1. Pain Management at the End of Life
APPENDIX A: TYPES OF PAIN (GRID)
SOMATIC VISCERAL
ACUTE
CHRONIC

2. Pain Management
APPENDIX B: DOSING INFORMATION
NON-OPIOIDS ANALGESIA DOSING INFORMATION*
Medication Name Route Usual Dosing Recommended
Maximum Dose
Acetaminophen (Tylenol®, plain and extra PO, PR 325-650 mg q 4 hr or PRN 650mg q 4 hr
strength) 4000mg/24 hr
Aspirin Products Acetylsalicylic acid (ASA) PO, PR 325-650 mg q 4 hr routinely or PRN 650 mg q 4 hr
(salicylic acid derivative); various brands of 5000 mg/24 hr
aspirin
Celecoxib (Celebrex®)), cox-2 selective PO 100-200 mg BID 200 mg BID
400 mg/24 hr
Chlorine Magnesium Trisalicylate (Trilisate®), PO 1000-1500 mg q 12 hr or 1500 mg q 8 hr
salicylic acid derivative 500 – 1000 mg q 8 hr 4500 mg/24 hr
Diclofenac PO, PR IR IR: 50-75 q6-8 hr 50 mg q 6 hr
(Cataflam®, Voltaren®), acetic acid derivative
PO SR SR: 75-100 mg q 8-12 hr 75 mg PO q 8 hr
225mg/24 hr
Diflunisal (salicylic acid derivative) Dolobid® PO 250-500 mg q 8-12 hr 500 mg q h
1500 mg/24hr
Etodolac (Lodine®), acetic acid derivative PO IR 200-500 mg q 6-12 hr 1200 mg/24 hr
PO SR 400-600 mg q 12 hr 1200 mg/24 hr
Flurbiprofen (various trade names), propionic PO 50-100 mg q 12 hr 200-300 mg/24 hr
acid derivative
Ibuprofen (Motrin®, Advil®), propionic acid PO 200-800 mg q 6-8 hr 800 mg q 6 hr
derivative 3200 mg/24 hr
Indomethacin (Indocin®), indole PO IR 25-75 mg q 8-12 hr 50 mg q 6 hr
PO SR 75 mg q 12-24 hr 200 mg/24 hr
PR 50 mg q 6 hr 200 mg/24 hr
Ketoprofen (Orudis®), propionic acid derivative PO 25-50 mg q 6-8 hr 150 mg/24 hr
Ketorolac (Toradol®), acetic acid derivative PO 20 mg initially followed by 10 mg QID PO: 40 mg/24 hr
(Not to exceed 5 days
combined PO/IM/IV)
IM single dose 60 mg or 30 mg q 6 hr IM: 120 mg/24 hr
IV single dose 30 mg or 15 mg q 6 hr IV: 120 mg/24 hr
Nabumetone (Relafen®) PO 1000-2000 mg q 12-24 hr 1000 mg q 12 hr
2000 mg/24 hr
Naproxen (Naprosyn®) propionic acid derivative PO 250-500 mg q 8-12 hr 500 mg q 8 hr
1500 mg/24 hr
Piroxicam (Feldene®), oxicam PO 10-20 mg q 12-24 hr 20 mg q 12 hr
1

