UCLA Pharmaceutical Services

Pain Management Medications - Dosing and Pharmacodynamic Chart

Pain Assessment Considerations

The following are considerations to guide pain assessment
General Considerations
• The pain experience should be considered a clinical emergency and • If a patient is receiving a narcotic for >7days, evaluate for tolerance
treated in a timely fashion.
• Whenever a pain medication is administered its effect should be
evaluated
• Unresolved pain (ie: after a fall, intervention, or procedure) is a
warning sign and is a high priority for assessment and treatment.
Reassess dose for efficacy.
• Unresolved escalating pain requires detailed assessment. This can
indicate other etiologies such as nerve pain that is typically
unresponsive to an opioid and needs a pain consult.
• Orders with variable dose/frequency (e.g., Vicodin 1-2 tabs every 4-
6 hours) may be used only when there are acceptable objective
modifiers (e.g., for mild, moderate or severe pain) for each dose or
dosage interval specified.
PCA
• If the # of attempts far exceeds the number of injections dose may
need to increased.
• If patient awakens in severe pain-evaluate for the addition of a basal
dose.
Tolerance
as patient may require increased doses.
Withdrawal Side Effects
• Prevention of withdrawal is essential if doses are reduced/stopped
for any reason.
Adjunctive Therapy
• Assess benefit of adjuvant therapy such as ice, heat, position
change, massage, relaxation techniques, etc.
High Risk
• Patients with a past medical history of drug abuse will require
greater dosing than less.
• Patients with a history of PVD or neuropathic pain (e.g., chronic
pain) with new onset acute pain may have additional needs.
• Patients with a history of depression, anxiety or psychosis may be at
increased risk for poor coping. Alternative/additional medication
choices should be considered.

Route Change
• When changing route from IV/oral and epidural to oral it is essential
to utilize equinalgesic doses.

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UCLA Pharmaceutical Services
Pain Management Medications - Dosing and Pharmacodynamic Chart

Onset of Duration of Route/Rate of

Medication Peak Effect1 Dose (D) Comments
action Action1 Administration
Oral Medications
Drowsiness, sedation, lightheadedness,
D: 30-60mg codeine (e.g.
Acetaminophen dizziness, nausea/vomiting, constipation,
1-2 tablets) every 4-6
325mg/codeine 30mg 30-45 minutes 1-2 hours 4-6 hours Oral dose related respiratory depression. Excess
hours. Maximum 12
(Tylenol #3) acetaminophen can cause hepatotoxicity. Do
tablets/day
not exceed 4gm acetaminophen/day.

Drowsiness, sedation, lightheadedness,

D: 5-10mg hydrocodone
Hydrocodone 5mg dizziness, nausea/vomiting, constipation,
(e.g. 1-2 tablets) every 4 –
/acetaminophen 500mg 10-30 minutes 0.5-1 hour 4–6 hours Oral dose related respiratory depression. Excess
6 hours. Maximum 8
(Vicodin) acetaminophen can cause hepatotoxicity. Do
tablets/day
not exceed 4gm acetaminophen/day.

Drowsiness, sedation, lightheadedness,

Hydromorphone 30 minutes 1.5-2 hours 4 hours Oral D: 2 mg every 3-6 hours dizziness, nausea/vomiting, constipation,
dose related respiratory depression.

Drowsiness, sedation, lightheadedness,

D: 5-20mg every 6-8
Methadone 30-60 minutes 1.5-2 hours 6 hours2 Oral dizziness, nausea/vomiting, constipation,
hours
dose related respiratory depression.

Morphine, immediate Drowsiness, sedation, lightheadedness,

D: 10-30 mg every 4
release 30-60 minutes 1-2 hours 4-5 hours Oral dizziness, nausea/vomiting, constipation,
hours
(MSIR) dose related respiratory depression.

Drowsiness, sedation, lightheadedness,

D: Give half the total
dizziness, nausea/vomiting, constipation,
Morphine, sustained daily dose of MSIR every
dose related respiratory depression. Sustained
release N/A3 3-8 hours 8-12 hours Oral 12 hours; or give 1/3 the
release formulations not for acute pain relief.
(MS Contin) total daily dose of MSIR
Immediate release products should be used
every 8 hours.
for breakthrough pain.

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UCLA Pharmaceutical Services
Pain Management Medications - Dosing and Pharmacodynamic Chart

Onset of Duration of Route/Rate of

Medication Peak Effect1 Dose (D) Comments
action Action1 Administration

Drowsiness, sedation, lightheadedness,

Oxycodone, immediate D: 5-15 mg every 4-6
- 1-1.5 hours 3-4 hours Oral dizziness, nausea/vomiting, constipation,
release hours
dose related respiratory depression.

Drowsiness, sedation, lightheadedness,

dizziness, nausea/vomiting, constipation,
D: give half the total daily
Oxycodone, sustained dose related respiratory depression. Sustained
N/A3 3 hours 12 hours Oral dose of immediate release
release (Oxycontin) release formulations not for acute pain relief.
oxycodone every 12 hours
Immediate release products should be used
for breakthrough pain

Drowsiness, sedation, lightheadedness,

Oxycodone 5mg / dizziness, nausea/vomiting, constipation,
D: 2.5-10mg oxycodone
acetaminophen 325mg - 1-1.5 hours 3-6 hours Oral dose related respiratory depression. Excess
every 6 hours.
(Percocet 5mg/325mg) acetaminophen can cause hepatotoxicity. Do
not exceed 4gm acetaminophen/day.

