• Prescribe analgesia for continuous pain on a regular basis, in addition to as-required analgesia.
• Consider a stepwise approach, using the World Health Organization analgesic ladder. Start at the appropriate point of the analgesic ladder, moving up the ladder when the maximum dose at each step is reached until the person is comfortable. The steps are:
• Non-opioid analgesic: paracetamol and/or nonsteroidal anti-inflammatory drug (mild pain).
• Weak opioid, with or without a non-opioid analgesic (mild-to-moderate pain).
• Strong opioid, with or without a non-opioid analgesic (severe pain).
• At any stage, consider the addition of a non-opioid adjuvant drug.
• Review regularly (consider a telephone call if appropriate), step treatment up or down as necessary, and stop unnecessary medication that has not worked.

In depth

• Paracetamol and/or a nonsteroidal anti-inflammatory drug (NSAID) are recommended first line.
• If an NSAID is appropriate and not contraindicated:
• Ibuprofen, diclofenac, and naproxen are the NSAIDs of choice.
• The oral route is preferred, but if this is not possible, consider alternative routes (such as rectal).
• Consider prescribing a proton pump inhibitor with an NSAID. For more information on minimizing the risks associated with NSAID treatment, see the CKS topic on NSAIDs - prescribing issues.
• Non-opioid adjuvant drugs may also be useful for some people with specific pain types; see:
• Scenario: Managing colic.
• Scenario: Managing intracranial pressure pain.
• Scenario: Managing muscle spasm pain.
• Scenario: Managing neuropathic pain.
• Scenario: Spinal cord compression.

In depth

• Codeine or dihydrocodeine is recommended:
• If flexibility of dosing and titration of analgesic effect are required, prescribe the weak opioid separately to paracetamol.
• If compliance is likely to be a problem and analgesic requirements are stable, consider prescribing a product combining 500 mg of paracetamol with 30 mg of codeine.
• To prevent constipation, prescribe a stimulant laxative (such as senna or bisacodyl) and a softening laxative (such as docusate).
• A laxative with both properties (for example, co-danthramer or co-danthrusate) is also an option.
• Avoid dantron-containing laxatives in people who are incontinent as these drugs can cause a chemical burn (reddening) of the perianal area.
• Dantron can also colour the urine red and alarm the person.

In depth

• Use the oral route of administration where possible.
• Morphine is recommended:
• For advice on how to initiate morphine and titrate the dose, see Initiating and titrating morphine.
• If the person's compliance with oral morphine is good, but pain is inadequately controlled:
• Review the cause of the pain.
• Consider using a non-opioid adjuvant drug to treat a specific type of pain. See:
• Scenario: Managing colic.
• Scenario: Managing intracranial pressure pain.
• Scenario: Managing muscle spasm pain.
• Scenario: Managing neuropathic pain.
• Scenario: Spinal cord compression.
• If compliance with oral morphine is good, but the person cannot tolerate an adequate dose, consider using an alternative oral opioid — seek specialist advice.
• If the oral route is not appropriate (for example, the person has nausea and vomiting, or cannot swallow, or has poor compliance with oral analgesia), consider:
• Switching to a subcutaneous diamorphine or morphine infusion. For more information, see Switching from morphine to another strong opioid.
• Switching to transdermal fentanyl if the person has stable analgesic requirements and has previously tolerated opioids — seek specialist advice.
• When prescribing a strong opioid:
• Prescribe an anti-emetic (such as metoclopramide for gastric stasis, otherwise low-dose haloperidol):
• If the person has experienced nausea with a previous opioid, give regularly for the first week, to prevent opioid-induced nausea and vomiting and then reassess, or
• If the person experiences nausea with morphine but has not experienced nausea with a previous opioid, prescribe for use on an as-required basis for 1 week.
• To prevent constipation, prescribe a stimulant (such as senna or bisacodyl) and a softening laxative (such as docusate):
• A laxative with both properties (for example, co-danthramer or co-danthrusate) is also an option.
• Avoid dantron-containing laxatives in people who are incontinent as these drugs can cause a chemical burn (reddening) of the perianal area.
• Dantron can also colour the urine red and alarm the person.
• Seek specialist palliative care advice if:
• There is doubt about how to manage a person's pain.
• Adverse effects limit treatment and cannot be adequately managed.
• An unfamiliar opioid or route of administration is being considered.
• The pain is still at 50% or more of its starting level after 2 weeks.

In depth