3. Pain Management
NON-OPIOIDS ANALGESIA DOSING INFORMATION*
Medication Name Route Usual Dosing Recommended
Maximum Dose
40 mg/24 hrs
Salsalate (Disalcid®), salicylic acid derivative PO 1000-1500 mg BID 3000 mg/24 hr
Sulindac (Clinoril ®), indole PO 150 mg q 12 hr 200 mg q 12 hr
400 mg/24 hr
* Dosing information reflects common medications and is not intended to be all inclusive.
OPIOIDS DOSING INFORMATION*
Medication Name Route Usual Starting Onset Peak Duration Half Life
Dose (Minutes) (Minutes) (Hours) Recommended Maximum
Dose (RMD)
Morphine PO/SL 15-30 mg q 4 hr; 30-60 60-120 3-6 Half life = 2-4 hrs
2.5-5 mg q 4 hr for RMD = No ceiling- based
elderly on patient report of pain
Controlled 15-30 mg q 4 hr 30-60 8-12 control or presentation of
release unmanageable side effects
Rectal 10-20 mg q 4 hr 30-60 20-60 4-5
IV 2.5-15 mg q 4 hr 5-10 20 3-4
SC 10 mg q 4 hr 10-20 50-90 3-4
IM 10 mg q 4 hr 10-20 30-60 3-4
Morphine extended PO 30 mg q 4 hr - - 24 RMD = 1600 mg/day due
release (Avinza®, to potentially serious renal
Kadian®) toxicity associated with
funaric acid
Codeine PO 30-60 mg q 4 hr 30-60 60-90 3-4 Half life = 2-4 hrs
SC 15-60 mg q 4 hr 10-20 Unknown 3-4 RMD = 600 mg/24 hrs; in
IM 15-60 mg q 4 hr 10-20 30-60 3-4 combination medications,
Combination 1-2 tablets PO q 4 limited to 12 tables per 24
medication hr ATC or PRN hrs (4 g acetaminophen
per 24 hrs)
2

4. Pain Management
OPIOIDS DOSING INFORMATION*
Medication Name Route Usual Starting Onset Peak Duration Half Life
Dose (Minutes) (Minutes) (Hours) Recommended Maximum
Dose (RMD)
Fentanyl Transdermal Therapy initiated 12-16h 24 hours 48-72 Half life = 13-24 hrs
patch with the 25 mcg/hr RMD = limited only by
(Duragesic system, dosage need and adverse effects
Patch®) adjusted as needed
and tolerated. Each
system may be
worn for 72 hrs
Transmucosal 200 mcg 15 45 1
(Actiq®)
IV 2 mcg 1h 1-5 3-5 0.5-4
IM 50-100 mcg q 4 hr 7-15 10-20 0.5-4
Hydrocodone PO 1-2 tabs q 4-6 h or 30-60 60-90 4-6 Half life = 4 hrs
(Vicodin® - various prn RMD = limited to 4 g
combinations with acetaminphen/24 hrs
acetaminophen)
Hydromorphone PO 1 mg titrate as 15-30 30-90 3-4 Half life = 2-3 hr
(Dilaudid®) needed q 4 hr ATC RMD = limited only by
q 1 hr prn need and adverse effects
SC 1 mg q 3 h ATC; q 10-20 30-90 3-4
30 min prn
IM 1 mg q 3 hr ATC; 10-20 30-90 3-4
30 min prn
IV via infusion 1mg q 1 hr + 5 10-20 3-4
breakthrough q 30
min prn
Rectal 15-30 30-90 3-4
3

5. Pain Management
OPIOIDS DOSING INFORMATION*
Medication Name Route Usual Starting Onset Peak Duration Half Life
Dose (Minutes) (Minutes) (Hours) Recommended Maximum
Dose (RMD)
Methadone PO 5 mg q 8 hr; can be 30-60 60-120 4-8 Half life = 12-190 hr
dependent on RMD = limited only by
conversion from need and adverse effects
another drug; titrate
dose q 7 days due
to delayed
clearance
SC 2.5-10 mg q 4 hr 10-20 60-120 4-8
IM 2.5-10 mg q 4 hr 10-20 60-120 4-8
Oxycodone IR PO 2.5-5 q 4 hr ATC 30-60 60-90 3-4 Half life = 2-4 PO, 4.5 CR
q 1 hr prn RMD = limited only by
CR PO 10 mg q 12 hr 30-60 90-180 8-12 need and adverse effects
PR (not 5-↑ q 4 h ATC 30-60 30-60 3-6
available in US) q 1 h prn
Propoxyphene PO 65 mg q 4 hr 30-60 60-90 4-6 Half life = 6-12 hr
hydrochloride (intermittent dosing RMD = 390 mg/24 hr;
(Darvon®) recommended) Darvocet N 100 contains
acetaminophen and has
RMD of 4 g/24 hr;
Not recommended in
chronic pain, in the elderly
or end-of-life care
* Dosing information reflects common medications and is not intended to be all inclusive.
4

