Adult oral analgesia

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General guidelines
  1. Use the oral route whenever possible.
  2. Give paracetamol and NSAIDS regularly and opioids as needed.
  3. Avoid the use of compound analgesia, eg co-codamol.
  4. Review analgesia regularly, at least once a day.
  5. When changing from one route of administration to another, use "step over" doses (equipotent) until you can assess the effect. Later you can change to "step-down" drugs (less potent).
  6. When changing from one route of administration to another, remember to use equipotent (equal strength) doses.
  7. A multi-modal approach improves pain relief, reduces the patient’s opioid requirements and hence opioid side effects.
  8. Do not prescribe compound analgesics. i.e co-codamol.
Non-steroidal anti-inflammatory analgesia (NSAIDs)

Please refer to NSAID guidelines.
Please remember the side-effects of NSAIDs and stop them if the patient develops dyspepsia or renal impairment.

Part One

Part two

Opioid analgesia
  • In the elderly use a reduced dose and longer dosing interval.
  • Patients with moderate to severe renal impairment (see acute pain management in adults with renal impairment) or liver impairment may need a reduced dose and a longer dosing interval.
  • In patients where constipation is a problem, ensure stimulant laxatives are prescribed, eg senna tablets.

Remember unexpected pain must be investigated for other causes, especially if the analgesia prescribed becomes ineffective. The patient's condition can change.

Oral Opioids

  • Combination of opioids should not be prescribed or given.
  • If you need to change opioids seek advice from Acute Pain Team and/or see Opioid Conversion Chart in the BNF or Palliative Care Formulary.
  • The most common side effects of opioids are:

Laxatives may need to be prescribed. Encourage a high fibre diet and adequate fluid intake. Assess for other causes.

Nausea and vomiting: 
An anti-emetic should be prescribed and administered. See PONV guidelines.

Assess cause – may not be opioid. Ondansetron can help or low dose naloxone.

Respiratory depression: 
If respiratory rate is less than 7 per minute and/or sedation score is 3:

  • Contact medical staff, clinical nurse practitioner or the Acute Pain Nurse.
  • Administer 10litres/min of oxygen via Hudson face mask.
  • Give naloxone intravenously in 100 microgram increments every minute, max 400mcg until patient’s sedation score is 0 or 1.


  • Use a reduced dose with a longer dosing interval in the elderly.
  • Refer to the acute pain management in Adults with Renal Impairment guidelines.
  • Contact acute pain team for advice on patients with severe liver impairment.

At Raigmore Hospital the Acute Pain Team includes:

Consultant Anaesthetist - Department of Anaesthesia
Clinical Nurse Specialists, Acute Pain Service
Senior Pharmacist - Pharmacy Department

Advice can be sought in office hours - 08.00 – 16.00 (page 1003 or 6056)
out of hours please contact the ITU anaesthetist.

Abbreviation Meaning
eGFR Estimated glomerular filtration rate
AKI Acute kidney injury
ACE inhibitors Angiotensin-converting-enzyme inhibitors
Editorial Information

Last reviewed: 30 November 2018

Next review: 30 November 2020

Author(s): Acute Pain Team

Version: 1

Approved By: TAM subgroup of ADTC

Reviewer Name(s): Acute Pain Nurse Specialist

Document Id: TAM100