Recommended Starting Dosages for Pain Management
First-Line Agents by Pain Type
Musculoskeletal Pain
Start with acetaminophen or NSAIDs as first-line therapy, with acetaminophen preferred due to its superior safety profile. 1
- Acetaminophen: 500-1000 mg every 4-6 hours (maximum 4000 mg/day in patients with normal liver function; reduce in liver disease) 1
- Ibuprofen: 400 mg every 4-6 hours as needed (maximum 3200 mg/day, though doses >400 mg show no additional analgesic benefit for acute pain) 2
- For chronic conditions (osteoarthritis/rheumatoid arthritis): Start 400-800 mg three to four times daily, titrate to 1200-3200 mg/day based on response 2
- Naproxen: 250-500 mg twice daily (maximum 1000 mg/day) 1
Neuropathic Pain
For neuropathic pain, initiate treatment with gabapentin, pregabalin, or duloxetine as first-line agents, starting at low doses with gradual titration. 1
Gabapentin
- Starting dose: 100-300 mg at bedtime OR 100-300 mg three times daily 1
- Titration: Increase by 100-300 mg every 1-7 days as tolerated 1
- Target/maximum: 1800-3600 mg/day in three divided doses 1
- Trial duration: 3-8 weeks for titration plus 2 weeks at maximum tolerated dose 1
- Critical caveat: Reduce dose in renal insufficiency based on creatinine clearance 1
Pregabalin
- Starting dose: 50 mg three times daily OR 75 mg twice daily 1
- Titration: Increase to 300 mg/day after 3-7 days, then by 150 mg/day every 3-7 days as tolerated 1
- Maximum: 600 mg/day (though 300 mg/day often equally effective with fewer side effects) 1
- Trial duration: 4 weeks 1
- Advantage: Linear pharmacokinetics allow faster titration than gabapentin 1
Duloxetine
- Starting dose: 30 mg once daily 1
- Titration: Increase to 60 mg once daily after 1 week 1
- Maximum: 60 mg twice daily 1
- Trial duration: 4 weeks 1
Tricyclic Antidepressants (Secondary Amines Preferred)
- Nortriptyline or desipramine starting dose: 25 mg at bedtime 1
- Titration: Increase by 25 mg every 3-7 days as tolerated 1
- Maximum: 150 mg/day 1
- Trial duration: 6-8 weeks with at least 2 weeks at maximum tolerated dose 1
Second-Line Agents (When First-Line Fails)
Tramadol
For patients not responding to first-line therapy with moderate pain, tramadol provides an intermediate option before strong opioids. 1
- Starting dose: 50 mg once or twice daily 1
- Titration: Increase by 50-100 mg/day in divided doses every 3-7 days 1
- Maximum: 400 mg/day (300 mg/day in patients >75 years) 1
- For osteoarthritis: Range studied is 37.5 mg (with 325 mg acetaminophen) once daily to 400 mg in divided doses 1
- Trial duration: Up to 3 months 1
- Important warnings: Lowers seizure threshold; risk of serotonin syndrome when combined with SSRIs/SNRIs 1
Strong Opioids (Third-Line)
Opioids should NOT be first-line for chronic pain and are reserved for patients with moderate-to-severe pain who fail first-line therapies, using the smallest effective dose with combined short- and long-acting formulations. 1
Morphine
- Starting dose (oral): 20-40 mg for opioid-naive patients 1
- Starting dose (parenteral): 5-10 mg 1
- For breakthrough pain: 10-15 mg every 4 hours as needed 1
- Trial duration: 4-6 weeks 1
Oxycodone
- Starting dose (oral): 20 mg 1
Key Opioid Prescribing Principles
- Always start with the smallest effective dose 1
- Combine short-acting (for breakthrough) and long-acting (for baseline) formulations 1
- For neuropathic pain: Consider morphine + gabapentin combination for additive effects and lower individual doses 1
- Mandatory pre-prescription risk assessment for misuse, diversion, and addiction potential 1
- Require opioid patient-provider agreement before initiating therapy 1
- Implement routine monitoring: urine drug testing, pill counts, prescription monitoring programs 1
Critical Dosing Principles Across All Agents
Start Low, Go Slow
The fundamental principle is initiating at the lowest effective dose and titrating gradually, particularly in elderly patients and those with renal/hepatic impairment. 1, 2
Duration Considerations
- Use the shortest duration necessary to balance efficacy and safety 2, 3
- Time-limited trials are appropriate for opioids in chronic pain 1
Special Populations
- Geriatric patients: Use lower starting doses and slower titration for all agents 1
- Renal insufficiency: Dose reduction required for gabapentin, pregabalin, and tramadol 1
- Liver disease: Reduce acetaminophen dosing 1
Common Pitfall to Avoid
Do not escalate to opioids without adequate trials of first-line agents at therapeutic doses for sufficient duration. The evidence strongly supports a stepwise approach prioritizing non-opioid options to minimize risks of respiratory depression, cognitive impairment, endocrine changes, and addiction 1.