Non-Opioid Treatment of Pain
When choosing pharmacological treatment for chronic pain, a combination of different types of non-opioid pain medications may be most effective. They may alleviate pain using different mechanisms in the pain pathway including peripheral and central nervous system.
Acetaminophen 650 mg Q6 hours (Max 3000 mg/day; max 2000 mg/day if liver disease or ≥ 3 alcoholic drinks/day)
Naproxen 500 mg Q12 hours or 500 Q AM plus 250BID (Max 1000 mg/24 hours)
Ibuprofen 600 mg every 6 hours (Max 2400 mg/day)
NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)
Meloxicam: 7.5 mg once daily
Salsalate: 1000 mg q8 hours or 1500 q 12h (Max 3000 mg/day)
Piroxicam : 20 mg orally once a day
Celecoxib: 100 or 200 mg orally twice a day
Patients on an NSAID who are older than 65 or have a history of heart failure, liver disease, diabetes, or concurrent nephrotoxic drugs should have a creatinine test within the past 3 months of initiation and 2-4 weeks thereafter.
Amitriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mgif taking an SSRI/SNRI)*
Nortriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mg if takingan SSRI/SNRI)*
Venlafaxine, start at 37.5 mg, titrate as needed up to 225mg QD
Duloxetine (60 mg QD) and/or Pregabalin (300-450 mg/day divided BID)
*Caution using Tricyclic Antidepressants in older adults (65+ years) or in patients on tramadol Patients receiving a tricyclic antidepressant (TCA) equivalent to 100 mg amitriptyline or 50 mg nortriptyline or 75 mg venlafaxine should have well-controlled blood pressure at baseline, and at recheck within the first two weeks. TCAs should not be used in patients 65 years or older.
- Cream: 0.025% or 0.075%. Apply cream 3-4x/day. It may take 8 weeks for optimal pain relief
- Patch: 8%. Used in one 60-minute application daily
- Gel: 1%, 2-4 g daily, 4x/day.
- Solution: apply 40 drops 4x/day
- Cream: apply 4x/day or as needed, max 300 mg/day
- Patch: Apply up to 3 patches daily at a time, use up to 12 hours within 24 hr period
- Apply to affected area 3-4x/day.
Gabapentin, titrate up to 900-1200mg TID
Pregabalin: 50 mg three times a day (150 mg/day)*
*dose may be increased within 1 week based on efficacy and tolerability