Mary Lynn McPherson, PharmD, BCPS, CDE

Appendix Analgesics in Older Adults Mary Lynn McPherson, PharmD, BCPS, CDE From: Aging Medicine: Handbook of Pain Relief in Older Adults: An Evidence-Based Approach Edited by: F. M. Gloth, III Humana Press Inc., Totowa, NJ 245

Analgesic Starting oral dose Maximum daily oral dose Special considerations Nonopioid analgesics Acetaminophen (Tylenol 325 mg every 4 6 4000 mg per day in divided *Reduce maximum dose 50 75% and others) hours doses in patients with hepatic insufficiency or history of alcohol abuse *Reduce dosage in renal insufficiency: CLcr 10 50 ml/minute: administer every 6 hours CLcr <10 ml/minute: administer every 8 hours Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) Carboxylic acid derivatives (salicylic acid derivatives) *All salicylates are contraindicated in patients with bleeding ulcers, hemophilia, angioedema, nasal polyps associated with asthma, thrombocytopenia *Consider risk benefit ratio with following medical conditions: anemia, compromised cardiac function, hypertension, gastritis, gout, peptic ulcer, hepatic or renal function impairment 246

Aspirin (acetylsalicylic acid, 325 mg every 4 6 Analgesic and antipyretic: *More ulcerogenic than other Bayer, and others) hours 4000 mg per day in divided salicylates Buffered aspirin (Bufferin, doses *Older patients may be more and others) Anti-inflammatory: 6000 mg susceptible to toxic effects Enteric-coated aspirin per day (monitor serum because of decreased renal (Ecotrin and others) concentrations) in divided function doses *Same considerations and contraindications as for all salicylates Choline magnesium 500 mg one to three 3000 mg per day in divided *Same considerations and trisalicylate (Trilisate times daily doses contraindications as for all and others) salicylates Diflunisal (Dolobid) Pain: 250 mg every 1500 mg per day in divided *Less likely than other NSAIDs 8 12 hours doses to increase presurgical Inflammation: 500 bleeding and to increase mg every 12 hours bleeding time *Higher risk than other NSAIDs in patients with renal impairment Salsalate (Disalcid) 500 mg twice daily 3000 mg per day in divided *Same considerations and doses contraindications as for all salicylates 247 (continued)

Analgesic Starting oral dose Maximum daily oral dose Special considerations *Risk benefit ratio for all NSAIDs should be considered when the following medical problems exist: asthma, anemia, compromised cardiac function (coronary heart disease), edema, hypertension, renal or hepatic impairment, gastrointestinal diseases, congestive heart failure, diabetes, sepsis, hemophilia, systemic lupus erythematosus Proprionic acid derivatives Fenoprofen (Nalfon) Pain: 200 mg every 3200 mg daily in divided doses *Muscle cramps or pain not 4 6 hours related to condition being Arthritis: 300 mg treated may occur three to four times daily Ibuprofen (Motrin and Pain: 200 mg every 3200 mg daily in divided doses *May cause stomach bleeding in others) 4 6 hours individuals who consume Arthritis: 400 mg large amounts of alcohol; may three to four interfere with cardioprotective times daily effect of aspirin Ketoprofen (Orudis) 25 mg three to four 300 mg in divided doses *Bleeding from rectum may times daily occur 248

Naproxen (Naprosyn, others) 250 mg every 6 8 1500 mg in divided doses *Ringing or buzzing in ears can hours occur *Shortness of breath or troubled breathing Naproxen sodium (Aleve, 225 mg every 6 8 1375 mg in divided doses *More rapid onset, but activity Anaprox) hours similar to naproxen Acetic acid derivatives Diclofenac (Arthrotec, 25 mg three to four 200 mg in divided doses *May precipitate acute attack of Volaren, and others) times daily hepatic porphyria *Blood dyscrasias and bone marrow depression may be induced or exacerbated Etodolac (Lodine) 200 mg every 6 8 1200 mg in divided doses *Use with caution in people with hours impaired renal and hepatic function, heart failure; in those on diuretics; in older adults Indomethacin (Indocin, 25 mg two to three 200 mg in divided doses *May aggravate epilepsy, Indocin SR) times daily depression, or other psychiatric disturbances or Parkinson s disease Sulindac (Clinoril) 150 mg twice daily 400 mg in divided doses *Use with caution when there is a history of renal calculus and in conjunction with adequate fluid intake (continued) 249

