To assess and manage the patient's pain, use a pain scale.

For mild pain (pain score: 1 to 4 on a zero-to-10 scale), start with aspirin, acetaminophen or an NSAID.

If the pain is not relieved or is moderate (pain score: 5 to 6), add oxycodone, tramadol or hydrocodone (or use a combination product that contains 5 mg of oxycodone or hydrocodone with aspirin, acetaminophen or NSAID).

For severe pain (pain score: 7 to 10), start therapy with oxycodone alone, hydromorphone or morphine. If transdermal opioid is desired, consider using transdermal fentanyl after the effective opioid dose has been identified by using immediate-release agents.

Transdermal fentanyl has a 14- to 24-hour “on” and “off” time.

If the pain is excruciating (pain score: 10 or higher), increase the opioid dose by 50 to 100 percent regardless of the amount of drug given, until pain is relieved.

For chronic pain, give around-the-clock therapy or “patient may refuse,” not “as-needed” therapy.

For pain between doses, give 10 percent of the total daily opioid dosage in immediate-release form (for example, the rescue dose for 200 mg of opioid is 20 mg).

Always prescribe a laxative (such as senna, with or without lactulose); do not give “as needed.” Patient may need an antiemetic for two to seven days.

Avoid benzodiazepine sleep medications.