with naloxone 2µg/kg q 30 seconds as needed
  6. Local Anesthetics
    1. Generally well tolerated
    2. Lidocaine and bupivicaine most often used but should be avoided in neonates
    3. Ropivacaine and L-bupivacaine have reduced cardiac risk compared to others
    4. Clonidine can enhance the effects of epidural local anesthetics

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