Analgesic Starting oral dose Maximum daily oral dose Special considerations Tometin (Tolectin, 200 mg three times 2000 mg in divided doses *Increased blood pressure; may Tolectin DS) daily reach hypertensive levels *Muscle cramps or pain may occur Fenamates Meclofenamate (Meclomen) 50 mg every 4 6 400 mg in divided doses *Hypoprothrombinemia when hours prothrombin activity is 10 20% normal; increased risk of bleeding Mefenamic acid (Ponstel) 250 mg every 6 1000 mg/day in divided doses *Should not use when nasal polyps hours associated with bronchospasm (aspirin induced) present Enolic acid derivatives Meloxicam (Mobic) 7.5 mg once daily 15 mg once daily *Do not use in patients with several renal impairment Piroxicam (Feldene) 10 mg once daily 20 mg once daily *Nausea, abdominal cramps, and epigastric pain may occur Naphthylakanones Nabumetone (Relafen) 500 mg twice daily 2000 mg in divided doses *May be no safer for gastrointestinal tract side effects than other nonselective NSAIDs 250

COX-2 specific NSAIDs Celecoxib (Celebrex) 200 mg once daily 600 mg in divided doses *Reduced dosage recommended in hepatic impairment *No specific dosing adjustment in renal impairment, but area under the curve may be increased *Use the lowest recommended dose in patients weighing less than 50 kg *Patients with indications for cardioprotective aspirin require aspirin supplement Rofecoxib (VIOXX) 12.5 mg once daily 50 mg once daily *Use in advanced renal disease is not recommended *No specific dosing adjustment in hepatic impairment, but area under the curve may be increased *Patients with indications for cardioprotective aspirin require aspirin supplement Valdecoxib (Bextra) 10 mg once daily 10 mg once daily *Do not use in patients with severe hepatic impairment or renal disease *Patients with indications for cardioprotective aspirin require aspirin supplement (continued) 251

Analgesic Starting oral dose Maximum daily oral dose Special considerations Other nonopioids Tramadol (Ultram) 50 mg every 4 6 300 mg per day in divided *CLcr < 30 ml/minute: dosage hours doses interval should be extended to 12 hours with a maximum daily dose of 200 mg *Patients with cirrhosis: recommended dose is 50 mg every 12 hours *Should not be used when following conditions are present: acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs because of risk of respiratory depression Opioids *Older adults are more likely to be affected by the acute and chronic toxicities of opioids *Begin with conservative dosing and titrate carefully Codeine (variety) Not recommended Not recommended *Not recommended because of adverse effects common even at minimally effective analgesic doses 252

Fentanyl (Duragesic) Note: transdermal 300 g *Lowest strength transdermal formulation not patch may be an excessive indicated for dose for frail, cachectic older acute pain adults; only patients who management require 60 mg per 24-hour 25 g patch (or oral morphine equivalent appropriate should begin transdermal conversion from therapy (with 25 g previous oral transdermal patch) opioid dosage) *Peak effects of first dose take 18 24 hours *Duration of effect is usually 3 days, but may range from 48 hours to 96 hours Hydrocodone (Vicodin, 2.5 mg every 4 6 Do not exceed 4000 mg *Hydrocodone only commercially Lortab, others) hours acetaminophen daily available in combination with (Available in combination acetaminophen with aspirin, *Opioid dose limited by fixedacetaminophen, dose combinations with or ibuprofen) acetaminophen or NSAIDs (do not exceed maximum daily dose of acetaminophen or NSAIDs) (continued) 253

Analgesic Starting oral dose Maximum daily oral dose Special considerations Hydromorphone (Dilaudid, 1 2 mg every 4 6 Titrate carefully to response *Short acting, may require others) hours dosing every 3 4 hours *Oral, long-acting formulation currently being reviewed by Food and Drug Administration Meperidine (Demerol) Not recommended Not recommended *Not recommended because of potential central nervous system side effects Methadone (various) Not recommended Not recommended *Not a first choice for older adult because of long and variable half-life and risk for drug accumulation Morphine (MSIR, MS Contin, 2.5 5 mg every 4 Titrate carefully to response *Toxic metabolites of morphine others) hours may limit usefulness in patients with renal insufficient or when high-dose therapy is required *Patients taking sustainedrelease oral formulation may require short-acting formulation for breakthrough pain 254

