Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Table Graphic Jump Location|Download (.pdf)|PrintVarious Adjuvant Agents Used for Pain ManagementDrug/principal mechanism of actionPain indicationsCommon dosing1Common side effectsSpecial considerationsTramadolDual mechanism: serotonin/norepinephrine reuptake inhibitionWeak mu-opioid receptor agonismAcute and chronic pain: moderate–severe1Postoperative pain2Neuropathic pain250–100 mg po q6–8 hNausea, vomiting, constipation, dizziness, headachesSerious reactions: seizures, serotonin syndromeCaution if history/risk of seizureAvoid abrupt cessationRisk of suicidalityPregnancy Class CClonidineCentral alpha-2 adrenergic agonistPeripheral neuropathy2Postherpetic neuralgia2Cancer pain2CRPS2Postoperative pain2Adjuvant in neuraxial and peripheral nerve blocks2Opioid withdrawal20.1 mg po q12 h weekly titration up to 2.4 mg/day0.1 mg/day transdermalUp to 0.6 mg/day30 μg/h epidural infusionHypotension, bradycardia, AV block, dry mouth, drowsiness, sedation fatigue, depression, feverAvoid abrupt withdrawal, risk of rebound hypertensionPregnancy Class CKetamineNMDA receptor antagonismIntraoperative and postoperative pain2Burn pain2Cancer pain2Neuropathic pain2Opioid-induced hyperalgesia2IV infusionTransdermalSQ infusionIn analgesic doses: hypersalivation, anorexia, nausea, elevated BP, hallucinations, withdrawal syndrome (long-term use)Black box warnings: emergence reactions—various degrees of psychologic manifestations from pleasant dream-like states to irrational behavior and emergence delirium. The 100 mg/mL concentration of ketamine hydrochloride injection should not be injected intravenously without proper dilutionPregnancy Class DLidocaineBlocks sodium channelsDecreases ionic flux through the neuronal membranePostherpetic neuralgia1Local anesthesia, postoperative pain1Neuropathic pain2Burn pain2Topical: transdermalmaximum three patches/ 24 hIV: various protocolsPregnancy Class C1FDA approved.2Off-label usage for neuropathic pain. ++Table Graphic Jump Location|Download (.pdf)|PrintMuscle Relaxant Agents Commonly Used in Pain ManagementDrug/principal mechanism of actionPain indicationsCommon dosing1Common side effectsSpecial considerationsBaclofenGABA-B agonistSpasticity2Myofascial pain3Trigeminal neuralgia3GERD3Oral: start at 5 mg TIDMaximum 80 mg/dayIntrathecal: for severe spasticityDrowsiness, weakness, fatigue, hypotension, constipation, nauseaBlack box warnings (for the intrathecal administration): avoid abrupt cessation—high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity after abrupt D/CPregnancy Class CBenzodiazepines:DiazepamClonazepamGABA-B agonistDiazepam:Muscle spasmAcute postoperative myofascial pain3Clonazepam:NeuralgiaPeriodic leg movementSpasticity3Diazepam:2–10 mg po q6–8 h5–10 mg IM/IV4q3–4 h prnClonazepam:0.5–4 mg po q8 hDrowsiness, dizziness, impaired coordination, amnesia, confusion, somnolence, irritabilitySignificant dependence, abuse and addiction potential associated with chronic benzodiazepine administrationPregnancy Class DTizanidineCentral alpha-2 adrenergic agonistSpasticity2Muscle spasm and pain3Acute pain3Chronic headache32–8 mg TIDDrowsiness, dry mouth, somnolence, asthenia, hypotension, bradycardiaAdditive effects with alcohol and other CNS depressantsReduced clearance with oral contraceptivesPregnancy Class CCyclobenzaprineCentrally acting muscle relaxantMuscle spasm and pain2Fibromyalgia3TMJ disorder35–10 mg po TIDDrowsiness, dry mouth, ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth