1. Formulary Analgesic Medications
Brian Erickson, MD
Clinical Assistant Professor, Psychiatry, UVM
FAHC Center for Pain Medicine
Psychiatry Consultation Service
Electroconvulsive Therapy
UVM Program in Integrative Health

2. Acute Pain

10. Opioids Codeine  morphine Hydrocodone  hydromorphone
Oxycodone  oxymorphone
Fentanyl patch
Methadone
Levorphanol
Buprenorphine
Freye, E. (2008). Opioids in Medicine: A comprehensive review on the mode of action and the use of analgesics in different clinical pain states. New York: Springer Publishing Co.
Smith, H. (2009). Opioid metabolism. Mayo Clinic Proceedings, 84(7),

11. Codeine “mild opioid” 130 mg = morphine 30 mg
May be combined with Tylenol, Butalbital
Available in 15, 30, 60 mg
Max dose 60 mg q4hr (higher dose not more analgesia, more side effects
Half-life 2.9 hr

12. Codeine Metabolites: codeine-6-glucuronidate morphine (10%)
Renal excretion
Caution ultra-rapid metabolizers CYP2D6 convert to morphine more rapidly with increased effects
Caution alcohol, benzodiazepines,

13. Codeine—Practice Agreement
“Universal Precautions” with opioids
Screen for history of substance abuse
Random drug screens
Lost/stolen scripts not refilled
One pharmacy
Involve family members
Document discussion of risks/benefits

14. Cautions with Opioids May cause depression/mania
Constipation, sedation, nausea, myoclonus
Decrease testosterone levels
Methadone – metabolite long half-life; QRS
Opioid-Induced Hyperalgesia
Death – patient, others
Krantz, M., Martin, J., Stimmel, B., Mehta, D. & Haigney, M. (2009). QTc interval screening in methadone treatment. Annals of Internal Medicine, 150(6),
Tenant, F. (2009, Nov/Dec). Testosterone replacement in female chronic pain patients. Practical Pain Management.
Webster, L. & Dove, B. (2007). Avoiding opioid abuse while managing pain. North Branch, MN: Sunrise River Press.

15. Ultram (tramadol)
Non-opioid– affinity for mu-receptor 10x less than codeine
Metabolite o-desmethyltramadol 200x greater affinity that tramadol
Inhibits serotonin and norepinephrine re- uptake (similar but less than SNRI)
Lower abuse potential than opioids

16. Tramadol Available 50 mg tabs Sustained Release 100mg,200mg,300mg
Dosage: 50 mg q 6hr prn
May use 50 mg qid
Max dose 100mg qid
Studied in osteoarthitis, back pain, others
Side effects: dizziness, nausea, constipation

17. Tramadol--warnings
Seizure risk: reported in recommended dosage range, increased risk combined with TCA, SSRI, SNRI, opioids, MAO-I
Serotonin Syndrome: other serotonergic drugs– triptans, neuromuscular activity,autonomic activity, altered mental status

18. Tramadol—warnings (cont)
Serotonin Syndrome management:
--stop agents, iv hydration, consider cyproheptadine
Suicide warning—class warning with antidepressants
Caution with alcohol, CNS depressants
Pregnancy cat C

19. Neurontin (gabapentin)
Structure similar to GABA, no known direct activity on GABA receptor
Acts on alpha-2 sub-unit Calcium Channel receptor in spinal cord
Approved for Partial-Complex Seizure,Post-Herpetic Neuralgia,
Used for neuropathic pain, migraine, Fibromyalgia (similar to Lyrica), CRPS

20. Gabapentin May help anxiety Sleep: enhance slow-wave, help Fibro
Not helpful in Bipolar D/O
Half-life 5.9 hours
Renal excretion, caution renal impairment
Side effects: somnolence, peripheral edema, weight gain, cognitive effects

21. Gabapentin Available 100mg, 300mg,600mg,800mg Dosage 100mg hs
100mg tid, increase by 100mg tid q 3days
Max 800mg two qid
Pregnancy cat C

22. Flexeril (cyclobenzaprine)
Relieves muscle spasm of local origin without interfering with muscle function
Not act at neuromuscular junction
Mechanism of action unknown, thought to act at brainstem rather than spinal level
Similar in structure and effect to tricyclic anti-depressants
Half-life 3.2 hrs

23. Cyclobenzaprine Primarily renal excretion
Some hepatic metabolism –caution p450 metabilism, CYP2D rapid metabolizers
Caution with TCA, MAO-I
Side effects anticholinergic: dry mouth, constipation, urinary retention, vision, cognitive, sedation
Caution alcohol, CNS depressants

24. Cyclobenzaprine Available 5mg, 10mg
Amrix(cyclobenzaprine extended release),15mg,30mg
Dosage 5mg tid to 10mg tid
Amrix 15mg to 30mg qd

25. Soma (carisoprodol) Muscle spams, low back pain
Mechanism of action unknown
Metabolized to meprobamate (carbamate, resembles barbituate)
Side effects drowsiness, dizziness, headache,
Caution porphyria
Caution of CNS agent

26. Carisoprodol Available 250mg, 350mg Dosage 250mg hs
May use 250qid up to 350 qid
Concern for misuse, street value

27. Compounded Formulations
Topical, sublingual, rectal, nasal delivery avoid systemic side effects, metabolism problems
NSAID—ketoprofen
Neuropathic agents—amitriptyline, gabapentin
Muscle relaxants—MgCl, baclofen
Topical anesthetics—bupivicaine

28. Compounded formulations (cont)
Intranal Lidocaine—migraines
Rectal baclofen—spasms
Naturopaths can’t use Schedule II presently
Some insurances will pay for compounds

30. Adjuvants to Opioids (Nitric Oxide activity)
Oxytocin 10 units q3-6 hr
Helps mood, anxiety, sexual interest
Side effects – fluid retention, vasopressin (Kovacs, 1993)
L-Arginine 1000 mg bid
Kovacs (1993). Role of oxytocin in neuroadaptation to drugs of abuse. Psychoneuroendocrinology, 19(1),