*Sustained-release oral formulations should be swallowed whole and not broken, chewed, or crushed Oxycodone (Roxicodone, 2.5 mg every 6 hours Titrate carefully to response *Oxycodon may be available in OxyContin, others) combination with acetaminophen or aspirin: opioid dose limited by daily maximum of nonopioid component *Patients taking sustainedrelease oral formulation may require short-acting formulation for breakthrough pain *Sustained-release oral formulations should be swallowed whole and not broken, chewed, or crushed Propoxyphene (Darvon, Not recommended Not recommended *Not recommended for use in Darvocet-N 100, older adults because of lack of others) efficacy and adverse effects caused by active metabolites (continued) 255

Analgesic Starting oral dose Maximum daily oral dose Special considerations Selected adjuvant analgesics Anticonvulsants Gabapentin (Neurontin) 100 mg at bedtime 300 900 mg three times daily *Titrate slowly against adverse effects of sedation and ataxia *May cause edema *Dosage adjustment in renal impairment: CLcr 30 60 ml/minute: administer 600 mg/day CLcr 15 30 ml/minute: administer 300 mg/day CLcr <15 ml/minute: administer 150 mg/day Corticosteroids Prednisone (Deltasone, 5 mg once daily Variable *Use lowest possible dose for others) shortest possible time to prevent chronic steroid effects *Anticipate adverse effects (e.g., fluid retention, hyperglycemia) Tricyclic antidepressants (TCAs) Desipramine 10 mg daily 25 100 mg daily (titrate to r *Preferred over other TCAs (Norpramin) esponse, generally increasing because of less-offensive sideevery 3 5 days) effect profile *TCA agents may cause significant anticholinergic adverse effects 256

*Patients may experience excitation and stimulation or sedation; administer in AM or PM accordingly Nortriptyline (Aventyl, 10 mg at bedtime 25 100 mg at bedtime (titrate *Preferred over other TCAs Pamelor) to response, generally because of less-offensive sideincreasing every 3 5 days) effect profile *TCA agents may cause significant anticholinergic adverse effects Source: Adapted from the following: American Pain Society. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. 2nd ed. Glenview, IL: American Pain Society; 2002. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50:1 20. Lexi-Comp. Geriatric Drug Therapy Handbook, 2001 2002. Hudson, OH: Lexi-Comp Inc.; 2001. 257

----------------------------------------- POSTTEST ANSWER KEY The Handbook of Pain Relief in Older Adults: An Evidence-Based Approach Please circle your answers. ChapterOne Chapter Six Chapter Eleven 1 A B C D 1 A B C D 1 A B C D 2 A B C D 2 A B C D 2 A B C D 3 A B C D 3 A B C D 3 A B C D 4 A B C D 4 A B C D 4 A B C D ChapterTwo Chapter Seven Chapter Twelve 1 A B C D 1 A B C D 1 A B C D 2 A B C D 2 A B C D 2 A B C D 3 A B C D 3 A B C D 3 A B C D 4 A B C D 4 A B C D 4 A B C D Chapter Three Chapter Eight Chapter Thirteen 1 A B C D 1 A B C D 1 A B C D 2 A B C D 2 A B C D 2 A B C D 3 A B C D 3 A B C D 3 A B C D 4 A B C D 4 A B C D 4 A B C D Chapter Four Chapter Nine 1 A B C D 1 A B C D 2 A B C D 2 A B C D 3 A B C D 3 A B C D 4 A B C D 4 A B C D Chapter Five ChapterTen 1 A B C D 1 A B C D 2 A B C D 2 A B C D 3 A B C D 3 A B C D 4 A B C D 4 A B C D Thank you for participating in this activity. You may claim credit for individual chapters or for the entire book, up to a total of 6.5 AMAIPRA AMAJPRA category I credits. Please tally the total number of credits you are claiming, using.5 credits for each chapter. (For example, for one chapter, you would claim.5 credits; for three chapters, you would claim 1.5 credits; for I3 chapters, you would claim 6.5 credits.) Please then sign and date this sheet at bottom and follow the check completion and mailing instructions on the previous page. Number of credits claimed Signature Date

