I.  Topicals  

A. NSAID / Analgesic

Diclofenac 1% gel

• Container: 100 g (≈3.5 oz)

• Dose: UE 2 g (0.07 oz); LE 4 g (0.14 oz)

• Doses/container: UE ≈50; LE ≈25

• Freq: QID
  
  

Lidocaine 4–5% cream

• Container: 30 g (≈1 oz)

• Dose: 0.5 g (0.018 oz)

• Doses/container: ≈60

• Freq: BID–TID
  Lidocaine 5% patch: 1 patch = 1 dose (12h on/12h off)
  
  

B. Anti-Inflammatory / Steroid

Hydrocortisone 1–2.5%

• Container: 30 g

• Dose: 0.5 g

• Doses: ≈60

• Freq: BID ≤14 days
  
  

Triamcinolone 0.1%

• Container: 45 g (≈1.6 oz)

• Dose: 0.5–1 g

• Doses: 45–90

• Freq: BID ≤2–3 wks
  
  

C. Dermatologic / Keratolytic

Urea–Salicylic Acid 39.5% / 2%

• Container: 30 g (1 oz), 60 g (2 oz)

• Dose: 0.5–1 g (0.018–0.035 oz)

• Doses: 30 g = 30–60; 60 g = 60–120

• Freq: QD–BID
  
  

Urea 10–20% lotion

• Container: 120 g (4 oz)

• Dose: ~1 g → ≈120 doses
  
  

D. Antifungal

Clotrimazole 1% / Ketoconazole 2%

• Container: 30 g

• Dose: 0.5 g

• Doses: ≈60

• Freq: BID × 2–4 wks
  
  

II. Cannabis Topicals (Adjunctive Pain Care)

Available OTC or via Trulieve

CBD topical (OTC)

• Container: 2 oz (≈56 g) or 3 oz (≈85 g)

• Dose: 0.5 g

• Doses: ≈110 (56 g); ≈170 (85 g)

• Freq: BID–TID
  
  

THC:CBD topical (medical)

• Container: 2–3 oz (56–85 g)

• Dose: 0.5–1 g

• Doses: ≈56–170

• Freq: BID
  
  

THC transdermal patch

• Container: 5–10 patches

• Dose: fixed per patch (systemic); 12–24 h
  
  

III. Compounded Topicals (Pain-Specific)

A. Neuropathic Pain

• Example: Lidocaine 5% + Gabapentin 6% ± Ketamine 5%

• Container: 60 g

• Dose: 0.5–1 g

• Doses: 60–120

• Freq: BID–TID
  
  

B. Inflammatory / Arthritic Pain

• Example: Diclofenac 3–5% + Baclofen 2% ± Cyclobenzaprine 2%

• Container: 60–120 g

• Dose: 1–2 g

• Doses: 30–120

• Freq: BID–TID
  
  

C. Myofascial / Spasm

• Example: Lidocaine 5% + Baclofen 2% + Menthol/Camphor*

• Container: 60 g

• Dose: 1 g

• Doses: ≈60

• Freq: BID
  *Avoid menthol if sensitive.
  
  

D. CRPS / Refractory Pain

• Example: Ketamine 5–10% + Lidocaine 5% ± Clonidine 0.1%

• Container: 30–60 g

• Dose: 0.5 g

• Doses: 60–120

• Freq: BID (specialist use)
  
  

IV. Rules of Thumb

• Palm-sized area ≈ 0.5 g

• Two palms / thick plaque ≈ 1 g

• Patches ≠ creams (systemic vs local)

V. Conversion Equations

• 1 oz = 28.35 g

• g → oz: g ÷ 28.35

• oz → g: oz × 28.35

• Doses/container: total g ÷ g per dose

• Days supply: doses ÷ applications/day

1) Non-Opioid Analgesics (APAP & NSAIDs): How do I dose safely and effectively?

FAQ: How should acetaminophen and NSAIDs be dosed to maximize analgesia while minimizing risk?
Answer: Acetaminophen (APAP) remains first-line for many pain states. Standard max is 3 g/day; reduce to ≤2 g/day in older adults, chronic EtOH use, or liver disease. NSAIDs provide superior anti-inflammatory benefit but require risk stratification. Ibuprofen 200–800 mg q6–8h (Rx max 3.2 g/day); naproxen 250–500 mg q12h (max 1 g/day). Avoid NSAIDs in eGFR <30, active GI bleed, or decompensated CHF. Consider topical diclofenac for OA to reduce systemic exposure. Add PPI for high GI risk. Monitor BP, Cr, K+ within 1–2 weeks of initiation in high-risk patients.

2) Opioid Stewardship: What are the numeric guardrails?

FAQ: What metrics define safe opioid initiation, monitoring, and tapering?
Answer: Opioids are reserved for moderate–severe pain after alternatives fail and functional goals are defined. Start with IR only; reassess within 1–4 weeks. Use the lowest effective dose; exercise caution at ≥50 MME/day and avoid or justify ≥90 MME/day. Co-prescribe naloxone for overdose risk (OSA, benzos, EtOH, ≥50 MME). Baseline UDS and periodic monitoring are standard; check PDMP at each Rx (state rules vary). Taper when risks outweigh benefits or goals unmet—often 5–10% dose reduction q2–4 weeks (slower if long-term). Avoid abrupt discontinuation. Document informed consent, risk mitigation, and objective functional outcomes.

3) Neuropathic Agents: How do I dose and choose correctly?

FAQ: How should gabapentinoids, SNRIs, and TCAs be selected and titrated?
Answer: Neuropathic pain responds best to targeted agents. Gabapentin start 100–300 mg qHS, titrate to 300 mg TID; usual 900–1800 mg/day (renal adjust). Pregabalin start 25–75 mg BID, typical 150–300 mg/day (renal adjust). Duloxetine 30 mg/day → 60 mg/day (avoid severe hepatic disease). TCAs (e.g., nortriptyline) 10–25 mg qHS, titrate cautiously (QT prolongation, anticholinergic effects). Expect onset in 2–4 weeks. Monitor sedation, dizziness, edema, falls; avoid stacking CNS depressants. Choose based on comorbidities (depression, sleep, migraine) and stop if no meaningful benefit after an adequate trial.

4) Muscle Relaxants: When are they appropriate and for how long?

FAQ: How should skeletal muscle relaxants be used safely in pain care?
Answer: Muscle relaxants are best for acute spasm, not chronic pain; evidence supports short-term use (≤2–3 weeks). Cyclobenzaprine 5 mg TID or 5–10 mg qHS (anticholinergic—avoid elderly). Tizanidine 2 mg q6–8h PRN, titrate cautiously (max 36 mg/day); watch hypotension and CYP1A2 interactions. Baclofen 5 mg TID, titrate to 10–20 mg TID; avoid abrupt discontinuation (withdrawal). Avoid combining with opioids/benzodiazepines when possible. Reassess frequently; discontinue if sedation, falls, or minimal benefit. Chronic tone disorders may warrant specialist management.

5) Topical Analgesics: How do I dose precisely and document days supply?

FAQ: What are exact dosing rules for common pain topicals?
Answer: Topicals provide localized relief with minimal systemic exposure. Diclofenac 1% gel: 2 g for upper extremity (UE) or 4 g for lower extremity (LE) up to QID; a 100 g tube ≈ 50 UE or 25 LE doses. Lidocaine 5% patch: 12h on/12h off, max 3 patches/day. Lidocaine cream: ~0.5 g per palm-sized area BID–TID. For compounded creams, start 0.5 g BID, titrate based on response; document area treated, grams per dose, frequency, and days supply. Avoid broken skin unless directed; counsel on local irritation.

6) Corticosteroids: What are safe burst and injection principles?

FAQ: How should systemic and injectable steroids be used in pain patients?
Answer: Short oral bursts can reduce acute inflammation. Prednisone 20–60 mg/day x 3–7 days is common; taper often unnecessary if ≤7–10 days, but consider if frequent courses. Counsel on insomnia, mood changes, hyperglycemia, BP/fluid retention, and GI upset; consider PPI with NSAIDs. For injections, limit frequency (commonly ≥3 months between injections; total/year individualized). Track cumulative exposure and monitor A1c, BP, bone risk in repeat users. Avoid in uncontrolled infection. Clearly document indication, response, and exit strategy.

7) Cannabinoid Therapeutics: How do I dose by route and ratio?

