What pain medications can be given?

Pain Medication Selection Based on Pain Severity

Pain medications should be selected according to the WHO analgesic ladder, starting with non-opioid analgesics for mild pain and progressing to weak or strong opioids for moderate to severe pain. 1

Assessment of Pain Severity

Before selecting pain medication, assess pain intensity using one of these validated scales:

• Visual Analogue Scale (VAS)
• Numerical Rating Scale (NRS)
• Verbal Rating Scale (VRS) 1

Treatment Algorithm Based on Pain Severity

For Mild Pain (NRS: 1-4)

• First-line options:

  • Acetaminophen (paracetamol): 500-1000 mg every 4-6 hours, maximum 4000 mg/day 1
  • NSAIDs (if no contraindications):
    • Ibuprofen: 400-600 mg every 6-8 hours, maximum 2400 mg/day 1, 2
    • Naproxen: 250-500 mg twice daily, maximum 1000 mg/day 1
    • Diclofenac: 50 mg 2-3 times daily, maximum 150 mg/day 1

• Cautions with NSAIDs:

  • Gastric protection recommended for prolonged use
  • Use with caution in patients with renal impairment, cardiovascular disease, or bleeding risk 1, 2
  • Consider lower doses of acetaminophen in patients with hepatic disease 2

For Moderate Pain (NRS: 5-7)

• First-line options:

  • Weak opioids in combination with non-opioid analgesics 1:
    • Codeine 30-60 mg + acetaminophen 500-1000 mg every 4-6 hours 1
    • Tramadol 50-100 mg every 4-6 hours, maximum 400 mg/day 1
    • Dihydrocodeine 60-120 mg (modified release) every 12 hours 1

• Alternative approach:

  • Low doses of strong opioids in combination with non-opioid analgesics 1

For Severe Pain (NRS: 8-10)

• First-line option:

  • Oral morphine (strong opioid of choice) 1
  • Start with immediate-release formulation for titration 1
  • Once stable, can switch to sustained-release formulation with rescue doses for breakthrough pain 1

• Alternative strong opioids:

  • Oxycodone: Consider when morphine causes intolerable side effects 3
  • Hydrocodone: Usually combined with acetaminophen, 5-10 mg every 4-6 hours 4
  • Fentanyl (transdermal): For stable pain, not for acute pain management 5

Important Considerations

Route of Administration

• Oral route is preferred when possible 1
• For severe pain requiring rapid control, consider intravenous administration 1
• Subcutaneous route is effective when oral route is not possible 1

Opioid Side Effect Management

• Always prescribe laxatives for prophylaxis of opioid-induced constipation 1
• Consider antiemetics (e.g., metoclopramide) for opioid-related nausea/vomiting 1
• Monitor for sedation and respiratory depression, especially during initiation 4

Special Populations

• Renal impairment: Use all opioids with caution at reduced doses and frequency 1
• Severe renal impairment: Fentanyl and buprenorphine are safer options 1, 5
• Elderly: Start with lower doses and titrate slowly 5

Combination Therapy

• Combining acetaminophen with ibuprofen provides superior analgesia compared to either agent alone and may reduce the need for opioids 6, 7
• Adding codeine 60 mg to acetaminophen 1000 mg offers enhanced analgesia over acetaminophen alone 8

Monitoring and Follow-up

• Regularly reassess pain control and adjust medication as needed
• Monitor for adverse effects
• For chronic pain, schedule regular dosing rather than "as needed" 1
• Always provide rescue doses for breakthrough pain when using long-acting opioids 1

Remember that the goal of pain management is to improve function and quality of life while minimizing adverse effects. The medication selection should be tailored based on pain severity, patient characteristics, and response to therapy.