6. Pain Management
MIXED AGONIST-ANTAGONISTS DOSING INFORMATION*
Medication Name Route Usual Starting Dose Onset Peak Duration Half Life
(Minutes) (Minutes) (Hours) Recommended Maximum
Dose (RMD)
Buprenorphine SL 0.3 mg q 6 hr 5 30-60 Unknown Half life = 2-3 hr
(Buprenex®) IV 5 10-20 3-4 RMD = 0.3 mg q 4 hr, IM
IM 10-20 30-60 3-6 only 0.6 mg q 6 hr
Butorphanol IV 2 mg q 3-4 hr 5 10-20 3-4 Half life = 3-4
(Stadol®) IM 10-20 30-60 3-4 RMD = ceiling for
Nasal spray 5-15 60-90 3-4 respiratory depression is
reached at 30-60 µg/kg
Nalbuphine IV 10 mg q 3-4 hr 5 10-20 3-4 Half life = 5 hr
(Nubain®) SC < 15 Unknown 3-4 RMD = respiratory ceiling
IM < 15 30-60 3-4 and analgesia ceiling
reached at 30 mg
Pentazocine PO 50-100 mg 1 3-4 hr 15-30 60-80 3-4 Half life = 2-3 hr
(Talwin®) RMD = 600 mg/24 hr of
little value in pain
management; should not
be considered for end-of-
life care
* Dosing information reflects common medications and is not intended to be all inclusive.
TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION*
Medication Route Usual Starting Usual Effective Dosing Schedule Uses
Name Dose Dose Range
Amitriptyline PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Migraines and other headaches,
(Elavil®) (e.g., q 8 h); titrate every 3-4 days arthritis, chronic low back pain,
to the effective dose fibromyalgia, painful diabetic
polyneuropathy, chronic facial pain
Imipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Arthritis, headache, painful diabetic
(Tofranil®) (e.g., q 8 h); titrate every 3-4 days polyneuropathy
to the effective dose
5

7. Pain Management
TRICYCLIC ANTIDEPRESSANTS DOSING INFORMATION*
Medication Route Usual Starting Usual Effective Dosing Schedule Uses
Name Dose Dose Range
Doxepin PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Co-existent pain and depression,
(Sinequan®) (e.g., q 8 h); titrate every 3-4 days headache, low back pain
to the effective dose
Clomipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Varied neuropathic pains,
(Anafranil®) (e.g., q 8 h); titrate every 3-4 days idiopathic pain
to the effective dose
Desipramine PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Post-herpetic neuralgia, painful
(Norpramine®) (e.g., q 8 h); titrate every 3-4 days diabetic neuropathy
to the effective dose
Nortriptyline PO 10-25 mg/day 50-150 mg/day HS, some pts prefer divided doses Mixed neuropathic pains
(Aventyl®, (e.g., q 8 h); titrate every 3-4 days
Pamelor®) to the effective dose
* Dosing information reflects common medications and is not intended to be all inclusive.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) ANTIDEPRESSANTS DOSING INFORMATION*
Medication Name Route Usual Starting Dose Usual Effective Dosing Schedule Uses
Dose Range
Fluoxetine PO 10-20 mg/day 20-40 mg/day QID
(Prozac®)
Paroxetine (Paxil®) PO 20 mg/day 20-40 mg/day QID Diabetic neuropathy
Sertraline (Zoloft®) PO 50 mg/day 150-200 mg/day QID or BID
* Dosing information reflects common medications and is not intended to be all inclusive.
6

