What can be given for severe pain?

Management of Severe Pain (9/10)

For severe pain rated 9/10, immediately initiate strong opioids—oral morphine is the first-line choice at 20-40 mg orally (or 5-10 mg IV/SC if urgent relief needed), combined with acetaminophen 1000 mg and/or an NSAID unless contraindicated. 1, 2

Immediate Treatment Algorithm

First-Line Strong Opioid Therapy

• Start oral morphine 20-40 mg immediately for opioid-naïve patients with severe pain 1, 2
• If urgent relief is required or oral route unavailable, use parenteral morphine 5-10 mg IV or SC (oral to IV/SC potency ratio is 1:2 to 1:3) 1
• Provide immediate-release (IR) morphine every 4 hours plus rescue doses available up to hourly for breakthrough pain 1

Multimodal Analgesia—Add Non-Opioids

• Combine with acetaminophen 1000 mg every 4-6 hours (maximum 4 g/day) as it is effective for all pain intensities in the short term 1, 3
• Add ibuprofen 400 mg every 4-6 hours if no contraindications, as NSAIDs are effective for all pain intensities and particularly useful for inflammatory or bone pain 1, 3, 4

Alternative Strong Opioids if Morphine Unavailable

• Oxycodone 20 mg orally (1.5-2 times more potent than oral morphine) 1, 2
• Hydromorphone 8 mg orally (7.5 times more potent than oral morphine) 1, 2
• IV fentanyl or buprenorphine for patients with renal impairment (eGFR <30 mL/min) 1

Critical Management Principles

Route of Administration

• Oral route is preferred when feasible, even for severe pain 1
• Parenteral routes (IV/SC) are reserved for patients requiring urgent relief, unable to swallow, or with poor oral tolerance 1

Dosing Schedule

• Administer analgesics on a regular schedule, not "as needed," for baseline pain control 1, 3
• Prescribe rescue doses (10% of total daily opioid dose as IR formulation) for breakthrough pain episodes 1, 3

Titration Strategy

• Titrate using IR morphine every 4 hours plus hourly rescue doses as needed 1
• Adjust total daily dose based on rescue medication requirements over 24 hours 1

Essential Prophylaxis and Monitoring

Mandatory Opioid Side Effect Management

• Prescribe laxatives routinely for all patients on opioids to prevent constipation 1
• Provide antiemetics (metoclopramide or antidopaminergics) for opioid-induced nausea/vomiting 1

Special Populations

• Renal impairment: Use all opioids with caution at reduced doses; fentanyl and buprenorphine are safest in advanced kidney disease (stages 4-5) 1, 3
• Hepatic impairment: Use acetaminophen cautiously but it remains safe at recommended doses even in cirrhotic patients 5

Common Pitfalls to Avoid

• Do not delay strong opioids for severe pain—the WHO ladder allows starting at step 3 for very severe pain 1
• Do not use weak opioids (codeine, tramadol) for pain rated 9/10—these are inadequate for severe pain 1
• Do not prescribe two sustained-release opioids together—use one long-acting formulation with IR for breakthrough 1
• Do not use transdermal fentanyl for rapid titration—it is only appropriate once pain is controlled with other opioids 2
• Do not withhold NSAIDs due to unfounded concerns—short-term use (<14 days) of ibuprofen 400 mg is safe in most patients 4, 5