ANALGESICS

Opioid Analgesics for adults Class II

• titrate to individual response

• dose does not apply to patients with renal or hepatic insufficiency

• Morphine
o Immediate release (MSIR): tab 15, 30 mg. Dose: 5-30 mg q2-6h
o MS Contin, Oramorph SR: Tab: 15, 30, 60, 100 mg. Dose 15-120 mg q12
o Roxanol SR: 30 mg. Dose 30 mg q8 prn
o Usual parenteral dose: 5-10 mg q4-5h

• Hydromorphone (Dilaudid)
o Tab: 2, 4, 8 mg. Dose: 2-6 mg po q3-4h
o 3 mg rectal suppository
o Usual parental dose: 1.5 mg q3-4h

• Levorphanol (Levo-Dromoran)
o Oral: 4 mg q6-8h
o Usual parental dose: 2 mg q6-8h

• Meperidine (Demerol)
o Oral dose not recommended
o Usual parenteral dose: 50-100 mg q3h, extreme caution if patient has renal failure,
accumulation of active metabolite may cause CNS excitement & seizure

• Methadone (Dolophine)
o Comes in 5, 10 mg
o Oral: 5-20 mg q6-8h
o Usual parenteral dose: 10 mg q6-8h

• Oxycodone
o Roxicodone: soln: 5 mg/5ml, 20 mg/ml, tab 5 mg. Dose: 5-10 mg q3-4h
o Oxycontin controlled release tab: 10, 20, 40, 80, 160 mg. Dose variable
o Parenteral: not available

• Oxymorphone (Numorphan)
o Oral: not available
o Usual parenteral dose: 1 mg q3-4h
Oral Opioid Analgesics Class III & IV

Hydrocodone (HC) + Acetaminophen (APAP)

Watch for overdose of Acetaminophen, especially in patient with liver dysfunction

Norco HC 10 mg + APAP 325 mg

HC 2.5 mg + APAP 500 mg

Lortab 2.5/500
Dose: 1-2 tab q4 prn

Anexia 5/500, Hydrocet, Lortab

HC 5 mg + APAP 500 mg
5/500, Vicodin, Zydone

Anexia 7.5/650, Lortab 7.5/500, HC 7.5 mg + APAP 500 or 650 mg

Vicodin ES Dose: 1-2 tab q4 prn

HC 10 mg + APAP 500 or 650 mg

Lortab 10/500, Vicodin HP
Dose: 1 tab q4 prn

HC 2.5 mg + APAP 120 mg/ 5 ml

Lortab elixir
dOSE: 15 ml q 4 prn

Hydrocodone (HC) + Aspirin or Ibuprofen

Watch out for GI side effects

Lortab ASA HC 5 mg + ASA 500 mg

Hydrocodone 7.5 mg + ibuprofen 200 mg

Vicoprofen
Dose: 1-2 tab q4 prn

Codeine Compounds
15, 30, 60 mg
Codeine Sulfate
Dose: 15-60 mg q 4 prn tab

#3: ASA 325 mg, codeine 30 mg

Empirin w codeine
#4: ASA 325 mg, codeine 60 mg

APAP 300 mg plus

• #2: 15 mg Codeine
Tylenol w codeine • #3: 30 mg Codeine
• #4: 60 mg Codeine
• Dose: 30- 60 mg of codeine q 4 prn

APAP 325 mg, codeine 30 mg, bultabital 50 mg, caffeine 40

Fioricet w codeine mg
Dose: 1-2 cap q4 prn, max 6 cap/day
 aspirin 325 mg, codeine 30 mg, bultabital 50 mg, caffeine
Fiorinal w codeine 40 mg
Dose: 1-2 cap q4 prn, max 6 cap/day