8. Pain Management
ANTICONVULSANTS DOSING INFORMATION*
Medication Name Route Usual Starting Dose Usual Effective Dose Dosing Schedule Uses
Range
Carbamazepine PO 200 mg/day 600-1200 mg/day; titrate q 6-8 hr Trigeminal neuralgia,
(Tegretol®) weekly to desired effect; post-herpetic neuralgia,
do not increase painful diabetic
because the 200 mg is neuropathies,
ineffective – increase glossopharyngeal
because neuralgia, paraxysmal
carbamazepine pain in Multiple
autoinduces it’s own Sclerosis, stabbing
metabolism pains after laminectomy,
lancinating pains from
cancer, phantom limb
pain
Phenytoin (Dilantin®) PO 200 mg/day in divided 200-400 mg/day in q 8 hr; q 24 if extended Painful diabetic
doses; loading dose divided doses preparation such as neuropathies, trigeminal
may be used (e.g., 500 Kapseals neuralgia, paroxysmal
mg x 2) pan in post-herpetic
IV 500-1000 mg/day Variable and unknown Variable and unknown neuralgia,
Gabapentin PO 100-300 mg/day Dose 300-3600 mg/day q 8 hr All types of neuropathic
(Neurontin®) may be increased daily pain, reflexive
sypathetic dystrophy,
HIV-related neuropathy,
post-herpetic neuralgia
Clonazepam PO 0.5 mg/day 0.5 mg/day q 8 hr Trigeminal neuralgia,
(Klonopin®) paroxysmal post-
laminectomy pain, post-
traumatic neuralgia,
lancinating phantom
limb pain,
Valproic Acid PO: Divalproex 250 mg/day 1500-300 mg/day q 8 hr Trigeminal neuralgia,
(Depakene®) sodium post-herpetic neuralgia
(Depakote®)
IV: Valproate Max 20 mg/kg over 5 Variable and unknown Variable and unknown
sodium min.
(Depacon®)
7

9. Pain Management
ANTICONVULSANTS DOSING INFORMATION*
Medication Name Route Usual Starting Dose Usual Effective Dose Dosing Schedule Uses
Range
Baclofen (Lioresal®) PO 5 mg q 8 hr 30-200 mg/day q 8 hr Spasticity, lancinating
pain, shooting pain,
paroxysmal neuropathic
pain, trigeminal
neuralgia
* Dosing information reflects common medications and is not intended to be all inclusive.
CORTICOSTEROIDS DOSING INFORMATION*
Medication Name USUAL STARTING DOSE Dose equivalents
Dexamethasone 0.75-9 mg PO QD divided BID, TID or QID, higher doses based on situation 2 mg
(Decadron®)
Methylprednisolone 8 mg
Prednisone 10 mg
* Dosing information reflects common medications and is not intended to be all inclusive.
LOCAL ANESTHETIC AGENTS DOSING INFORMATION*
Medication ROUTE USUAL STARTING DOSE – USUAL EFFECTIVE DOSE DOSING SCHEDULE ONSET
Name Based on 4 hr dosing RANGE
Mexiletine PO 150 mg/day 900-1200 mg/day Every 8 hrs
(Mexitil®) Can increase dose every 3
days as tolerated
Tocainide PO 400 mg/day 1200-1600 mg/day Q8h
(Tonocard®)
Lidocaine® IV brief infusion 2-5 mg/kg over 20-30 min - - 15-30 min
IV or SC 1 mg/kg/h - -
continuous
infusion
* Dosing information reflects common medications and is not intended to be all inclusive.
8

10. Pain Management
PSYCHOSTIMULANTS DOSING INFORMATION*
Medication Name ROUTE USUAL STARTING DOSE – Based on USUAL EFFECTIVE DOSING SCHEDULE
4 hr dosing DOSE RANGE
Caffeine PO 50-150 mg/day per dose of opioid or
NSAID
Dextroamphetamine PO 2.5 mg/day after breakfast 10-30 mg/day BID, avoid evening dosing, may
(Dexadrine®) increase titration by 50% per day to
achieve desired effects
Methylphenidate PO 2.5 mg/24 hr 10-30 mg/24 hr BID – one tablet at breakfast and one
(Ritalin®) tablet at lunch, avoid evening dosing,
may increase titration by 50% per day
to achieve desired effects; also
available SR
* Dosing information reflects common medications and is not intended to be all inclusive.
9