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Index 259 Index A Acetaminophen, adverse effects, 93, 94 combination therapy, 91, 92 dosing, 94, 246 indications, 91 93 mechanism of action, 91 Addiction, definition, 120, 223 Adherence, see Compliance Adhesions, lysis, 142, 143 Adverse drug reactions, aging effects, 88 Alcohol, assessment of use, 45, 46 Allodynia, definition, 3 Analgesia, definition, 3 preventive, see Preventive analgesia Anticonvulsants, adjuvant analgesia, 126, 127, 176 Aspirin, dosing and precautions, 247 Assessment, pain, clinician communication with other clinicians, 23, 31 cognitive function assessment, 25 communication impairment issues, 18, 19 cultural considerations, 32 delirium and dementia considerations, 20 duration of pain, 22 hearing and vision loss considerations, 24, 25 history, 21 23, 29 importance, 20 localization of pain, 21, 22, 32 medication history, 23 nursing homes, 171 175 overview, 15, 16 pain scale selection for the elderly, 16 18 physical examination, 23 25, 33 research vs clinical care instruments, 19 21 social support structure, 23 time requirements of assessment, 21 timing of pain, 22 B Bisphosphonates, adjuvant analgesia, 124, 125 Botulinum toxin, adverse reactions, 157 contraindications, 156 duration of effects, 157 efficacy of pain relief, 155, 156 mechanism of action, 155 C Carbamazepine, adjuvant analgesia, 126 Causalgia, definition, 3 Celecoxib, dosing and precautions, 251 Celiac plexus block, 136 139 Centers for Medicare and Medicaid Services (CMS), initiation of public policy change, 233 Central pain, definition, 3 CME, see Continuing medical education CMS, see Centers for Medicare and Medicaid Services Codeine, adverse effects, 252 formulations, 122 metabolism, 122 Compliance, pharmacotherapy, 91, 222, 225, 226 rehabilitation, 83 Continuing medical education (CME), pain programs, 234 Corticosteroids, adjuvant analgesia, 125 dosing and precautions, 255 D Dementia, pain comorbidity, 20, 90 Depression, pain comorbidity, 90, 227 Desipramine, dosing and precautions, 256, 257 Diclofenac, dosing and precautions, 249 Dysesthesia, definition, 3 259

260 Index E Education, health care professionals on pain, 234, 235 Electronic medical records (EMR), advantages, 215, 217 popularity of use, 208, 209 prospects for use, 218, 235, 236 selection of system, 216 218 Electrotherapy, pain management, 78, 79 EMR, see Electronic medical records Epidural steroid therapy, indications, 146, 147 Etodolac, dosing and precautions, 249 Exercise, pain rehabilitation, 74 76 F Facet blocks, 136 Fenoprofen, dosing and precautions, 248 Fentanyl, administration, 121 dosing and precautions, 253 metabolism, 121 transdermal formulation, 122, 253 FPS, see Functional Pain Scale Functional Pain Scale (FPS), advantages, 17, 18 overview, 16, 17 Present Pain Intensity Scale comparison, 21 G Gabapentin, adjuvant analgesia, 127 dosing and precautions, 256 H Herbal and nutritional supplements, adverse effects, 30, 35, 226, 227 pharmacological effects, 35 popularity of use, 35 types and mechanisms of action, 39 43 Hospice care, pain management, 177, 178 Hydrocodone, dosing and precautions, 253 Hydromorphone, administration, 121 dosing and precautions, 254 metabolism, 121 Hydroxyzine, dosing, 38 Hyperalgesia, definition, 3 Hyperesthesia, definition, 3 Hyperpathia, definition, 3 Hypoalgesia, definition, 3 Hypoesthesia, definition, 3 I Ibuprofen, dosing and precautions, 248 IDET, see Intradiscal electrothermal annuloplasty Indomethacin, dosing and precautions, 249 Internet, pain advocacy Web sites, 209, 210 pain management Web sites, 210 212 reputable resource selection, 207, 208 specialist directory Web sites, 210 use by seniors, 208 Web site ratings, 212 Web sites by disease, 213 215 Intradiscal electrothermal annuloplasty (IDET), contraindications, 154 efficacy, 153, 154 indications, 153 principles, 153 Intrathecal therapy, non-pump delivery, 150, 151 opioids, 147, 148 pumps, 148, 150 titration algorithm, 149 J JCAHO, see Joint Committee on Accreditation of Healthcare Organizations Joint Committee on Accreditation of Healthcare Organizations (JCAHO), rating of care, 237 K Ketoprofen, dosing and precautions, 248 Kinematic therapy, pain management, 80, 81, 83 Kinesio taping, pain management, 81, 83 Kyphoplasty, 151, 152

