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Analgesia

WHO pain ladder — paracetamol, NSAIDs, opioids & PRN prescribing

Assess pain before prescribing. The WHO analgesic ladder guides step-up treatment. Always co-prescribe antiemetic and laxative when starting opioids. Review within 1–2 hours of any new opioid prescription.

What to do

1 · Assess pain (SOCRATES)

Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating factors, Severity 0–10. Is this expected, or a new surgical/medical complication?

2 · Review the drug chart

What is already prescribed? Has it been given? Are PRN doses available? Don't duplicate opioids — check carefully before adding.

3 · Step 1: Paracetamol 1g QDS

Regular paracetamol is the backbone of analgesia. Ensure it's prescribed regularly (QDS), not just PRN. Reduce to 500mg if <50kg or liver disease.

4 · Step 2: Weak opioid

Codeine 30–60mg QDS PO — check renal function (accumulates in AKI).

Tramadol 50–100mg QDS — lower ceiling, caution in epilepsy.

5 · Step 3: Strong opioid

Morphine 5–10mg PO/SC PRN (opioid-naive). Titrate carefully.

Opioid-experienced: use 1/6 of daily total as PRN dose.

6 · Co-prescribe antiemetic + laxative

Mandatory with every new opioid:

Ondansetron 4mg PRN (antiemetic)
Senna 2 tabs nocte minimum (laxative)

Document in notes.

Drugs

Drug	Dose	Route	Notes
Paracetamol	1g	PO/IV QDS	Max 4g/day. Reduce to 500mg if <50kg or liver disease.
Codeine phosphate	30–60mg	PO QDS	Avoid in AKI, severe liver disease. Ineffective in poor CYP2D6 metabolisers (~10%).
Morphine sulphate	5–10mg	PO/SC PRN	Opioid-naive. Reduce in elderly, renal impairment. 4-hourly PRN.
Ibuprofen	400mg	PO TDS	Contraindicated: AKI, CKD, GI bleed, anticoagulation, post-GI-anastomosis, asthma.

Red flags

RR <8 + oversedation after opioid — hold next dose, consider naloxone 400mcg IV
Worsening abdominal pain post-op — surgical complication, not just pain management failure
Pain uncontrolled despite step 3 — anaesthetics/pain team referral
AKI developing — opioids accumulate, reduce dose or frequency

Reference: WHO Pain Relief Ladder / BNF / NICE Palliative Care NG31