Drowsiness, sedation, lightheadedness,

dizziness, nausea/vomiting, dose related
Propoxyphene 65mg/ D: 1 tablet every 4 hours,
15-60 minutes 2 hours 4-6 hours Oral respiratory depression. Excess
acetaminophen 650mg maximum 6 tablets/day
acetaminophen can cause hepatotoxicity. Do
not exceed 4gm acetaminophen/day.
1. These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age.
2. Methadone duration of action prolonged with repeat dosing.
3. Sustained release formulations not for acute pain relief. Immediate release products should be used for breakthrough pain

2/10/03
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UCLA Pharmaceutical Services
Pain Management Medications - Dosing and Pharmacodynamic Chart

Onset of Duration of Route/Rate of

Medication Peak Effect1 Dose (D)2,3 Comments
action Action1 Administration
Parenteral Medications

D: (IV/SC) 1-10mg every Respiratory depression, tachycardia,

IV: 20 min
IV: 4-6 min Give over 4-5 2-4 hours bradycardia, nausea, vomiting, hypotension,
SC: 50-90 min
Morphine 4-5 hours minutes; may be miosis, dizziness, drowsiness, sedation,
IM: 10-30 min diluted to 4-5ml D: (IM) 5-20mg every 4 biliary or urinary tract spasm, histamine
IM: 30-60min
hours release

D: (IV) 0.2-1 mg every 3

hours Respiratory depression, tachycardia,
IV:15-30 min IV: 2-3 hrs
Hydromorphone IV: administer bradycardia, nausea, vomiting, hypotension,
IM: 10-15 min
(Dilaudid) slowly D: (SC/IM) 1-2 mg every miosis, dizziness, drowsiness, sedation,
IM: 30-60 min IM: 4-5 hrs
4-6 hours biliary or urinary tract spasm

Respiratory depression, tachycardia,

bradycardia, nausea, vomiting, hypotension,
miosis, dizziness, drowsiness, sedation,
Meperidine IV: 1 minute IV: 5-7 mins Give over 4-5
biliary or urinary tract spasm, histamine
(Demerol) 2-4 hours minutes; may D: 50-100mg
release
least preferred agent IM: 10-15 min IM: 30-50 min dilute to 4 - 5ml
**Administration with MAOIs may lead
to fatal drug interaction - Avoid MAOIs
within the last 15 days**

1. These parameters may be affected by the dose of the drug and/or the patient’s physical status, underlying pathology, body size, weight and age.
2. IM route of administration should be avoided
3. Doses at the lower or upper limits should prompt patient reassessment (e.g., step down to oral agents or increase to continuous infusion, PCA, etc.)

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Pain Management Medications - Dosing and Pharmacodynamic Chart

Patient Controlled Analgesia - Intravenous

Medication Route Comments
Opiates - PCA IV (PCA) Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, miosis, dizziness,
(morphine, fentanyl, drowsiness, sedation, biliary or urinary tract spasm, histamine release
hydromorphone)

Patient Controlled Analgesia – Epidural

Medication
Local anesthetics + Opiates –
epidural, PCEA
(bupivacaine or ropivacaine +
fentanyl, morphine, or hydro-
morphone)
Route Comments
Epidural Respiratory depression, tachycardia, bradycardia, nausea, vomiting, hypotension, orthostasis, miosis,
(PCEA) dizziness, drowsiness, sedation, urinary retention, histamine release/pruritus
Local anesthetics may cause CNS excitation or depression with excessive doses or inadvertant
intravascular administration (e.g., catheter migration).

Inadvertant intrathecal administration will cause decreased sensation in buttocks, paresis of legs, or
absent knee jerk within a few minutes.

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Pain Management Medications - Dosing and Pharmacodynamic Chart

Naloxone (Narcan®) Administration

Indication Route/Rate of Dose Comments
Administration
Mild – Moderate Respiratory Depression secondary Dilute 1ml (0.4mg) IV: 0.5ml (=0.02mg) IVP Any patient receiving opioids for more than
to opiate treatment (not in extremus) naloxone in 9ml q 2 minutes 7 days will be sensitive to antagonists (i.e.,
normal saline (total naloxone); the dose MUST be diluted and
volume = 10ml ). carefully titrated to avoid precipitation of
May be given IV acute withdrawal, severe pain, or seizures.
push (preferred), IM, Whenever naloxone is administered
or subcutaneously immediate and continued reassessment is
required.
Severe Respiratory Depression – Respiratory arrest IV push (preferred) IV: 0.4mg – 2mg IV q 2 For severe, life-threatening situations
secondary to opiate treatment May be given IM or minutes; if no response naloxone is administered undiluted and
subcutaneously after 10mg reassess cause immediately. Notify physician. Whenever
naloxone is administered immediate and
continued reassessment is required.

2/10/03
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