FAQ: What are evidence-informed dosing strategies for THC/CBD?
Answer: Start low, go slow. Inhaled: 1–2 puffs; onset minutes; duration 2–4h. Oral: start THC 2.5 mg qHS (or 1–2.5 mg if sensitive), titrate every 2–3 days; CBD often 10–25 mg/day start. Balanced THC:CBD (1:1) supports pain/sleep; CBD-dominant reduces intoxication risk. Topicals are largely local; transdermal patches can be systemic. Review CYP interactions (e.g., warfarin, AEDs). Avoid driving/intoxication; caution in psychosis, pregnancy. Document route, dose, ratio, and patient education.

8) Adjuvant Agents (Ketamine, α2-Agonists): When and how?

FAQ: Where do adjuvants fit for refractory pain?
Answer: Adjuvants are reserved for refractory cases with monitoring. Ketamine (IV protocols vary) may reduce central sensitization; oral/topical use is specialist-driven. Monitor BP, dissociation, urinary symptoms with chronic exposure. α2-agonists (e.g., clonidine 0.1 mg qHS–BID or patch) can help sympathetically mediated pain or withdrawal-related symptoms; watch hypotension/bradycardia. Avoid stacking sedatives. Define target symptoms (allodynia, hyperalgesia, sleep) and predefine stop rules if no benefit. Document informed consent and monitoring plan.

9) Polypharmacy & Deprescribing: How do I reduce harm?

FAQ: What is a structured approach to deprescribing in pain care?
Answer: Identify duplications and high-risk combinations (opioid+benzo; opioid+gabapentinoid; anticholinergic burden). Prioritize non-pharmacologic strategies and the fewest effective meds. Change one variable at a time. Typical tapers: sedatives 10–25% q2–4 weeks; opioids 5–10% q2–4 weeks. Screen for falls, cognition, constipation, and sleep-disordered breathing. Use Beers Criteria in older adults. Track function (ADLs, work tolerance) rather than pain scores alone. Document shared decision-making and follow-up cadence.

10) Special Populations: What adjustments are essential?

FAQ: How do comorbidities change medication choices?
Answer: Elderly: start at ~½ dose; avoid anticholinergics; high fall risk. Renal disease: avoid NSAIDs if eGFR <30; renal-dose gabapentinoids. Hepatic disease: limit APAP ≤2 g/day; avoid duloxetine severe disease. OSA/COPD: minimize opioids/benzodiazepines; co-prescribe naloxone. Pregnancy: avoid NSAIDs late gestation; prefer non-pharm/APAP. Psychiatric comorbidity: caution THC (psychosis risk) and steroids (mood). Individualize, monitor closely, and document rationale.

I. Purpose of Steroid Equivalency

• Convert between steroids when changing route, potency, duration, or side-effect profile
  
  

• Standardize anti-inflammatory vs immunosuppressive effects
  
  

• Avoid over- or under-dosing and reduce HPA-axis risk
  
  

II. Glucocorticoid Equivalent Dose Table (Anti-Inflammatory)

Approximate oral dose equivalents

• Hydrocortisone = 20 mg
  
  

• Cortisone acetate = 25 mg
  
  

• Prednisone = 5 mg
  
  

• Prednisolone = 5 mg
  
  

• Methylprednisolone = 4 mg
  
  

• Triamcinolone = 4 mg
  
  

• Dexamethasone = 0.75 mg
  
  

• Betamethasone = 0.6 mg
  
  

(All above ≈ same glucocorticoid effect)

III. Mineralocorticoid Activity (Na⁺/Fluid Retention)

• High: Hydrocortisone, Cortisone
  
  

• Moderate: Prednisone, Prednisolone
  
  

• Low/None: Methylprednisolone, Triamcinolone
  
  

• None: Dexamethasone, Betamethasone
  → Prefer low mineralocorticoid steroids in CHF, HTN, edema
  
  

IV. Duration of Action

• Short-acting (8–12 h): Hydrocortisone
  
  

• Intermediate (12–36 h): Prednisone, Prednisolone, Methylprednisolone
  
  

• Long-acting (36–72 h): Dexamethasone, Betamethasone
  
  

V. Common Clinical Conversions (Examples)

• Prednisone 20 mg ≈ Methylprednisolone 16 mg
  
  

• Prednisone 10 mg ≈ Dexamethasone 1.5 mg
  
  

• Medrol Dose Pack (24 mg day 1) ≈ Prednisone 30 mg
  
  

VI. Pain & MSK “Burst” Ranges (Typical)

• Prednisone: 20–60 mg/day × 3–7 days
  
  

• Methylprednisolone: 16–48 mg/day
  
  

