Acute Multimodal Pain Management

Original Date: 07/2025

Starting multimodal pain regimen (MMPR):

  • Acetaminophen 1 g PO QID
  • Ibuprofen 400 mg PO TID
  • Pantoprazole EC tablet 40 mg PO daily
    (lanzoprazole suspension 30 mg PO daily for patients with feeding tubes)
  • Lidocaine patch 5% topical apply for 12 hours on 12 hours off daily (up to three patches total)
  • Ketamine infusion 0.2 mg/kg/hour (for ICU and IMU patients)
  • Oxycodone 5 mg PO q 4 hours prn pain score 6-10

Geriatric MMPR (age ≥65 years):

  • Acetaminophen 1 g PO TID
  • Ibuprofen 400 mg PO TID
    (or celecoxib 100 mg PO BID)
  • Pantoprazole EC tablet 40 mg PO daily
    (or lanzoprazole suspension 30 mg PO daily for patients with feeding tubes)
  • Lidocaine patch 5% topical apply for 12 hours on 12 hours off daily (up to three patches total)
  • Ketamine infusion 0.15 mg/kg/hour (for ICU and IMU patients)
  • Oxycodone 5 mg PO q 4 hours prn pain score 6-10

Adjunct Medications:

  • Neuropathic pain
    • Increase gabapentin (maximum dose is 3,600 mg in one day)
    • Pregabalin 50 mg PO TID (maximum dose is 600 mg in one day)
  • Muscle spasms
    • Methocarbamol 500 mg PO QID (maximum dose is 4,500 mg in one day)
  • Anxiety
    • Hydroxyzine 25 mg PO QID
  • History of substance use
    • Dronabinol 10 mg PO BID
  • Uncontrolled background pain – long acting opioids
    • Oxycodone ER 10 mg PO BID
    • Methadone 5 mg PO BID
  • Uncontrolled breakthrough pain – increase prn oxycodone dosages
    • Oxycodone 5 mg PO q4 hours prn pain score 4-6
    • Oxycodone 10 mg PO q4 hours prn pain score 7-10

De-Escalation

  • As patients progress along their hospital stay, the prn oxycodone doses should be used more infrequently.
  • Once a patient is using none or few prn oxycodone doses, the oxycodone is discontinued and the ibuprofen is made prn QID.

Discharge

  • Prescriptions given to patient (<65 years):
    • Acetaminophen 1 g PO QID (four week supply)
    • Ibuprofen 400 mg PO TID (four week supply)
    • Pantoprazole EC tablet 40 mg PO daily (four week supply)
    • Lidocaine patch 5% topical apply for 12 hours on 12 hours off daily (up to three patches total)
    • Oxycodone (see below)
  • Prescriptions given to geriatric patient (age ≥65 years):
    • Acetaminophen 1 g PO TID (four week supply)
    • Ibuprofen 400 mg PO TID (two week supply) (or celecoxib 100 mg PO BID)
    • Pantoprazole EC tablet 40 mg PO daily (two week supply)
    • Lidocaine patch 5% topical apply for 12 hours on 12 hours off daily (up to three patches total)
    • Oxycodone (see below)
  • Oxycodone prescribing
    • Number of pills to prescribe: take the average number of prn doses used over the last two hospital days and multiply by 7
    • Example: Zero prn doses given in last two days = 0 x 7 = 0. Give no oxycodone.
    • Example: Three prn doses given in each of last two days = 3 x 7 = 21. Give 21 tabs of oxycodone.