Bone Pain

Nonsteroidal anti-inflammatory drugs (NSAIDs) are quite helpful in the alleviation of pain from lesions in bones or skeletal muscles. The nonacetylated salicylates (e.g., salsalate [Disalcid], choline magnesium trisalicylate [Trilisate]) are less toxic to the gastric mucosa and do not inhibit platelet function (Zucker and Rothwell, 1978) but are less potent analgesics. The newer nonsalicylate NSAIDs are more potent, more convenient, more expensive, and less toxic than aspirin.

Table 5-5 Dosing Data for Opioid Analgesics

Guidelines

1. Evaluate pain for all patients using a 0 to 10 scale:

B. Moderate pain: 4-7

C. Severe pain: 8-10

2. For chronic moderate or severe pain, do the following:

A. Give baseline medication around the clock.

B. Order 10% of the total daily dose for PRN administration given every 1 to 2 hours for the PO route or every 30 to 60 minutes for the SC or IV route.

C. For continuous infusion, PRN administration can be the hourly rate every 15 minutes or 10% of the total daily dose every 30 to 60 minutes.

D. Adjust the baseline upward daily in an amount roughly equivalent to the total amount used for PRN.

E. Negotiate with the patient the target level of relief, usually achieving a level at least <4.

3. In general, the oral route is preferable, then transcutaneous, subcutaneous, and intravenous routes.

4. When converting from one opioid to another, some experts recommend reducing the equianalgesic dose by one third to one half and then titrating as in guideline 2.

5. Elderly patients or those with severe renal or liver disease should start on one half of the usual initial dose.

6. If parenteral medication is needed for mild to moderate pain, use one half of the usual starting dose of morphine or an equivalent.

7. Refer to the Physicians' Desk Reference for additional fentanyl guidelines.

8. Naloxone (Narcan) should be used only in emergencies: Dilute 0.4mg of naloxone with 9mL of normal saline; give 0.1mg (2.5mL) by slow IVP until effect; and monitor patient every 15 minutes. It may be necessary to repeat naloxone again in 30 to 60 minutes.

9. Short-acting preparations should be used in the initial period and postoperatively. Switch to long-acting preparations when the pain is chronic and after the total daily dose is determined.

Medication*

Equianalgesic Dose (for chronic dosing)

Usual Starting Dosesf(for opioid-naïve patients)

Comments

Pain

Half- life (hr)

Duration (hr)

Relative Generic Cost

IM/IV (onset 15-30min)

PO(onset 30-60min)

Parenteral

PO

Morphine

10mg

30mg

5-10mg IV/SC q3-4hr (2.5-5mg)+

15-30mg q3-4hr (IR or oral solution (5-15mg)|

Immediate-release tablets

(20mg/mL), can give buccally Sustained-release tablets

(15, 30, 60, 100, 200mg) q12hr Rectal suppositories (5, 10, 20, 30mg) Use cautiously in severe renal disease

Mod to sev

1.5-2

$ (SR) $ (IV)

Oxycodone

Not available

20mg

Not available

10mg q4-6hr (5mg)*

Immediate-release tablets (5mg)

Immediate-release liquid (20mg/mL) Sustained-release

(10, 20, 40, 80mg) q12hr Percocet (oxycodone/acetaminophen):

2.5/325, 5/325, 7.5/500, 10/650mg). Monitor total acetaminophen dose.

Mod to sev

No data

4-6

$ (comb w/APAP) $ (IR) $ (liquid) $$ (SR)

Hydromorphone

1.5mg

7.5mg

1-2mg IV/SC q3-

4-8mg q3-4hr

Immediate-release tablets (2, 4, 8mg)

Mod to

2-3

4-5

$$ (IR)

(Dilaudid)

4hr(0.5-1mg)+

(2-4mg)+

Immediate-release liquid (1mg/1mL) Sustained-release (12, 16, 24, 32mg) Acceptable with renal disease; high equi-analgesic potency

sev

(SR) $$ (IV)

Methadone

Oral/IV ratio

Oral 24-hr

Oral

Total: 5-10mg/24hr

5-10mg q12hr

Tablets (5, 10, 40mg)

Mod to

15-190 (huge

6-12

$ (PO)