Carisoprodol 200 mg, ASA 325 mg, codeine 16 mg

Soma compound w codeine
Dose: 1-2 tab qid

dihydrocodeine 16 mg, aspirin 356.4 mg, caffeine 30 mg

Synalgos-DC
Dose: 2 cap q4 prn

Opiod Agonist-Antagonist and partial Agonist

Darvon Propoxyphene 65 mg 1 tab q 4 prn

Darvon N Propoxyphene 100 mg 1 tab q4 prn

Propoxyphene 50 mg, APAP 325

Darvocet N50 2 tab q4 prn
mg

Propoxyphene 100 mg,

Darvocet N100 1 tab q4 prn
acetaminophen 650 mg

Propoxyphene 65 mg, ASA 389

Darvon compound - 65 1 cap q4 prn
mg, caffeine 32.4 mg

propoxyphene 65 mg,
Wygesic 1 tab q4 prn
acetaminophen 650 mg

pentazocine 25 mg, acetaminophen

Talacen 1 q 4 prn
650 mg

Talwin compound pentazocine 12.5 mg, ASA 325 mg 2 qid prn

pentazocine 25 mg, naloxone 0.5

Talwin NX 1 cap q3 prn
mg
 OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY
EQUIANALGESIC POTENCY*
IM or SC
Nonproprietary (Trade) Name ORAL dose
Dose
Morphine Sulfate 10 mg 40-60 mg
Hydromorphone HCl
1.3-2 mg 6.5-7.5 mg
(DILAUDID)
Oxymorphone HCl
1-1.1 mg 6.6 mg
(Numorphan)
Levorphanol tartrate (Levo-
2-2.3 mg 4 mg
Dromoran)
Meperidine HCl (Demerol) 75-100 mg 300-400 mg
Methadone HCl (Dolophine) 10 mg 10-20 mg
Muscle relaxant
Generic Formulations
(Brand name) Usual Dose & Notes

Tab: 350 mg
Dose: 350 mg tid
Carisoprodol (Soma) Metabolized to meprobamate, has been frequently associated
with drug-seeking behavior and dependency.
Abrupt cessation may produce withdrawal symptoms

Carisoprodol 200 mg + aspirin 325 mg tab

Soma compound
Dose: 1-2 tab qid

Soma compound w Carisoprodol 200 mg + aspirin 325 mg + codeine 16 mg

codeine Dose: 1 - 2 tab q6

tab: 10 mg
Cyclobenzaprine Dose: 10 mg tid
(Flexeril) Use with caution in patients with urinary retention and closed-
angle glaucoma

Chlorzoxazone
Caplet: 500 mg
(Parafon forte, Paraflex
Dose: 500 mg tid to qid
)

Tab: 400 mg
Dose: 800 mg tid to qid
Metaxolone (Skelaxin)
May cause hemolytic anemia and elevated hepatic serum
transaminases

Methocarbamol tab: 500, 750 mg

(Robaxin) Dose: 750 to 1500 tid

Methocarbamol tab: Methocarbamol 400 mg + aspirin 325 mg

(Robaxisal) Dose: 2 tab q6

Ext release tab: 100 mg

dose: 1 tab bid
Orphenadrine (Norflex)
Use with caution in patients with urinary retention and closed-
angle glaucoma

Orphenadrine 25 mg + aspirin 385 mg + caffeine 60 mg

Orphenadrine
dose: 1-2 tab tid
(Norgesic)
Caution: see Orphenadrine

Orphenadrine 50 mg + aspirin 770 mg + caffeine 60 mg

Orphenadrine
dose: 1 tab tid
(Norgesic forte)
Caution: see Orphenadrine
,

Antidepressant: Selective Serotonin Reuptake Inhibitor (SSRI)

• Block reuptake of Serotonin, less effect on Histaminic and Muscuranic receptors.
• Effective for Depression, some may be effective for anxiety, post traumatic stress disorder,
obsessive compulsive disorder, eating disorders.
• Better tolerated than Tricyclics.
• All are taken once a day except fluvoxamine.
• Relapse rate high (30%), but respond well to dose increase.
• Adding Tricyclics is an alternative, Lithium may be helpful if there is bipolar in the family
• Reduced dopamine release secondary to serotonin actions on 5HT2 heteroreceptors can
aggravate Parkinsonism.
• Tremors and akathisia can occur. A few cases of tardive dyskinesia have been reported in
patients taking SSRI chronically.
• Sometimes alleviate migraine headaches, but can also cause exacerbations of migraines .
• Not effective in chronic pain as TCAs and nefazodone.
• SSRI should not be given to patients taking deprenyl for the risk of development of toxic
serotonin syndrome.
• Drugs that increase serotonin concentrations:
o MAOIs, tramadol (Ultram), sibutramine (Meridia), meperidine (Demerol),
sumatriptan (Imitrex)
• Serotonin syndrome:
o mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering,
tremor, diarrhea, incoordination, and fever. May be life-threatening.

