From the Guidelines
If Tylenol with codeine (T4) is unavailable, alternative pain management options include other opioid combinations like morphine, which has been shown to have a significantly higher response rate and earlier onset of response compared to "weak opioids" like codeine, as seen in a randomized trial 1. When considering alternatives, it's crucial to assess the patient's pain intensity, current analgesic therapy, and concomitant medical illnesses to determine the optimal analgesic selection.
- Other opioid options may include hydromorphone, oxymorphone, and fentanyl, but these should be used with caution in patients with fluctuating renal function due to the potential accumulation of renally cleared metabolites that may cause neurologic toxicity 1.
- Non-opioid alternatives can include regular acetaminophen (up to 3000mg daily divided into 3-4 doses) combined with an NSAID like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily) if not contraindicated.
- For moderate pain, tramadol (50-100mg every 4-6 hours) offers an option with different mechanisms.
- Non-pharmacological approaches such as physical therapy, heat/cold therapy, massage, and relaxation techniques can complement medication. The choice of alternative depends on pain severity, patient characteristics, and contraindications, with NSAIDs being avoided in patients with kidney disease, certain cardiovascular conditions, or gastrointestinal ulcers. Multimodal analgesia, which combines different mechanisms like acetaminophen, NSAIDs, and opioids, has been shown to spare opioid use and side effects by 30% 1, and can often provide better pain control with fewer side effects than higher doses of a single medication.
From the FDA Drug Label
Patients were permitted up to 4 grams of acetaminophen per day as needed for pain, in addition to pregabalin.
If T4 (Tylenol with codeine) is not available, alternative pain management strategies may include:
- Using acetaminophen alone, up to 4 grams per day, as mentioned in the drug label 2
- Considering pregabalin as an alternative, as it has been shown to statistically significantly improve endpoint mean pain score and increase the proportion of patients with at least a 50% reduction in pain score from baseline 2
- Other pain management options may be considered, but they are not directly mentioned in the provided drug label.
From the Research
Alternative Pain Management Strategies
If T4 (Tylenol with codeine) is not available, there are several alternative pain management strategies that can be considered:
- Non-steroidal anti-inflammatory drugs (NSAIDs) are widely accepted as analgesics and can be used as an alternative to T4 3
- Muscle relaxants, such as cyclobenzaprine or baclofen, can provide some relief of pain 3
- Antidepressants, such as amitriptyline, can be analgesic and may be used to relieve pain, especially if depression is a contributing factor 3
- Anticonvulsants, such as gabapentin or pregabalin, can be used to treat neuropathic pain 3, 4
- Topical analgesic agents can also be used to manage pain 3
Combination Therapy
Combination therapy, such as the use of oxycodone and tapentadol, can be effective for managing intractable pain 5
- The use of a combination of m-opioid receptor agonists, such as morphine or oxycodone, with tapentadol, which has a noradrenaline reincorporation-inhibiting action, can be an effective remedy for alleviating intractable pain complicated with neuropathic pain 5
Other Options
Other options for pain management include:
- Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine or venlafaxine, which can be used to treat depression and pain 4
- Celecoxib, a nonsteroidal anti-inflammatory drug, can be used to treat pain and inflammation 4
- Gabapentin or pregabalin can be used in combination with SNRIs for synergistic effect 4