The Pain Clinic - About Pain - Analgesic Flowchart

Copyright 2009 www.PainClinic.org Use this flow chat (algorithm) for online advice about pain relief medication. Most of the medications can be bought over the counter (paracetamol, the anti-inflammatory ibuprofen, cocodamol 8/500). If you require stronger prescription dugs, you will need to make an appointment with your family doctor. Rate your pain as Mild, Moderate, or Severe and choose the correct starting place in the left hand column. Pain Mild Analgesic Advice Start with regular paracetamol Comments See Pain Types and Medication Types for advice about which analgesics are best for particular types of pain. Be aware of the side effects and contra-indications of NSAIDs. Be aware of the side effects and contra-indications of NSAIDs, and codeine. All these medications can be bought over the counter at your local pharmacy. Always read the instruction leaflet about dose and frequency. If you are taking any other medication from your doctor or you are pregnant, please ask your pharmacist or GP for further advice. 7% of the population can't convert codeine to morphine in the liver, making codeine totally ineffective for them. Consider Tramadol / Buprenorphine / Morphine instead. Dihydrocodeine and Tramadol are both available in normal release and slow release preparations.

Change to regular paracetamol plus an NSAID (e.g. ibuprofen)

Moderate

Change to regular cocodamol (8 mg / 500 mg) plus an NSAID (e.g. ibuprofen)

See your doctor to change to regular cocodamol (30 mg / 500 mg) plus an NSAID (e.g. ibuprofen)

See your doctor to change to regular paracetamol plus an NSAID (e.g. ibuprofen) plus either dihydrocodeine OR tramadol See your doctor to change to regular paracetamol plus an NSAID (ibuprofen) plus oral morphine (10 mg 4 hourly) Calculate the 24 hour dose of morphine and convert if necessary to twice daily slow release oral morphine (MST). Use normal release morphine 4 hourly for breakthrough pain (single dose = 1/6th total daily dose). If necessary the daily morphine dose can be increased by 50-100% as

Severe

If you have nerve type pain, see your doctor about medications specific for that type of pain (see Antidepressants, Anti-convulsants, Nerve Pain).

Alternatives to morphine include oxycodone, hydromorphone, fentanyl patches, and buprenorphine (patches and sublingually). Avoid oral pethidine as it only lasts 1.5 hours. Remember that morphine (and any other morphine-like drug) causes constipation. The best cure for this is lactulose (for lubrication) plus senna (for movement). Nausea and vomiting can be troublesome initially but usually passes with acclimatisation. If you are actively vomiting then anti-emetics by mouth will be ineffective. Some anti-emetics are available sublingually or by suppository and can therefore bypass this problem.

smaller dose increases may not produce any clinically noticeable effect.

Consider Pain Clinic referral for specific non-drug interventions e.g. nerve blocks, epidural injections, joint injections etc.