Analgesia Ladder

Step 1 – Simple Analgesia

• Paracetamol: 500-1000 mg QDS (max 4 g/day)
• Topical NSAIDs: Ibuprofen gel, diclofenac gel - useful for localised musculoskeletal pain
• Suitable for: Mild pain, headaches, sprains/strains, osteoarthritis

Step 2 - Add/Consider Oral NSAID

• Ibuprofen: 400 mg TDS (max 2.4 g/day)
• Naproxen: 250-500 mg BD (anti inflammatory and longer acting)

Co-prescribe PPI (e.g. Omeprazole 20 mg OD):

• When NSAID used for >2 weeks
• In adults aged ≥65 years
• If history of dyspepsia, peptic ulcer, on aspirin/anticoagulant

• Monitor: Renal function, blood pressure, GI symptoms
• Suitable for: Inflammatory pain, arthritis, menstrual pain, dental pain

Step 3 – Add Weak Opioid

• Codeine phosphate: 15–60 mg QDS
• Co-codamol: 8/500 or 30/500, 1–2 tablets QDS
• Dihydrocodeine: 30-60 mg QDS
• Can be taken with NSAID

Prevent constipation: Consider Senna or Macrogol if using for more than a few days

• Monitor: Sedation, nausea, bowel habit
• Suitable for: Moderate post operative pain, severe musculoskeletal pain

Step 4 – Strong Opioids (Often prescribed by Specialist Use)

• Oral Morphine: 2.5-5 mg every 4 hours (immediate release) with breakthrough doses
• Oxycodone: Consider in renal impairment or intolerance to morphine
• Modified-release formulations: Start once pain stabilised (e.g. Zomorph BD)
• Always prescribe with: Laxative + PRN breakthrough dose

Buprenorphine Patches (Butec) - Suitable in Primary Care:

• Start with 5 mcg/hour patch (7-day)
• Titrate: 10 → 15 → 20 mcg/hour (max licensed: 40 mcg/hour)
• Change patch every 7 days
• Useful for chronic pain in stable patients unable to tolerate oral opioids

Neuropathic Pain Pathway

• First line: Amitriptyline 10 mg ON (titrate to 25-75 mg)
• Alternatives: Gabapentin (100 mg TDS), Pregabalin (75 mg BD)
• Trial period: 4-6 weeks to assess effect
• Combine with: Paracetamol or topical agents for mixed pain
• Suitable for: Diabetic neuropathy, sciatica, post-herpetic neuralgia

When to Refer to Pain Management Clinic

• Pain persisting >3 months despite stepwise analgesia
• Complex pain syndromes (e.g. fibromyalgia, CRPS)
• Opioid tolerance or dose escalation with limited benefit
• Patient already on strong opioids without clear functional benefit
• Concerns about medication misuse, overuse, or dependency
• Functional impairment, distress, or sleep disturbance due to chronic pain

Referral pathway: Use local MSK or pain clinic referral forms, include full analgesia history and impact on life/function.

Red Flags – Escalate Immediately

• New neurological deficit (weakness, numbness, bladder/bowel symptoms)
• Suspected fracture, malignancy, spinal infection, or cauda equina
• Persistent night pain, weight loss, systemic symptoms

Action: Escalate to GP or acute services. Consider 2WW or urgent imaging if indicated.

References:
- NICE CKS. Analgesia – mild-to-moderate pain (May 2023)
- NICE NG193. Chronic pain in over 16s (2021)
- BNF. Opioid analgesics and buprenorphine patches
- SEL ICS Pain & MSK Pathways
- Faculty of Pain Medicine. Core standards for pain management services