Ward · prescribing
Analgesia
Step 1
Ladder
- 1 · base, regular: paracetamol ± NSAID
- 2 · weak opioid: tramadol
- 3 · strong opioid: morphine, oxycodone
- add an adjuvant at any step for neuropathic pain
Step 2
Doses
| drug | dose | caution |
|---|---|---|
| Paracetamol | 1 g QDS (max 4 g/day) | reduce if < 50 kg, frail, or liver disease |
| Ibuprofen | 400 mg TDS (max 2.4 g/day) | avoid in AKI, GI bleed risk, cardiac, elderly |
| Ketorolac | 10–30 mg IV/IM (max 90 mg/day; 60 mg if elderly or < 50 kg; max 5 days) | NSAID cautions; short-term only |
| Tramadol | 50–100 mg QDS (max 400 mg/day) | serotonergic, lowers seizure threshold, caution in elderly |
| Morphine (oral IR) | 5–10 mg PRN (2.5–5 mg if frail / renal) | see renal note |
| Morphine (IV) | 2–5 mg, titrated in 1–2 mg increments | monitor sedation + RR |
Step 3
Conversion
approximate: verify against local / palliative guidance
| from → to | factor |
|---|---|
| Tramadol → oral morphine | ÷ 10 (approx) |
| oral morphine → oral oxycodone | ÷ 1.5–2 |
| oral morphine → SC morphine | ÷ 2 |
| oral morphine → SC diamorphine | ÷ 3 |
- Breakthrough dose = 1/6 of the total 24-hour opioid dose
Step 4
Renal
- Avoid morphine and codeine: active metabolites (M6G) accumulate, giving sedation and respiratory depression. Avoid below a creatinine clearance of about 30 mL/min
- Prefer fentanyl or alfentanil (specialist hands), or oxycodone with dose reduction and monitoring
- Reduce all doses and lengthen intervals
Step 5
Co-prescribe
- A laxative: opioids constipate predictably
- A PRN antiemetic
- Naloxone available for toxicity
- Ward opioid toxicity / opioid-dependent: 100 mcg (0.1 mg) IV, repeat every 2–3 min, titrate to respiratory rate > 12 (not to full alertness)
- Severe respiratory depression / peri-arrest: 400 mcg (0.4 mg) IV/IM, repeat every 2–3 min; no IV/IM access: 2 mg intranasal
- Recurrent depression → infusion at approximately two-thirds of the effective bolus dose per hour
Neuropathic pain
- Amitriptyline, gabapentin / pregabalin, or duloxetine: first-line over opioids
Step 6
Safety
Opioid toxicity
- Falling respiratory rate or rising sedation score → hold the opioid, reassess, naloxone if toxic
Naloxone wears off before the opioid does
- Respiratory depression recurs as naloxone washes out: keep monitoring well beyond the dose, longer after modified-release opioids, methadone or a patch
- Repeat doses needed → infusion + higher-level monitoring; doses in Step 5
Two more traps
- Gabapentinoids with opioids: serious respiratory depression. Highest risk if age ≥ 65, COPD, renal impairment, or concurrent benzodiazepines
- Combination tablets: count the paracetamol they contain toward the daily maximum
On-call approach
Pain uncontrolled on current analgesia: the bedside approach when the regimen is not working.
Last clinically reviewed · June 2026 · Last updated · October 2026
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.