<30 31-99 100-299 300-499 500-999 >1000

morph/

meth ratio

2:1 4:1 8:1 12:1 15:1 20:1

Can give by continuous infusion or intermittent dosing qid (half starting dose for elderly; limited availability)*

(2.5mg)+

Liquid (1, 2 10mg/mL) Generally given bid or tid. Long variable T1/2; small dose change makes big difference in blood level. Always write or advise "hold for sedation." PRN is one sixth to one tenth of daily dose 2-3 times per day maximum. Acceptable in cases of renal disease. Request consult for high-dose conversion, IV conversion, or if presciber is inexperienced.

sev

variation)

$$$ (IV)

Fentanyl

100^g (single

Oral 24-hr

Initial

50-100 ^g IV q1-2hr

25 ^g/hr TD

TD: see PDR for details of dose

Mod to

3-4(IV)

1-2 (IV)

$$$ (TD)

(Duragesic

dose)

MS dose

patch

(50mg)+

q72hr (not

transition; 12-hr delayed onset

sev

12 (TD)

48-72

$ (IV)

patch)

200^g (cont

(mg)

recommended

and offset with patch.

(TD)

$$$

(PO)

infusion)

90 180 360

25^g/hr 50^g/hr 100^g/ hr

for opioid na'ive)*

IV: very short acting; associated with chest wall rigidity. Include short-acting supplement for breakthrough pain.

Oral: available but difficult to dose or control (request consult)

Meperidine

75-100mg

300mg

75mg

Not

Not recommended for standard

Mod to

3-4

2-4

$$(PO)

(Demerol)

IV/SC/IM q2-3hr (25-50mg)+ Generally not recommended

recommended

analgesia; may be useful for shivering and procedural analgesia or sedation. Toxic metabolites accumulate with repeated doses and with renal or hepatic disease Contraindicated with MAOIs

sev

$ (IV)

Table 5-5 Dosing Data for Opioid Analgesics —cont'd

Codeine

120mg (IM only)

200mg

30mg IM/SC 30-60mg Codeine alone: schedule if q3-4hr (15mg)+ q3-4hr prescription

IV contraindicated (15-30mg)* Tylenol No. 3 (30mg of codeine plus

300mg of acetaminophen) Tylenol No. 4 (60mg of codeine and

300mg of acetaminophen) Tylenol w/codeine sol. (12mg of codeine and 120mg of acetaminophen per 5mL) Monitor total acetaminophen dose

Mild to 3 mod

Hydrocodone (Vicodin, Lortab)

Not available

30mg

Not available 5-10mg q4-6hr Vicodin (5mg of hydrocodone and

(5mg)| 500mg of acetaminophen)

Vicoprofin (7.5mg of hydrocodone and 200mg of ibuprofen) Lortab (hydrocodone/ acetaminophen: 2.5/500; 5/500; 7.5/500mg

Norco (10mg of hydrocodone and 325mg of acetaminophen) Monitor total acetaminophen dose

*New York State currently requires triplicate reporting. tAdult >50kg.

^One-half dose for elderly patients or those with severe renal or liver disease.

IR, immediate release; IVP, intravenous push; MAOIs, monoamine oxidase inhibitors; meth, methadone; mod, moderate; morph, morphine; MS, morphine sulfate; PDR, Physicians' Desk Reference; sev, severe; sol, solution; SR, sustained release; TD, transdermal.

Adapted from Storey P: Primer of Palliative Care, 3rd ed. Glenview, IL, American Academy of Hospice and Palliative Medicine, 2004, p 11.

Table 5-6 Physician's Checklist when Prescribing Opioids

Although no single agent has been shown to be consistently more efficacious, particular patients do seem to favor one drug over another. If swallowing large tablets becomes a problem, piroxicam (Feldene) capsules, naproxen (Naprosyn) suspension, or indomethacin (Indocin) rectal suppositories may be used. The cyclooxygenase-2 (COX-2) inhibitor celecoxib (Celebrex) offers comparable analgesia and less gastrointestinal toxicity but at a higher risk of stroke or heart attack (which may not be an issue in the final weeks of life) and a higher cost. Steroids may also be a helpful adjuvant for bone pain.

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