Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.
N.B. Refer to guidelines on AthenA for management of persistent pain.
This guideline is aimed at providing quick and general guidance on acute pain and palliative care. Many of the principles remain the same, however differences in prescribing are detailed in separate sections, prescribing notes for acute pain and palliative care.
This guideline does not replace the more detailed local guidelines available, which should be referred to as appropriate. If the patient's pain remains unresolved despite using this guideline, or more detailed local guidelines, then refer to the appropriate pain team for further advice.
There is good evidence that effective pain relief reduces patient morbidity, helps facilitate early recovery, mobilisation and discharge from hospital. As pain is subjective, drug regimens need to be tailored to meet individual requirements. There are local variations in which particular drugs from each class of analgesics may be preferred and may be indicated in a specialty specific analgesic ladder.
Detailed pain assessment is essential. The pain score and pain descriptors obtained from the patient may influence the choice of analgesic within the WHO analgesic ladder.
In addition to the general principles of assessing pain above:
In addition to the general principles of assessing pain above:
Ascertain whether patient is intolerant to any analgesic. If intolerant to opioid, establish which one as most patients are not intolerant of every opioid.
Prescribe analgesia regularly according to guidelines further below or as per local guidelines, bearing in mind any documented sensitivities / allergies. Use oral route whenever possible and appropriate, also consider potential side effects of analgesia.
Review analgesia at least daily and always at discharge.
If an analgesic has failed to control the pain, step up to the analgesic on the next step of the ladder. N.B. Some patients may not respond to codeine but may respond to other Step 2 analgesics.
For older patients early review of response to analgesia is required as they are more likely to experience side effects like confusion and constipation.
Below is the basic analgesic pain ladder which is used to manage most types of pain. The differences in pharmacological management between the types of pain are outlined in the Prescribing Notes section so establish which type of pain your patient has, then manage as for:
Refer to guidelines on AthenA for management of persistent pain.
e.g. Paracetamol (see relevant prescribing notes, links above). +/- NSAID |
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Use weak opioid e.g. co-codamol 30/500 (see relevant prescribing notes, links above) +/- NSAID |
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Use opioid for moderate to severe pain (see relevant prescribing notes, links above) +/- NSAID |
Adjuvant, paracetamol and anti-emetics can be considered in each step for palliative pain (see prescribing notes for palliative care). N.B. Remember that analgesia can be stepped down as well as up.
Guideline reviewed | April 2019 |
Page updated | June 2023 |