For Prescribers

Step 1 Medications:

Simple analgesics

1. Acetaminophen 650 mg Q6 hours (Max 3000 mg/day; max 2000 mg/day if liver disease or ≥ 3 alcoholic drinks/day).
2. NSAIDs: Try at least two (except in patients with renal impairment, peptic ulcer disease, or age > 65 ).
3. 1^st line: Naproxen 500 mg Q12 hours or 500 Q AM plus 250 BID (Max 1000 mg/24 hours).
4. 2^nd line:
5. Salsalate 1000 mg q8 hours or 1500 q 12h (Max 3000 mg/day).
6. Etodolac 300 mg every 8 hours or 500 mg every 12 hours (Max 1000 mg/day).
7. Ibuprofen 600 mg every 6 hours (Max 2400 mg/day).
8. Piroxicam 10mg once daily.

Complementary pain treatments

1. Yoga
2. Massage Therapy
3. Acupuncture

Topicals

1. 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

2. Capsaicin:

• Cream: 0.025% or 0.075%.  Apply cream 3-4x/day. It may take 8 wks for optimal pain relief.
• Patch: 8%.  Used in one 60-minute application daily

3. Bengay (Camphor 4%, menthol 10%, Methylsalicylate 30%): apply to affected area 3-4x/day.

4. Diclofenac:

• Gel: 1%, 2-4 g daily, 4x/day.
• Solution: apply 40 drops 4x/day

Step 2 Medications:

1. Gabapentin, titrate up to 900-1200mg TID.
2. Cyclobenzaprine 5-10mg QHSTID.
3. Venlafaxine, titrate up to 225mg QD.
4. Duloxetine (60 mg QD) and/or Pregabalin (300-450 mg/day divided BID).

Step 4 Medications:

Tricyclic Antidepressants (TCA): try at least two

1. *Amitriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mg if taking an SSRI/SNRI).
2.  Nortriptyline, start at 10-25 mg, titrate to 100 mg (max 50 mg if taking an SSRI/SNRI).

*Avoid TCA’s in older adults (65+ years) or in patients on tramadol

Step 5 Medications:

Mild Opioids

1. Tramadol (avoid combining with SSRI, SNRI, or TCA)
2. Start 25 mg BID or TID and titrate to 100 mg QID (Max 300 mg/day if age > 75; max 100 mg BID if eGFR < 30, max 50 mg BID if eGFR <10; max 50 mg BID if cirrhosis).
3. Use concurrent Acetaminophen, 500-650mg dosed with Tramadol TID-QID.

Step 6 Medications:
Opioids

Source: These recommendations are based on expert consensus.

All information is provided for educational purposes only. This information should not be used for the diagnosis or treatment of any health problem or disease. THIS INFORMATION IS NOT INTENDED TO REPLACE CLINICAL JUDGMENT OR GUIDE INDIVIDUAL PATIENT CARE in any manner.