Step 1: mild intensity pain

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paracetamol
1g four times daily

or non-steroidal anti-inflammatory drug (NSAID)
(if not contra-indicated – refer to "Adjuvant therapies" section below)

± other adjuvant
  • Consider reducing paracetamol dose to 500mg four times daily when poor nutritional status, low body weight (<50kg), hepatic impairment and/or chronic alcohol abuse (check local policy for paracetamol and NSAIDs if patient receiving chemotherapy).

 

Step 2: mild to moderate intensity pain

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weak opioid
Codeine 30mg to 60mg four times daily or dihydrocodeine 30mg to 60mg four times daily

Alternative: use a combined paracetamol codeine preparation such as co-codamol 30/500, 2 tablets four times daily (refer to notes above about restrictions)

+ paracetamol
(Dose as above,
If no benefit stop after 3 to 4 days)

or NSAID
(If not contra‑indicated)

± other adjuvant
  • Prescribe a laxative and consider anti-emetic

 

Step 3: moderate to severe intensity pain

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strong opioid

+ paracetamol
(Dose as above)
(stop if no benefit)

or NSAID
(if not contra-indicated)

± other adjuvant

Stop any step 2 opioid
Codeine or dihydrocodeine 60mg 4 times daily≈24mg oral morphine in 24 hours

Seek advice:

severe pain not responding to treatment:

  • unacceptable side effects or toxicity

If titrating with immediate release oral morphine prescribe 5mg, 4 hourly and as required for breakthrough pain

If starting with modified release oral morphine prescribe 10mg to 15mg,
12 hourly and immediate release morphine 5mg as required for breakthrough pain
  • Consider prescribing a laxative and anti-emetic.
  • Use lower doses and increase dose more slowly if patient is frail, elderly or has renal impairment.
  • In severe renal impairment, an alternative opioid may be needed (refer to Choosing and changing opioids guideline).

 

Dose titration for Step 3 

(using morphine as an example)

  • Increase regular oral morphine dose each day in steps of about 30% (or according to breakthrough doses used) until pain is controlled or side effects develop.
  • Increase laxative dose as needed.
  • Convert to modified release morphine when stable.
    • Divide 24 hour dose of immediate release morphine by 2.
    • Prescribe as modified release morphine, 12 hourly.
    • Prescribe breakthrough analgesia at correct dose (1/6th to 1/10th of 24 hour morphine dose up to a maximum of 6 doses in 24 hours).

 

Anti-emetic

Regular laxative

(refer to Constipation guideline)
QTMetoclopramide 10mg up to three times a day

Senna 2 tablets at night or

bisacodyl 5mg to 10mg at night plus

docusate 100mg twice daily

QTHaloperidol 500 micrograms to 1.5mg daily

Prescribe as required for 5 to 10 days

 Macrogol 1 to 3 sachets per day

 

Subcutaneous (SC) analgesia

  • Usually given via a syringe pump over 24 hours.
  • Calculate the 24 hour dose of oral morphine.
  • Convert this to SC morphine.
  • Oral morphine 30mg≈SC morphine 15mg.
  • When large doses of breakthrough SC analgesia are required consider SC diamorphine.
  • Prescribe 1/6th to 1/10th of the 24 hour SC opioid dose as required, via SC route for breakthrough pain.
  • Refer to Syringe pumps guideline.

Breakthrough pain

Defined as a transient exacerbation of pain which occurs either spontaneously or in relation to a specific trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

  • Prescribe immediate release morphine at 1/6th to 1/10th of the regular 24 hour dose, as required up to a maximum of 6 doses in 24 hours. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review.
  • Assess 30 to 60 minutes after a breakthrough dose.
  • If pain persists give a second dose as required.
  • If pain is still not controlled seek advice.
  • Change breakthrough dose if regular dose altered.

 

Movement or incident related predictable pain

Can be difficult to manage; a dose of short-acting opioid before moving or when pain occurs may help. If pain is short-lived and the patient develops excessive drowsiness seek specialist advice.

 

Opioid toxicity – seek advice

  • Can be precipitated by several factors including rapid dose escalation, renal impairment, sepsis, electrolyte abnormalities, drug interactions.
  • Wide variation in the dose of opioid can cause symptoms of toxicity.
  • Prompt recognition and treatment are needed. Symptoms include:
    • persistent sedation (exclude other causes)
    • vivid dreams, hallucinations, shadows at the edge of visual field
    • delirium
    • muscle twitching/myoclonus/jerking
    • abnormal skin sensitivity to touch.
  • If the pain is controlled reduce the opioid dose by a third. Ensure the patient is well hydrated. Seek advice.
  • If patient still in pain consider reducing opioid dose by a third. Consider adjuvant analgesics, alternative opioids or both (refer to Choosing and changing opioids guideline). Seek advice.
  • Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression (refer to Naloxone guideline).

 

Adjuvant therapies

  • NSAID: for bone pain, liver pain, soft tissue infiltration, or inflammatory pain (side effects: gastrointestinal ulceration or bleeding [consider proton pump inhibitor (PPI)], renal impairment, fluid retention, adverse cardiac events).
  • Other analgesics: Nefopam is a non-opioid, non-NSAID analgesic occasionally preferred where alternatives are contraindicated or ineffective, or used as add-on therapy when pain is inadequately controlled. There is limited evidence regarding dose conversions. Seek specialist advice if considering prescribing.
  • Antidepressant or anticonvulsant: for nerve pain. Start at low dose: titrate slowly (refer to Neuropathic pain guideline). No clear difference in efficacy between the two types of medicine for this indication.
    • amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
    • gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
    • amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
    • gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
  • Corticosteroids: †dexamethasone
    • 8mg to 16mg daily for raised intracranial pressure.
    • 4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
    • Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
    • 8mg to 16mg daily for raised intracranial pressure.
    • 4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
    • Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
  • TENS, nerve block, radiotherapy, surgery, bisphosphonates, ketamine  (specialist use) and skeletal or smooth muscle relaxants.