What tablet should be taken for pain management?

Pain Management Tablet Selection

For neuropathic pain, start with gabapentin 100-300 mg at bedtime or pregabalin 50 mg three times daily; for acute moderate-to-severe pain, use NSAIDs like naproxen or ibuprofen over codeine-acetaminophen combinations; for severe acute pain requiring opioids, use hydromorphone 0.015 mg/kg IV over morphine. 1

Neuropathic Pain Management

First-line agents for neuropathic pain include gabapentin, pregabalin, tricyclic antidepressants (TCAs), and SNRIs. 1

Gabapentin Dosing

• Start at 100-300 mg at bedtime or 100-300 mg three times daily 1
• Increase by 100-300 mg every 1-7 days as tolerated 1
• Maximum dose: 3600 mg/day in 3 divided doses 1
• Requires 6-8 weeks for adequate trial, including 2 weeks at maximum tolerated dose 1
• Caution: Gabapentin has nonlinear pharmacokinetics requiring careful titration and dose reduction in renal insufficiency 1

Pregabalin Dosing

• Start at 50 mg three times daily or 75 mg twice daily 1
• Increase to 300 mg/day after 3-7 days, then by 150 mg/day every 3-7 days as tolerated 1
• Maximum dose: 600 mg/day (though 300 mg/day is often as effective with fewer side effects) 1
• Requires 4 weeks for adequate trial 1
• Advantage: Linear pharmacokinetics make dosing more straightforward than gabapentin, with potentially faster pain relief 1

Tricyclic Antidepressants

• Use secondary-amine TCAs (nortriptyline or desipramine) preferentially 1
• Start at 25 mg at bedtime 1
• Increase by 25 mg/day every 3-7 days as tolerated 1
• Maximum: 150 mg/day 1

Acute Mild-to-Moderate Pain

NSAIDs are superior to codeine-acetaminophen combinations for acute mild-to-moderate pain. 1

NSAID Selection

• Recommend naproxen or ibuprofen over codeine-acetaminophen 1
• Number needed to treat: 2.7 for naproxen and ibuprofen versus 4.4 for codeine-acetaminophen 1
• NSAIDs provide longer time to re-medication with safer side effect profile 1
• Avoid CNS depressing effects of codeine 1
• Critical consideration: Certain genotypes may not metabolize or may hyper-metabolize codeine due to CYP2D6 polymorphism 1

NSAID Safety Warnings

• Can cause ulcers and bleeding in stomach/intestines at any time, potentially without warning 2
• Risk increases with: corticosteroids, anticoagulants, longer use, smoking, alcohol, older age, poor health 2
• Use at lowest effective dose for shortest time needed 2
• Contraindicated right before or after heart bypass surgery 2

Acute Severe Pain Requiring Opioids

For acute severe pain in the emergency department, hydromorphone is superior to morphine. 1

Intravenous Opioid Selection

• Hydromorphone 0.015 mg/kg IV is comparable and potentially superior to morphine 0.1 mg/kg IV 1
• Hydromorphone has quicker onset of action 1
• Morphine's longer onset increases risk of dose stacking, toxicity (especially in renal failure), and hypoventilation 1
• Fentanyl (1 mcg/kg, then ~30 mcg every 5 minutes) is recommended over morphine for patients with morphine allergies or when rapid onset is critical 1

Hydromorphone Dosing Principles

• Oral hydromorphone is 7.5 times more potent than oral morphine 3
• Initial oral dose for opioid-naive patients: 8 mg 3
• No maximum daily dose ceiling—titrate to effect as rapidly as possible 3
• Breakthrough dose: 10% of total daily dose 3
• If more than 4 breakthrough doses per day needed, increase baseline long-acting formulation 3

Morphine Dosing (if used)

• IM/IV starting dose: 5-10 mg for opioid-naive adults 4
• If using IV morphine: 0.1 mg/kg, then 0.05 mg/kg at 30 minutes, maximum suggested dose 10 mg 1
• IM morphine is approximately 3 times more potent than oral morphine 4
• Bolus doses can be ordered every 15 minutes for breakthrough pain 4
• Caution in renal impairment: Morphine metabolites accumulate and contribute to toxicity 4

Critical Prescribing Considerations

• Avoid tablet splitting for narrow therapeutic index drugs (warfarin, digoxin) as 23.9-36.7% of half-tablets fall outside acceptable drug content specifications 5
• Geriatric patients require lower starting doses and slower titration for all agents 1
• All calcium channel α2-δ ligands (gabapentin, pregabalin) require dose reduction in renal insufficiency 1
• Side effects (nausea, vomiting, pruritus) can be managed with antiemetics, laxatives, and opioid rotation if necessary 3