Name
Formulation, Usual dose for depression, notes
(Brand)

• 10, 20, 40 mg, 10mg/5ml liquid

• Dose: 10-20 mg/day, may increase to 80 mg per day.
Fluoxetine • Half life 2-4 days, may be taken qod.
(Prozac) • Activating, usually taken in am, may be preferable in "lethargic"
depression

• 25, 50, 100 mg tab

• Dose: 50 mg qd, titrate up slowly to avoid nausea.
Fluvoxamine • Dose range 50-300 mg/day
(Luvox) • FDA indicated for OCD, available in Europe since 1983, effective for
depression

• 10, 20, 30, 40 mg tab, elixir 10 mg/5 ml (orange)

• Paxil CR: 12.5, 25, 37.5 mg
Paroxetine (Paxil, • Dose: 20 - 50 mg/day
Paxil CR) • Tends to be more sedating and constipating, probably because of its
anticholinergic activity.
 • 25, 50, 100 mg tab, elixir 100 mg/5 ml (menthol)
Sertraline • Dose: 50-200 mg/day
(Zoloft) • Neither activating nor sedating, may cause loose stool.

• Tab: 20, 40 mg (scored, can be broken in half), elixir 10 mg/5 ml

(peppermint)
Citalopram • Dose: 10 - 80 mg qd
(Celexa) • Less cytochrome P-450 enzyme inhibition. Low potential for drug
interactions.

• comes in 10, 20 mg
Escitalopram • dose: 10 mg qd
oxalate (Lexapro) • Single isomer of Citalopram

Dose for obsessive compulsive disorder may be higher.

Increasing dose further than above may not improve response rate for depression.
Antidepressant: Tricyclic/Tetracyclic/Dibenzoxapine
Name Formulations / Usual dose Notes

Amitriptyline Tab: 10, 25, 50, 75, 100, 150 mg

(Elavil) Dose: start low dose 10-25 mg hs, up to 300 mg hs Anticholinergic
side effects,
Doxepin Cap: 10, 25, 50, 75, 100, 150 mg very sedating
(Sinequan) Dose: start at low dose hs, up to 300 mg hs

Desipramine less
(Norpramine) Formulations: 10, 25, 50, 75, 100, 150 mg
sedating, less
Dose: start at 25 mg qd, to 300 mg qd. May have to take
anticholinergic
Nortriptyline in am
effect
(Pamelor)

Antidepressant: miscellaneous non-SSRI

• Tab: 50, 100, 150 mg
Dose: 25 to 50 mg hs, increase to 400 mg/day
Trazadone • Mostly a 5HT2 antagonist, often used as a hypnotic, very sedating
(Desyrel) • Elimination half-life of about 5 hours.
• Rarely cause pripiasm.

• Tab: 75, 100 mg

Dose: 75- 100 mg bid, up to 450 mg/day. For smoking cessation, start at
150mg/day. Always give bid.
• May cause agitation, insomnia, less anticholinergic side effect.
• Avoid if there is history of psychosis.
Bupropion • Dopamine reuptake inhibitor, makes it an initial choice for depressed patients
(Wellbutrin, with Parkinson's disease.
Zyban)
• May help to improve attention in brain damaged patients, attention deficit
disorder.
• Also used for smoking cessation.
• May increase risk for seizure, especially dose >450mg/day

• Tab: 100, 150, 200, 250 mg

Dose: 100 mg bid, up to 300 mg/day, reduce dose for elderly
• Both a serotonin reuptake inhibitor (SRI) and a 5HT2 antagonist
Nefazodone
• Rare cases of liver failure. The reported rate is one per 250,000 to 300,000
(Serzone)
patient-years.
• Watch for orthostatic hypotension.
• Drug interactions. Increase effect of Alprazolam, terfenadine, digoxin, Haldol
 etc.
• Trazadone is one of its metabolites.
• Alternative for patient unable to tolerate SSRI due to sexual dysfunctions.
• Reduces symptoms of fibromyalgia and may be useful for other forms of
chronic pain.

• Formulations: 37.5, 50, 75, 100 mg

XR: 37.5, 75, 150, 225 mg
• Effective in treating patients with Generalized anxiety disorder,
with or without depression.
• Dose: start at 37.5 mg qd to avoid nausea, jitteriness, up to 225 mg/day
Venlafaxine
(Effexor) • Inhibits reuptake of Serotonin, Norepinephrine; to a lesser extent dopamine.
• At doses > 200 mg per day, may increase blood pressure
• Onset of antidepressant activity may be more rapid.
• Discontinuation syndrome may occur with abrupt discontinuation, should be
tapered by reducing the daily dose by 75 mg at weekly intervals.

• Tablet: 15, 30, 45 mg

Dose: 15-45 mg per day
• Antagonizes 5HT2, 5HT3 and adrenergic alpha2 receptors
• May cause sedation, weight gain.
Nirtazapine
• No anticholinergic, adrenergic, and serotonin-related side effects
(Remeron)
• Has 5HT3 antagonism, useful for nausea and may have some antipsychotic
effects.
• Does not cause sexual dysfunction, orthostatic hypotension.