![]() Tramadol (Ultram): 25 mg every 4 to 6 hours, titrated to 50 to 100 mg as needed Oxycodone/acetaminophen 2.5 mg/325 mg to 10 mg/ 325 mg every 4 to 6 hours Hydrocodone/ibuprofen: 2.5 mg/200 mg to 10 mg/ 200 mg every 6 to 8 hours Opioid sparing effect with decreased risk of adverse events Superior effectiveness compared with single agent Maximum: 4,000 mg per day of acetaminophen Hydrocodone/acetaminophen: 2.5 mg/325 mg to 10 mg/325 mg every 4 to 6 hours Opioid plus acetaminophen or NSAID combinations single agentsĬombining medications has lower risk of adverse effects than high doses of single agents Food and Drug Administration boxed warning for increased risk of cardiovascular diseaseĬelecoxib (Celebrex): 100 to 200 mg per dayĬombinations have superior effectiveness vs. Maximum: oral 40 mg per day IM/IV 120 mg per dayĬelecoxib has a U.S. IM: 30 to 60 mg as a single dose or 15 to 30 mg every 6 hours Naproxen: 250 mg every 6 to 8 hours or 500 mg every 12 hours Ibuprofen: 200 to 400 mg every 6 to 8 hoursĬonsider adding proton pump inhibitor or switching to a selective COX-2 NSAID to decrease gastrointestinal risk May be combined with NSAIDs for postoperative pain ≤ 2,000 mg per day in patients with advanced hepatic disease and severe alcohol use disorder Maximum: 75 mg per kg per day, not to exceed 4,000 mg per dayįirst-line treatment in patients with renal and hepatic impairment and cardiovascular disease IV: ≥ 50 kg, 650 mg every 4 hours or 1,000 mg every 6 hours < 50 kg, 12.5 mg per kg every 4 hours or 15 mg per kg every 6 hours Orally or rectally: 325 to 1,000 mg every 4 to 6 hours ![]() 12, 17, 25, 63, 64Įxpert consensus opinion, clinical guidelines Opioids should be used for no more than three days, only for severe or refractory acute pain, and only in combination with other medications. Meta-analysis (gabapentinoids), systematic review (gabapentinoids and antidepressants), mixed results from high-quality studies (gabapentinoids)Ĭannabinoids used to treat chronic neuropathic pain should not be used to treat acute pain. Gabapentinoids and antidepressant medications used to treat chronic neuropathic pain should not be used to treat acute pain. Systematic review, multiple randomized controlled trials Muscle relaxants are effective adjunctive medications for acute low back pain and neck pain. Systematic reviews, consistent randomized controlled trials, clinical guidelines ![]() Medication selection should be based on minimizing risks for the specific patient. Nonsteroidal anti-inflammatory drugs, acetaminophen, or a combination is an effective initial treatment approach for acute pain syndromes. Systematic review, consistent randomized controlled trials, evidence-based guidelines Topical nonsteroidal anti-inflammatory drugs are safe and effective for treating acute pain. The opioid epidemic has increased physician and community awareness of the harms of opioid medications however, severe acute pain may necessitate short-term use of opioids with attention to minimizing risk, including in patients on medication-assisted therapy for opioid use disorder. For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations. Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate (e.g., muscle relaxants may be useful for acute low back pain). Selective cyclooxygenase-2 NSAIDs are a more expensive treatment alternative and are used to avoid the gastrointestinal adverse effects of nonselective NSAIDs. Nonselective NSAIDs are effective but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease. ![]() Acetaminophen is well tolerated however, lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder. Topical NSAIDs are recommended for non–low back, musculoskeletal injuries. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain. Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions. ![]()
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