PAIN STEP-UP

Mild: APAP, NSAID, topical
Moderate: Oxy PO, topical adjunct
Severe: IV opioid
Spasm: muscle relaxer
Neuropathic: gaba/pregabalin/duloxetine
Refractory: pain consult / ketamine / infusion

1️⃣ NON-OPIOIDS

Acetaminophen (Tylenol) PO/IV

  • 650 q6 PRN or 1000 q8 PRN

  • 30–60 min | 4–6 hr | 4 g/day (often use 3 g inpatient)

  • Use: fever, mild pain, multimodal

  • Avoid: liver disease, heavy EtOH

Ketorolac (Toradol) IV

  • 15–30 mg q6 PRN

  • <30 min | 4–6 hr | 60 mg (>65y), 120 mg (<65y)

  • Use: renal colic, MSK, HA

  • Avoid: AKI, GIB, AC, low plt, HF, dehydration

Ibuprofen PO

  • 400–600 q6 PRN

  • 30 min | 4–6 hr | 3200/day

  • Use: mild MSK, HA

  • Avoid: AKI, GIB, CHF, CVA, AC

Naproxen PO

  • 250–500 BID

  • <60 min | 12 hr | 1000/day

  • Use: arthritis, longer NSAID

  • Avoid: usual NSAID risks

Celecoxib PO

  • 100–200 BID

  • 1 hr | 12–24 hr | 400/day

  • Use: arthritis, lower GI risk

  • Avoid: AKI, CHF, CV risk

2️⃣ MUSCLE RELAXERS

Methocarbamol

  • 500–1000 q6–8

  • <30 min | 4–6 hr | 8 g/day

  • Use: back/neck spasm

  • Avoid: AMS, sedation, ESRD

Cyclobenzaprine

  • 5–10 TID PRN

  • 30 min | 12–24 hr | 30/day

  • Use: spasm

  • Avoid: elderly, delirium, retention, sedation

Tizanidine

  • 2 mg q6–8 start low

  • 1 hr | 3–6 hr | 36/day

  • Use: neck/back spasm

  • Avoid: hypotension, sedation

Baclofen

  • 5 mg TID start

  • Use: spasticity / neuro causes

  • Avoid: renal failure, sedation

3️⃣ TOPICALS

Lidocaine Patch

  • 1–3 patches daily

  • 12 hr ON / 12 hr OFF

  • Use: rib fx, focal back pain, local neuropathy

Lidocaine 4% Cream

  • TID PRN

Diclofenac Patch

  • 1 patch BID

  • Use: strain/sprain

Diclofenac Gel

  • 2–4 g QID

  • Use: OA joints

Capsaicin

  • Use: focal neuropathy

  • Takes days

Menthol/Camphor

  • PRN mild aches

4️⃣ NEUROPATHIC

Gabapentin

  • 100–300 TID start

  • ~1 day | 8 hr | 3600/day

  • Use: burning / neuropathy

  • Avoid: AMS, renal adjust

Pregabalin

  • 25–50 BID

  • ~1 day | 12 hr | 600/day

  • Use: neuropathy

Duloxetine

  • Use: neuropathy, fibromyalgia, mood

  • Takes weeks

Nortriptyline / Amitriptyline

  • Use: neuropathy

  • Avoid: anticholinergic, falls, retention

5️⃣ OPIOIDS

Oxycodone PO

  • 5 / 10 / 15 mg q3–6 PRN

  • <30 min | 4–6 hr

  • Use: moderate pain, transition from IV

Hydromorphone (Dilaudid) IV

  • 0.25–0.5 / 0.5–1 / 1–3 mg q2–4 PRN

  • 5 min | 4 hr

  • Use: severe pain, NPO, AKI better than morphine

Fentanyl IV

  • 12.5–25 frail | 25–50 standard | 75–100 severe

  • 1 min | 30–60 min

  • Use: procedure, ESRD, unstable BP

Morphine IV

  • 1–3 / 2–6 mg q2–4 PRN

  • <10 min | 4 hr

  • Use: severe pain

  • Avoid: AKI

MS Contin PO

  • 15–30 q12 scheduled

  • <60 min | 12 hr

  • Use: cancer/chronic/home regimen

  • Avoid: opioid naïve, AKI

🔴 QUICK PICKS

AKI / CKD

Avoid NSAIDs, morphine
Prefer fentanyl / dilaudid

Elderly

Low dose everything
Avoid cyclobenzaprine

Spasm

Methocarbamol first

Neuropathy

Gabapentin / pregabalin

Severe acute pain

Dilaudid IV

Transition to discharge

Oxycodone PO