ANALGESIC LADDER FOR IN‐PATIENT USE

SEVERE MODERATE Oral intake MILD – constant Regular PARACETAMOL 1g qds MILD – intermittent Regular PARACETAMOL 1g qds + Regular PARACETAMOL 1g qds (oral or PR) Regular NSAID* (oral or PR) + (IBUPROFEN 400mg tds) + Regular NSAID* + prn PARACETAMOL 1g qds PRN NSAID* (oral IBUPROFEN 400mg tds or if unable to prn MORPHINE (Oramorph) 10mg every (oral or PR) (oral IBUPROFEN 400mg tds) tolerate oral medications PR DICLOFENAC two hours 50mg tds) No oral intake + Regular PR PARACETAMOL 1g qds Regular CODEINE PHOSPHATE§ + 30 to 60mg qds Regular NSAID* (PR DICLOFENAC 50mg tds)

+ Paracetamol and codeine can be prescribed IV MORPHINE protocol as co‐codamol 30/500 OR TWO tablets up to FOUR times a day; (via Acute Pain Team) Patient‐Controlled † ensure paracetamol alone is not also Analgesia / Epidural analgesia charted as this can lead to overdose.

Additional Notes: *NSAID §Codeine phosphate Pain not controlled by pain ladder – contact Acute Pain Team. Please ensure that the pain Stop if regular NSAIDs give no benefit • Avoid with bowel surgery patients ladder has been used and medications given prior to contacting the service. Contra‐indications • Avoid if severe constipation Tramadol 50 to • History of hypersensitivity to aspirin/NSAIDs 100mg qds is alternative • Active GI ulceration or bleeding • May be added as “regular” in severe pain Prescribe anti‐emetic e.g. cyclizine 50mg tds • Severe heart failure, hepatic failure & renal failure †The IV morphine protocol or Patient‐Controlled • Coagulopathy Analgesia should be used in preference to Consider non‐pharmacological factors e.g., anxiety, lack of information, need for • Anti‐coagulants intramuscular analgesia physiotherapy and role of alternative therapies • Last trimester of pregnancy Caution in IV paracetamol (Record patient’s weight and reduce dose if less than 50kg) and (IV/IM) • Asthma diclofenac can be given if both oral and PR routes are unavailable • Elderly (reduce dose) • Renal impairment • CVD (and in those at risk of CVD)

Endorsed by ABHB MTC: October 2012 Page 1 of 2

ANALGESIC LADDER FOR PRIMARY CARE USE

SEVERE MODERATE MILD – constant Regular PARACETAMOL 1g qds MILD – intermittent Regular PARACETAMOL 1g qds + Regular PARACETAMOL 1g qds + Regular NSAID* + Regular NSAID* (IBUPROFEN 400mg tds) prn NSAID* (IBUPROFEN 400mg tds) + prn PARACETAMOL 1g qds (IBUPROFEN 400mg tds) consider co‐prescribing a ppi MORPHINE modified release (prescribe BY + BRAND) twice daily† PRN/regular CODEINE PHOSPHATE§ Stop weak opioid and consider co‐prescribing an (varying preparations are available – start antiemetic and/or laxative(s)

with the lowest dose possible) † Strong opiates should only be used/considered in accordance with local guidance on the Use of Strong Opiates in Chronic Non‐malignant Pain 2010: http://www.wales.nhs.uk/sites3/Documents/814/OpioidInN onMalignantPain‐GwentGuidance%5BFinal%5DJan2010.pdf See also: Opioid medicines for persistent pain – information for patients. British Pain Society January 2010 http://www.britishpainsociety.org/book_opioid_patient.pdf

Additional Notes: *NSAID §Codeine phosphate Ensure that patients’ expectations are managed – acute onset pain should only require a Stop if regular NSAIDs give no benefit • Avoid if severe constipation Tramadol 50 to 100mg short period of analgesia/treatment. Chronic pain is not about CURE but MANAGEMENT. Contra‐indications qds is alternative Total pain relief is not often achieved. • History of hypersensitivity to aspirin/NSAIDs • Ensure that the need is reviewed regularly • Active GI ulceration or bleeding • Ensure dose is titrated to maximum before Consider non‐pharmacological factors e.g., anxiety, lack of information, TENS, need for • Severe heart failure, hepatic failure & renal switching to stronger opioid physiotherapy and role of alternative therapies. failure • Ensure that the pain is nociceptive in nature; is the • Coagulopathy pain neuropathic? A neuropathic agent may then Useful tools are • Anti‐coagulants be more appropriate. See local guidance on The Pain Toolkit http://www.paintoolkit.org • Last trimester of pregnancy Diagnosis and Management of Neuropathic Pain The Back Book http://www2.nphs.wales.nhs.uk:8080/BackBookRequests.nsf/MainForm Caution in 2008: Expert Patient Programmes http://www.wales.nhs.uk/expertpatient • Asthma http://www.wales.nhs.uk/sites3/Documents/814/Neuropat • Elderly (reduce dose) hicPainGuidance%2DGwentNov09.pdf

• Renal impairment • CVD (and in those at risk of CVD)

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