WHO pain ladder
Adjuvants: anticonvulsants (neuropathic), TCAs
Non-opioid (aspirin, paracetamol, NSAID) ± adjuvant
Opioid for mild/moderate pain (Co-codamo) ± Non-opioid ± Adjuvant
for moderate/severe pain (morphine, diamorphine, fentanyl, oxycodone,
hydromorphone) ± Non-opioid ± Adjuvant. Oral morphine is drug
Morphine is available in liquid, tablet, normal and controlled release
preparations. Oral morphine should be given every 4 hours.
Starting dose is 2.5-10mg 4 hourly (reduce in elderly or impaired renal function).
Pain which occurs between regular doses: give a dose equivalent to
the 4 hourly dose. Normal regime continued even if breakthrough dose taken. After 24 hours the
new dose of morphine is the net morphine in that time divided by 6 (if given 6 times a day), and
the rescue doses increased accordingly.
: Once dose titrated, patient may prefer convenience of controlled release
perparation of morphine. The 12 hourly controlled release (MST Slow Release,
tradename zomorph) is the 24 hour dose divided by 2.
Nausea/vomiting, hallucinations, itching, tolerance/dependence (rare if true pain)
Give morphine with an anti-emetic e.g. cyclizine 50mg PO/IV/IM TDS. Maximum 150mg in 24h.
At higher doses morphine has poor solubility & oxycodone is preferred.
Divide morphine dose by 3
Mild to moderate pain, diarrhoea
Oral 30-60mg every 4h
Co-codamol is combination of codeine/paracetamol, where x is mg of codeine phosphate, and y is mg of paracetamol.
Often 30/500 for moderate pain
Pain relief, anti-inflammatory
Pain/inflammation in rheumatoid arthritis, acute gout, post-op
“”, fever/pain in children, dysmenorrhoea, migraine. 1.2-1,8g daily in divided doses
GI discomfort/bleeding (should take with meals), hypersensitivity, renal failure
Asthma, hypersensitivity to any NSAID, severe heart failure. COX2s are
CI in some CVS diseases now. NSAIDs may interfere with renal function,
COX inhibitor, an NSAID. Aniplatelet: stops aggregation of platelets.
300-900mg every 4-6 h, max 4g daily. Alternative: paracetamol
CVS disease as an antiplatelet:
75mg daily. Alternative: clopidogrel
GI bleeding/irritation (so take after food), bronchospasm
Reyes's syndrome, Children < 16y, breast feeding, Hypersensitivity,
Previous reaction to an NSAID e.g. asthma/angiodema
COX inhibition. It is not an NSAID: does not irritate the lining of the
stomach, affect blood coagulation as much as NSAIDs, or affect function
of the kidneys.
Mild to moderate pain, pyrexia
Dose: 0.5-1g every 4-6h to a max 4g daily. Can also be given (rarely) as IV infusion, rectal
Liver damage in overdose. Rashes, blood disorders (e.g. thrombocytopenia).