and ibuprofen may limit the administration of the combination products. Oxycodone and hydromorphone as single-ingredient products may be alternatives when maximum dose limits prevent continued use of combination products. 91 Serious adverse effects (e.g., excessive sleepiness, difficulty breastfeeding, or respiratory depression) could be fatal in the infant if codeine or tramadol is used in breastfeeding women. 92 The CDC recommends avoiding short-acting (or immediate-release) opioids as single agents for treating acute pain in opioid-naïve patients. Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. In general, long-acting opioids or extended- release formulations should be avoided for acute pain
treatment. In most situations, the duration of opioid analgesic treatment for acute pain should not exceed 3 days, and more than 7 to 10 days is rarely required. 91 A review of current guidelines or online references provides updated recommendations for managing acute pain following dental or surgical procedures or common emergency medical conditions. See, for example, recommendations developed by the University of Michigan (2022) at https:// opioidprescribing.info/ Assessment of acute or chronic pain should be multidimensional. Consideration should be given to several domains, including the physiological features of pain and its contributing factors, with physicians and other clinicians assessing patients for function, quality of life, mental health, and emotional health. In addition to a complete medical and medication history typically obtained at an office visit, document pain intensity, location, duration, and factors that aggravate or alleviate pain. 99
Table 10: Oral Opioids for Acute Pain in Opioid-Naïve Adults Medication Available Oral Strengths Moderate Pain
Severe Pain Clinical Considerations
Codeine- acetaminophen • Tylenol with codeine
Tablets : 15 mg/300 mg 30 mg/300 mg 60 mg/300
1 to 2 tablets every 4 hours as needed for pain
Increasing doses do not improve efficacy and result in more adverse effects. Limit codeine to no more than 60 mg/dose. Do not exceed codeine 360 mg/24 hours. The maximum dose of acetaminophen is 4,000 mg/ day (from all sources). Metabolism of codeine to morphine (its active form) varies between patients; drug interactions may affect response. Dosage limited by acetaminophen maximum dose (4,000 mg/day [from all sources]).
Hydrocodone- acetaminophen
Tablets : 2.5 mg/325 mg 5 mg/300 mg 5 mg/325 mg 7.5 mg/300 mg 7.5 mg/325 mg 10 mg/300 mg 10 mg/325 mg Oral solution:
1 to 2 tablets PO every 6 hours as needed
1 to 2 tablets PO every 4 to 6 hours as needed
• Lorcet • Lortab • Norco • Vicodin
7.5 mg/325 mg per 15 mL 10 mg/300 mg per 15 mL 10 mg/325 mg per 15 mL
Oxycodone- acetaminophen*
Tablets: 2.5 mg/325 mg 5 mg/325 mg
1 to 2 tablets PO every 6 hours as needed
1 to 2 tablets PO every 4 to 6 hours as needed
Dosage limited by acetaminophen maximum dose (4,000 mg/day [from all sources]).
• Endocet • Percocet • Primlev • Roxicet • Xolox
7.5 mg/325 mg 10 mg/325 mg Oral solution: 5 mg/325 mg per 5 mL
Book Code: TN24CME
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