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About PainAnalgesic Flowchart
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Use this flow chart(algorithm) for online advice about using
pain relief medication for conditions like back pain, period pain,
toothache and arthritis. Most of the medicines mentioned in this
analgesic ladder can be bought over the counter (paracetamol, the
anti-inflammatory ibuprofen, cocodamol 8/500).
If you require strong narcotic prescription pain relieving
drugs, you will need to make an appointment with your family
doctor.
Let your mouse hover some of the drug names for simple analgesic
dosing recommendations (route of administration, dose, frequency
etc).
Rate your pain as Mild, Moderate or Severe, and choose the
correct starting place in the left hand column.
PainAnalgesic AdviceCommentsMild
Start with regular paracetamol
See Pain Types and Medication Types for advice about which
analgesics are best for particular types of pain.
Change to regular paracetamol plus an NSAID (e.g. ibuprofen)
Be aware of the side effects and contra-indications of
NSAIDs
Moderate
Change to regular cocodamol 8/500 plus an NSAID (e.g.
ibuprofen)
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.
See your doctor to change to regular cocodamol 30/500 plus an
NSAID (e.g. ibuprofen)
7% of the population can't convert codeine to morphine in the
liver, making codeine totally ineffective for them. Consider
Tramadol / Buprenorphine / Morphine instead.
See your doctor to change to regular paracetamol plus an NSAID
(e.g. ibuprofen) plus either dihydrocodeine OR tramadol
Dihydrocodeine and Tramadol are both available in normal release
and slow release preparations.
Severe
See your doctor to change to regular paracetamol plus an NSAID
(e.g. ibuprofen) plus oral morphine (10 mg 4 hourly)
If you have nerve type pain, see your doctor about medications
specific for that type of pain (see Anti-depressants,
Anti-convulsants, Nerve Pain).
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 smaller dose increases may not produce any clinically noticeable
effect.
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.
Consider Pain Clinic referral for specific non-drug
interventions e.g. nerve blocks, epidural injections, joint
injections etc.
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