• Dexamethasone: 2–6 mg/day
  (Short courses ≤7–10 days often do NOT require taper)
  
  

VII. Tapering Principles

• Needed if:
  
  

  • >10–14 days, OR
    
    

  • Repeated bursts, OR
    
    

  • Cushingoid features
    
    

• Typical taper: ↓ 10–20% q3–7 days
  
  

• Watch for adrenal insufficiency: fatigue, hypotension, nausea
  
  

VIII. Key Safety Monitoring

• Glucose (esp DM)
  
  

• BP / fluid retention
  
  

• Mood / sleep
  
  

• GI risk (↑ with NSAIDs)
  
  

• Bone health if recurrent use
  
  

IX. Quick Memory Rule

• Pred 5 = Medrol 4 = Dex 0.75 = HC 20
  
  

1) Injectable Corticosteroid Equivalent Doses (Procedural / MSK)

A. Approximate Glucocorticoid Equivalents (Parenteral)

Anti-inflammatory equivalence

• Hydrocortisone (IV/IM) = 20 mg
  
  

• Methylprednisolone acetate/sodium (IM/IA/IV) = 4 mg
  
  

• Triamcinolone acetonide (IM/IA) = 4 mg
  
  

• Dexamethasone sodium phosphate (IV/IM/ESI) = 0.75 mg
  
  

• Betamethasone (IM/IA) = 0.6 mg
  
  

Memory rule:
Medrol 4 mg = Kenalog 4 mg = Dex 0.75 mg = HC 20 mg

B. Common Procedural Doses (Pain Practice)

Epidural Steroid Injections (ESI)

• Dexamethasone (non-particulate): 4–10 mg
  – preferred for cervical / transforaminal (↓ embolic risk)
  
  

• Triamcinolone (particulate): 40–80 mg
  
  

• Methylprednisolone (particulate): 40–80 mg
  
  

Large Joint (Knee, Shoulder, Hip)*

• Triamcinolone: 40 mg (up to 80 mg knee)
  
  

• Methylprednisolone: 40 mg
  *Hip often image-guided.
  
  

Small Joint / Soft Tissue

• Triamcinolone: 10–20 mg
  
  

• Methylprednisolone: 10–20 mg
  
  

Trigger Point Injections

• Dexamethasone: 2–4 mg (or none; often local anesthetic alone)
  
  

C. Particulate vs Non-Particulate (Critical)

• Non-particulate: Dexamethasone → safer for cervical, TFESI
  
  

• Particulate: Triamcinolone, Methylprednisolone → longer tissue effect, higher embolic risk
  
  

D. Duration of Effect (Approx.)

• Dexamethasone: shorter tissue duration, strong potency
  
  

• Triamcinolone / Methylprednisolone: longer local anti-inflammatory effect
  
  

3) Pain-Specific Steroid Selection Algorithm

Step 1: Identify Pain Generator

• Radicular (disc/foraminal) → epidural
  
  

• Facet / SI / joint → intra-articular or medial branch pathway
  
  

• Myofascial → trigger point ± minimal steroid
  
  

• Inflammatory flare → short oral burst
  
  

Step 2: Choose Steroid by Location & Risk

Cervical spine / TFESI

• Dexamethasone 4–10 mg
  
  

• Rationale: non-particulate, safer vascular profile
  
  

Lumbar interlaminar / caudal

• Triamcinolone 40–80 mg or Methylprednisolone 40–80 mg
  
  

• Rationale: longer local duration acceptable risk
  
  

Peripheral joint OA / bursitis

• Triamcinolone 40 mg (large joint)
  
  

• Avoid frequent repeats (≥3 months typical)
  
  

Trigger points / muscle pain

• No steroid or Dex 2–4 mg
  
  

• Rationale: limit myotoxicity
  
  

Step 3: Systemic Considerations

• DM: prefer lower dose, dexamethasone; warn hyperglycemia
  
  

• CHF/HTN/Edema: avoid hydrocortisone/prednisone
  
  

• Repeated injections: track cumulative exposure, bone risk
  
  

Step 4: Frequency & Limits (Common Practice)

• Same region: ≥3 months apart
  
  

• Typical max: 3–4 steroid injections/year/region (individualize)
  
  

Step 5: Exit Strategy

• If <30–50% relief after 2 injections → reassess dx
  
  

• Transition to PT, RFA, regenerative, or surgical eval as indicated