Index 261 L Lumbar sympathetic block, 139 M Massage, pain management, 80 Meclofenamate, dosing and precautions, 250 Media, alternative sources for public communication, 240, 241 biases and challenges, 200 202 interviews of health care professionals, 199, 200 marketing of public policy, 198, 199 print media guidelines, 200, 201 Mefenamic acid, dosing and precautions, 250 Meloxicam, dosing and precautions, 250 Meperidine, adverse effects, 122, 123, 196, 197, 254 allergy, 44 hospital policy development, 196, 197 Methadone, adverse reactions, 123, 24 metabolism, 123 potency, 123 Metoclopramide, dosing, 38 Morphine, administration, 120 dosing and precautions, 254 intrathecal therapy, 147, 148 metabolism, 121 pharmacokinetics, 120, 121 N Nabumetone, dosing and precautions, 250 Naproxen, dosing and precautions, 249 Natraceuticals, see Herbal and nutritional supplements Nausea and vomiting, antihistamine antiemetic management, 34, 38 opioid induction, 34, 36 Nerve ablation therapy, cryoablation, 139, 141 intrathecal neurolysis, 142 neuritis as complication, 142 radiofrequency ablation, 142 Nerve blocks, efficacy, 135, 136 facet blocks, 136 principles, 134 risks, 134, 135 sympathetic blocks, celiac plexus block, 136 139 lumbar sympathetic blok, 139 stellate ganglion block, 136 superior hypogastric plexus block, 139 Neuralgia, definition, 3 Neuritis, definition, 3 Neuropathy, definition, 3 Nociceptor, definition, 3 Nonsteroidal anti-inflammatory drugs (NSAIDs), see also specific drugs, adjuvant analgesia, 124 adverse effects, aspirin interactions and cardioprotective effect ablation, 102, 103 gastrointestinal toxicity, 98 100, 176, 223 hypertension, 101, 102 peripheral edema, 101 renal toxicity, 100, 101 thrombosis, 102 indications, 95, 96 mechanism of action, 94, 95 metabolism, 97, 98 nursing home use, 176 prescription drug mixing with over-thecounter drugs, 226 selection of drug, 103 Nortriptyline, dosing and precautions, 257 Noxious stimulus, definition, 3 NSAIDs, see Nonsteroidal anti-inflammatory drugs Nucleoplasty, contraindications, 154, 155 indications, 153 principles, 154

262 Index Nursing homes, demographics, 165 pain, assessment, 171 175 barriers to assessment and management, 169 171 effects on health outcomes, 165, 166 epidemiology, 167 169 management, 175 178 prospects for assessment and management, 180 quality improvement, 178, 179, 236 238 rating of care, 237 regulation and pain management, 9, 179 staff limitations, 166 Nutritional supplements, see Herbal and nutritional supplements O Opioids, see also specific drugs, addiction, 120 addiction, 223, 224 adverse effects and management, 34, 36, 37, 118 120, 226 classification, 115, 116 fear of use, 222 224 guidelines for use, 4, 116 118 Agency for Health Care Policy and Research, 116, 117 American College of Rheumatology, 118 American Geriatrics Society, 4, 118 American Medical Directors Association, 118 American Pain Society, 117 intrathecal therapy, 147, 148 laxative recommendations, 34 mechanism of action, 115, 116 nursing home use, 175, 176 patient-controlled analgesia, 116, 117 physical dependence, 120, 223 receptors, 115 selection of drug, 124 tolerance, 223 withdrawal, 24, 29 Osteopathic manipulation, pain management, 80 Oxycodone, dosing and precautions, 255 osteoarthritis pain management, 117, 118 preparations, 121 safety, 121 P Pain, assessment, see Assessment, pain barriers to management in the elderly, health professional factors, 6 institutional factors, 7 nursing homes, 169 171 overview, 4 6 patient factors, 6 regulations, 8, 9 causes in the elderly, 2 comorbidity, 2 components, 63 cultural dimensions, 64 cycle of pain, treatment, increased activity, and injury, 8, 227, 228 management improvement overview, 7, 10 pathophysiology, 134 prevalence in the elderly, 1, 87 prevention, see Preventive analgesia reporting deficiency, 224, 225 sex differences, 2 terminology, 2, 3 undertreatment, 87, 88 vicious cycle, 73, 74 Pain Relief Promotion Act, advocates and resistance, 191 194 Pain threshold, definition, 3 Pain tolerance level, definition, 3 Paresthesia, definition, 3 Patient s bill of rights, 221, 222 Pharmacodynamics, aging effects, 90 Pharmacokinetics, aging effects, absorption, 88, 89 distribution, 89 elimination, 89, 90 metabolism, 89 Phenytoin, adjuvant analgesia, 126, 127

