Pain Medications in ED patients

Pain Treatment for Senior ED Patients
General Guidelines
Parenteral medications in ED:
 Morphine 2 mg to 4 mg IV or SQ prn
 Hydromorphone 0.5 mg IV or SQ prn
Oral medications in ED or for outpatient management:
 Scheduled Acetaminophen 1 gram q8hrs or 650 mg q6hr
 Oxycodone 2.5 mg -5 mg PO Q 3-4 hours prn
 Morphine 7.5 mg PO Q 3-4 hours prn
 Doses of opioids are for opioid naïve patients. Contact pharmacist for dosing patients on chronic
opioid therapy.
 IV medications can be repeated as frequently as q15”, SQ medications q30”.
 Oxycodone preferred over morphine in renal impairment.
 If patient’s pain is due to a fall: Consider addition of Vitamin D and a recommendation for a
Vitamin D level as an outpatient: OsCal 500 with D plus Vitamin D 400 units daily (800 units total
per day reduces falls risk by 20%).
Medications to Avoid
Tricyclic Antidepressants
 Amitriptyline (Elavil)
 Imipramine (Tofranil)
 Doxepin (Sinequan)
High anticholinergic effects: Can cause delirium, falls,
constipation, urinary retention.
Muscle Relaxants
 Carisprodal ( Soma)
 Methocarbamol ( Robaxin)
 Cyclobenzaprine ( Flexeril)
 Metazolone ( Skelexin)
Orphenadrine ( Norflex)
Sedating, some have anticholinergic effects, increased
risk of falls, delirium, constipation, urinary retention.
 Indomethacin has highest incidence of adverse
Certain Opioids
 Pentazocine (Talwin): more CNS effects than
other opioids.
 Fentanyl patch: delay to maximal effect,
prolonged effects after removal, rapid titration
may cause overdose, contraindicated in opioid
naïve patients.
 Meperidine (Demerol): toxic metabolite in
patients with renal dysfunction, use restricted
to certain indications at SHS.
For Neuropathic Pain:
 If CrCl > 50 ml/min: Gabapentin (Neurontin) –
300 mg at bedtime x 1 day, then 300 mg BID x
1 day, then 300 mg TID; If CrCl < 50 ml/min,
check drug reference for dosing.
 Lidocaine 5% Patch - 12 hrs on, 12 hrs off
 Duloxetine (Cymbalta) 30 mg daily, may
increase to 60mg daily in 1 week based on
 Nortriptyline 10 mg at bedtime (has some
anticholinergic effects)
 Opioid, acetaminophen combination
 Tizanidine (Zanaflex) 2 mg q8hrs prn. Not
recommended in patients prone to orthostasis.
Opioid, acetaminophen combination
NSAIDs and COX-2 inhibitors may be
considered with extreme caution in highly
selected individuals per American Geriatric
Society Pain Guidelines.
 If an NSAID is prescribed, add a proton pump
inhibitor or misoprostol for GI protection.
For Long-term Pain Relief:
 Morphine SR 15 mg q12hrs
 Morphine 7.5 mg PO Q 3-4 hours prn
Or if significant renal Impairment
 Oxycodone SR 10 mg q12hrs
 Oxycodone 2.5 mg to 5 mg q4hrs prn
Adapted from: J Am Geriatr Soc 2010; 58: 1299-1310; BMJ 2009; 339:b3692; JAMA 2004;291:1999-2006.
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