Analgesia 💊

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🧠 Understanding Pain

  • Assess pain severity (mild / moderate / severe)
  • Use patient’s self-report, visual analogue scale, or behavioural cues
  • Identify type: nociceptive (somatic/visceral) vs. neuropathic
  • Treat underlying cause when possible

📈 WHO Pain Ladder

  • Step 1 – Mild Pain: Paracetamol ± NSAIDs
  • Step 2 – Moderate Pain: Add weak opioid (e.g. codeine, tramadol)
  • Step 3 – Severe Pain: Switch to strong opioids (e.g. morphine, oxycodone)
  • Adjuvants: Consider for neuropathic pain (e.g. amitriptyline, gabapentin)

💊 Medication Guide

  • See full table below for common analgesics and their dosing
  • Paracetamol: Safe in most patients. Caution in liver disease.
  • Ibuprofen: Avoid in AKI, GI bleed, asthma. Ensure PPI with NSAIDs.
  • Codeine: Causes constipation, drowsiness.
  • Tramadol: Watch for delirium, serotonin syndrome.
  • Morphine (oral): Titrate to pain. Adjust for renal function.
  • Oxycodone: Preferred in renal impairment.
  • Amitriptyline: 10–25 mg nocte for neuropathic pain. Sedating.

📋 Practical Prescribing Tips

  • Always prescribe laxatives with opioids (e.g. Senna, Lactulose)
  • For elderly: start low, go slow — avoid long-acting opioids initially
  • Consider co-analgesia early: paracetamol + NSAID or weak opioid
  • Document pain score, response, and side effects

⚠️ Special Considerations

  • Renal impairment: Avoid NSAIDs; dose-reduce or avoid morphine
  • Liver disease: Adjust paracetamol dose, avoid co-codamol
  • Delirium risk: Avoid tramadol, amitriptyline in older adults
  • Opioid-naive vs. tolerant: Always confirm prior use before prescribing
  • Palliative care: May require stepwise titration and breakthrough doses

📌 Common Mistakes to Avoid

  • Underprescribing (esp. in postop or fracture pain)
  • Forgetting PRN doses when regular analgesia is started
  • Forgetting laxatives with opioids
  • Forgetting PPI with NSAIDs in at-risk patients
  • Not reassessing or escalating appropriately

🔗 Related Tools

WHO Pain Ladder - Analgesia Guide

Stepwise approach to pain management

Step 1: Non-opioids (Mild Pain)

Paracetamol
PO / PR / IV
Dose:1g
Frequency:QDS
Notes: Caution in liver disease.
Ibuprofen
PO
Dose:400mg
Frequency:TDS
Notes: Avoid in AKI, asthma, PUD. Ensure PPI with NSAIDs
Diclofenac
PO / PR / IM
Dose:50mg
Frequency:TDS
Notes: Avoid in cardiac disease. Ensure PPI with NSAIDs

Step 2: Weak opioids (Moderate Pain)

Codeine
PO
Dose:30mg
Frequency:QDS
Notes: May cause constipation
Solpadeine
PO
Dose:2 tabs
Frequency:QDS
Notes: Contains 8mg codeine
Solpadol
PO
Dose:2 tabs
Frequency:QDS
Notes: Contains 30mg codeine

Step 3: Strong opioids (Severe Pain)

Morphine (IV/SC/PO)
IV / SC / PO
Dose:2.5–10mg
Frequency:4–6 hourly
Notes: Max 30mg/day initially
Oramorph
PO
Dose:10–20mg
Frequency:4 hourly
Notes: Use in breakthrough pain
Oxycodone (Oxynorm)
PO
Dose:5mg
Frequency:4–6 hourly
Notes: Breakthrough pain
Oxycodone (Oxycontin)
PO
Dose:5–10mg
Frequency:BD
Notes: Slow-release; potent
Fentanyl Patch
Transdermal
Dose:12mcg/hr
Frequency:72 hrly
Notes: Chronic stable pain only

Adjuvant Analgesics

Gabapentin
PO
Dose:300–900mg
Frequency:TDS (titrated)
Notes: Neuropathic pain
Pregabalin
PO
Dose:75mg
Frequency:BD
Notes: Neuropathic pain
Carbamazepine
PO
Dose:100mg
Frequency:BD
Notes: Trigeminal neuralgia
Lidocaine Patch
Topical
Dose:12 hr on/off
Frequency:Daily
Notes: Max 3/day
Hyoscine Butylbromide
PO / IV / IM
Dose:20mg
Frequency:QDS
Notes: For colicky pain
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