PAIN MANAGEMENT IN ADULTS

 

ANALGESICS COMMENTS
STEP 1: MILD PAIN (NON-OPIOID ± ADJUVANTS)
  • Paracetamol 1 g every
    6 hours (500 mg in
    elderly)
    And/or
  • Ibuprofen 400 mg
    every 6- 8 hours (max
    2,400 mg/daily)
    or
  • Diclofenac 50 mg
    every 8 hours
  • Continue with step 1
    analgesics when moving to
    step 2 and 3
  • Prolonged use of high doses
    of paracetamol may cause
    liver toxicity
  • Do not use NSAIDS in renal
    impairment
  • Caution when using NSAIDS
    for more than 10 days
STEP 2: MODERATE PAIN
(WEAK OPIOID ± NON-OPIOID ± ADJUVANT)
  • Morphine 2.5-5 mg
    every 4 hours during
    day, double dose at
    night
    Or
  • Codeine 30-60 mg
    every 6 hours (max
    240 mg)
    Or
  • Tramadol 50-100 mg
    every 6 hours (max
    400 mg)
  • Low dose morphine is
    considered step 2 analgesic
    and recomended first line if
    available
  • Discontinue step 2
    analgesics when starting
    step 3
  • Give Bisacodyl 10-15
    mg nocte to prevent
    constipation except if
    diarrhoea is present

    • Add liquid paraffin 10 ml
      once a day if Bisacodyl is not
      enough
STEP 3: SEVERE PAIN
(STRONG OPIOID ± NON-OPIOID ± ADJUVANT
  • Morphine 7.5-10 mg
    every 4 hours during
    day and double dose at
    night

    • If breakthrough
      pain, give equivalent
      additional dose
    • Increase dose by
      30-50% as required to
      control patient’s pain
    • Give additional dose
      30 minutes before an
      activity causing pain
      (e.g. wound dressing)
  • Elderly and renalt
    impairment may require
    dose adjustment
  • Give Bisacodyl 10-15 mg
    nocte to prevent constipation
    except if diarrhoea is present

    • Add liquid paraffin 10 mL
      once a day if Bisacodyl not
      enough
  • If modified release tablets
    are available, use the same
    24-hour dose but given in 1
    or 2 doses daily

Adjuvants

  • Amitriptyline 12.5–25 mg nocte for neuropathic pain
    (max 50-75 mg if tolerated)
  • Clonazepam 0.5-1 mg nocte for neuropathic pain
    (second line)
  • Dexamethasone 4-8 mg once a day for swelling or
    oedema
  • Hyoscine 20 mg every 6 hours for smooth muscle spasm
  • Diazepam 5-20 mg nocte for painful skeletal muscle
    spasms
Caution
  • Do not use pethidine for chronic pain; accumulates with severe side-effects on the gut. Only use as one off-dose
    for acute severe pain if morphine not available
  • Side effects of NSAIDS: gastritis, renal toxicity, bleeding, bronchospasm
  • Avoid amitriptyline in heart disease
  • Side effects of opioids