| Medication/dosing | Pain level | Best use | Risk | Comments | Cost* |
|---|---|---|---|---|---|
| Acetaminophen | |||||
| Orally or rectally: 325 to 1,000 mg every 4 to 6 hours IV: ≥ 50 kg, 650 mg every 4 hours or 1,000 mg every 6 hours; < 50 kg, 12.5 mg per kg every 4 hours or 15 mg per kg every 6 hours Maximum: 75 mg per kg per day, not to exceed 4,000 mg per day | Mild to moderate | Mild osteoarthritis Generalized headache Ankle sprain | Hepatotoxicity | Well tolerated First-line treatment in patients with renal and hepatic impairment and cardiovascular disease ≤ 2,000 mg per day in patients with advanced hepatic disease and severe alcohol use disorder May be combined with NSAIDs for postoperative pain | Tablet: $3 ($5) Suppository: — ($12) IV: NA |
| Nonselective NSAIDs | |||||
| Ibuprofen: 200 to 400 mg every 6 to 8 hours Maximum: 1,200 mg per day | Mild to moderate | Migraine Low back pain Dysmenorrhea Renal colic Postoperative pain | Cardiovascular Gastrointestinal Renovascular Bronchospasm (aspirin) | Anti-inflammatory effects Consider adding proton pump inhibitor or switching to a selective COX-2 NSAID to decrease gastrointestinal risk May have a ceiling analgesic effect | $5 ($10) |
| Naproxen: 250 mg every 6 to 8 hours or 500 mg every 12 hours Maximum: 1,000 mg per day | $10 ($200) | ||||
| Diclofenac: 50 mg every 8 hours Maximum: 150 mg per day | $10 ($750) | ||||
| Ketorolac Orally: 10 mg every 4 to 6 hours IM: 30 to 60 mg as a single dose or 15 to 30 mg every 6 hours IV: 10 to 15 mg every 6 hours Maximum: oral 40 mg per day; IM/IV 120 mg per day | Tablets: $20 (—) Syringes: $15 (NA) | ||||
| Meloxicam: 7.5 to 15 mg per day Maximum: 15 mg per day | $10 ($500) | ||||
| Selective COX-2 NSAIDs | |||||
| Meloxicam: 7.5 mg per day | Mild to moderate | Migraine Low back pain Dysmenorrhea Renal colic Postoperative pain | Cardiovascular Renovascular | More expensive than nonselective NSAIDs Celecoxib has a U.S. Food and Drug Administration boxed warning for increased risk of cardiovascular disease | $10 ($300) |
| Celecoxib (Celebrex): 100 to 200 mg per day | $20 ($225) | ||||
| Acetaminophen plus NSAID combinations | |||||
| See individual medications | Mild to moderate May continue use for severe pain | Pain refractory to either agent alone Postoperative pain | See individual medications | Combinations have superior effectiveness vs. single agents Effective for postoperative pain Combining medications has lower risk of adverse effects than high doses of single agents | See individual medications |
| Opioid plus acetaminophen or NSAID combinations | |||||
| Hydrocodone/acetaminophen: 2.5 mg/325 mg to 10 mg/325 mg every 4 to 6 hours Maximum: 4,000 mg per day of acetaminophen | Persistent moderate to severe pain | Pain refractory to other agents Postoperative pain Fracture pain | See individual medications | Superior effectiveness compared with single agent Opioid sparing effect with decreased risk of adverse events | $25 ($150) |
| Hydrocodone/ibuprofen: 2.5 mg/200 mg to 10 mg/ 200 mg every 6 to 8 hours Maximum: 1,200 mg per day of ibuprofen | $40 ($50) | ||||
| Oxycodone/acetaminophen 2.5 mg/325 mg to 10 mg/ 325 mg every 4 to 6 hours Maximum: 4,000 mg per day of acetaminophen | $25 ($800) | ||||
| Dual-action opioid medications | |||||
| Tramadol (Ultram): 25 mg every 4 to 6 hours, titrated to 50 to 100 mg as needed Maximum: 400 mg per day | Persistent moderate to severe pain | Pain refractory to other agents, with goal of limiting more potent opioids | Dizziness, sedation, constipation Opioid use disorder Serotonin syndrome Tramadol decreases the seizure threshold | Adverse effects comparable to full agonists with less pain relief | $10 ($110) |
| Tapentadol (Nucynta): 50 to 100 mg every 4 to 6 hours Maximum: 600 mg per day | — ($215) | ||||
| Full agonist opioids | |||||
| Oxycodone: 5 mg orally every 4 to 6 hours as needed | Persistent severe pain | Short course for severe acute pain Pain refractory to other medications | Nausea, emesis Constipation Sedation Respiratory depression Opioid use disorder | Limit prescription to 3-day course Continue other medication classes as tolerated Higher doses may be required for patients taking chronic opioid therapy or naltrexone (Revia) | $10 ($60) |
| Morphine: 1 to 4 mg IV every 4 hours titrated up as needed; 10 to 15 mg IV every 4 to 6 hours for severe pain Maximum: limited by opioid-related adverse effects | NA | ||||
| Hydromorphone (Dilaudid) Orally: 2 to 4 mg every 4 to 6 hours IV: 0.2 to 1 mg every 2 to 3 hours Maximum: reserve for severe pain; use caution with dosing to prevent oversedation | Tablets: $10 ($125) IV: NA | ||||