Non-Opioid Treatment of Pain
When choosing pharmacological treatment for chronic pain, a combination of different types of non-opioid pain medications may be most effective. They may alleviate pain using different mechanisms in the pain pathway including peripheral and central nervous system.
Over-the-Counter Analgesics
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Acetaminophen 650 mg Q6 hours (Max 3000 mg/day; max 2000 mg/day if liver disease or ≥ 3 alcoholic drinks/day)
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Naproxen 500 mg Q12 hours or 500 Q AM plus 250BID (Max 1000 mg/24 hours)
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Ibuprofen 600 mg every 6 hours (Max 2400 mg/day)
NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)
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Meloxicam: 7.5 mg once daily
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Salsalate: 1000 mg q8 hours or 1500 q 12h (Max 3000 mg/day)
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Piroxicam : 20 mg orally once a day
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Celecoxib: 100 or 200 mg orally twice a day
Patients on an NSAID who are older than 65 or have a history of heart failure, liver disease, diabetes, or concurrent nephrotoxic drugs should have a creatinine test within the past 3 months of initiation and 2-4 weeks thereafter.
Antidepressants
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Amitriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mgif taking an SSRI/SNRI)*
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Nortriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mg if takingan SSRI/SNRI)*
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Venlafaxine, start at 37.5 mg, titrate as needed up to 225mg QD
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Duloxetine (60 mg QD) and/or Pregabalin (300-450 mg/day divided BID)
*Caution using Tricyclic Antidepressants in older adults (65+ years) or in patients on tramadol Patients receiving a tricyclic antidepressant (TCA) equivalent to 100 mg amitriptyline or 50 mg nortriptyline or 75 mg venlafaxine should have well-controlled blood pressure at baseline, and at recheck within the first two weeks. TCAs should not be used in patients 65 years or older.
Topicals
Capsaicin
- Cream: 0.025% or 0.075%. Apply cream 3-4x/day. It may take 8 weeks for optimal pain relief
- Patch: 8%. Used in one 60-minute application daily
Diclofenac
- Gel: 1%, 2-4 g daily, 4x/day.
- Solution: apply 40 drops 4x/day
Lidocaine
- Cream: apply 4x/day or as needed, max 300 mg/day
- Patch: Apply up to 3 patches daily at a time, use up to 12 hours within 24 hr period
Methyl Salicylate
- Apply to affected area 3-4x/day.
Anti-Epileptics
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Gabapentin, titrate up to 900-1200mg TID
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Pregabalin: 50 mg three times a day (150 mg/day)*
*dose may be increased within 1 week based on efficacy and tolerability
