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5-12: Pharmacologic Pain Management Strategies

Michael W. Rabow; Steven Z. Pantilat; Ann Cai Shah; Lawrence Poree; Raj Mitra

Pain generally can be well controlled with nonopioid and opioid analgesic medications, complemented by nonpharmacologic adjunctive and interventional treatments. For mild to moderate pain, acetaminophen, aspirin, and NSAIDs (also known as COX inhibitors) may be sufficient. For moderate to severe pain, especially for those with acute pain, short courses of opioids are sometimes necessary; for those with cancer pain or pain from advanced, progressive serious illness, opioids are generally required and interventional modalities should be considered. In all cases, the choice of an analgesic medication must be guided by careful attention to the physiology of the pain and the benefits and risks of the particular analgesic being considered.

ACETAMINOPHEN, ASPIRIN, CELECOXIB, & NSAIDS (COX INHIBITORS)

Table 5–5 provides comparison information for acetaminophen, aspirin, the COX-2 inhibitor celecoxib and the NSAIDs. An appropriate dose of acetaminophen may be just as effective an analgesic and antipyretic as an NSAID but without the risk of GI bleeding or ulceration. Acetaminophen can be given at a dosage of 500–1000 mg orally every 6 hours, not to exceed 4000 mg/day maximum for short-term use. Total acetaminophen doses should not exceed 3000 mg/day for long-term use or 2000 mg/day for older patients and for those with liver disease. Hepatotoxicity is of particular concern because of how commonly acetaminophen is also an ingredient in various over-the-counter medications and because of failure to account for the acetaminophen dose in combination acetaminophen-opioid medications such as Vicodin or Norco. The FDA has limited the amount of acetaminophen available in some combination analgesics (eg, in acetaminophen plus codeine preparations).

Table 5–5.Acetaminophen, aspirin, and useful NSAIDs and COX inhibitors.
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Table 5–5. Acetaminophen, aspirin, and useful NSAIDs and COX inhibitors.
Medication (Proprietary) Usual Dose for Adults Based on Weight Cost1 Comments2
Acetaminophen (Ofirmev) ≥ 50 kg: 1000 mg intravenously every 6–8 hours

Per unit: $24.00 per vial of 1000 mg

For 30 days: $2880.00

  
Acetaminophen or paracetamol3 (Tylenol, Datril, etc)

≥ 50 kg: 325–500 mg orally every 4 hours or 500–1000 mg orally every 6 hours, up to 2000–4000 mg/day

< 50 kg: 10–15 mg/kg every 4 hours orally; 15–20 mg/kg every 4 hours rectally, up to 2000–3000 mg/day

Per unit: $0.02/500 mg (oral) OTC; $0.43/650 mg (rectal) OTC

For 30 days: $3.60 (oral); $77.40 (rectal)

Not an NSAID because it lacks peripheral anti-inflammatory effects. Equivalent to aspirin as analgesic and antipyretic agent.

Limit dose to 4000 mg/day in acute pain, and to 3000 mg/day in chronic pain. Limit doses to 2000 mg/day in older patients and those with liver disease.

Be mindful of multiple sources of acetaminophen from combination analgesics, cold remedies, and sleep aids.
Aspirin4

≥ 50 kg: 325–650 mg orally every 4 hours

< 50 kg: 10–15 mg/kg every 4 hours orally; 15–20 mg/kg every 4 hours rectally

Per unit: $0.02/325 mg OTC; $1.46/300 mg (rectal) OTC

For 30 days: $7.20 ...

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