Index 263 Physical dependence, definition, 120, 223 Piroxicam, dosing and precautions, 250 Politics of pain, communication resources, 239 241 contributions to campaigns, 188 190 election of physicians and representation establishment, 185 187 fear of legislation as motivating factor, 195, 196 groundwork for public policy, 197, 198 health care professional influences on candidates, 187, 188 local action, 196, 197 media management, 198 202 Pain Relief Promotion Act, 191 194 professional society influences, 190 regulation influences by health care professionals, 190 195 Prescriptions, policy modifications for controlled substances, 235 Preventive analgesia, barrier identification, 31, 32 clinical response assessment, 47, 48 clinician communication with other clinicians, 31 definitions, 48, 49 drug dependency assessment, 45, 46 evaluation of patients, drug allergies, 34, 44 history, 32, 33 overview, 29 31 past drug experience considerations, 44 physical examination, 32, 33 risk assessment, 46, 47 social history and habits, 33, 34 herbal and nutritional supplement considerations, 34, 35, 39 43 indications, 48, 49 patient expectations, 44, 45 pharmacotherapy assessment, 47 surgery patients, 48, 49 Prochlorperazide, dosing, 38 Promethazine, dosing, 38 Propoxyphene, potency and metabolism, 123 precautions, 255 Public policy, see Politics of pain R Rehabilitation, compliance, 83 cryotherapy, 76, 77 electrotherapy, 78, 79 exercise, 74 76 kinematic therapy, 80, 81, 83 manual therapy, 79, 80 pain relief paradigm to increase activity while maintaining comfort, 228, 229 thermal therapy, 77, 78 vicious cycle of pain, 73, 74 Religion, see Spirituality Rofecoxib, dosing and precautions, 251 S Salicylates, dosing and precautions, 247 SCS, see Spinal cord stimulation Smoking, preventive analgesia considerations, 33, 46 Spinal cord stimulation (SCS), efficacy, 143, 145 indications, 143 145 led implantation, 145 prospects, 145 Spinal manipulation, pain management, 79 Spirituality, beneficial effects on health outcomes, 67 cultural differences, 65, 66, 68 definitions, 64, 65 history taking with FICA, 67, 68 intercessory prayer, 69 pain interactions, 63 65 prevalence of faith, 64 Stellate ganglion block, 136 Suffering, definition, 63 Sulindac, dosing and precautions, 249 Superior hypogastric plexus block, 139 T Tai chi, pain management, 75, 76 TCAs, see Tricyclic antidepressants TENS, see Transcutaneous electrical nerve stimulation

264 Index Tolerance, definition, 223 Tometin, dosing and precautions, 250 Tort reform, pain considerations, 239 Tramadol, adverse effects, 105, 252 dosing, 104 106, 252 indications, 103 105 mechanism of action, 103 Transcutaneous electrical nerve stimulation (TENS), nursing home use, 177 pain management, 78, 79 Tricyclic antidepressants (TCAs), adjuvant analgesia, 125 adverse effects, 125, 126 dosing and precautions, 256, 257 nursing home use, 176 V Valdecoxib, dosing and precautions, 251 Vertebroplasty, 151, 152 Vitamin D deficiency pain syndrome, 177 W Web sites, see Internet World Health Organization analgesic ladder, 117