Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Acute Kidney Injury – Introduction Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Management of Acute Kidney Injury SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Renal Transplants Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
In this section Close
In this section

Warning: Undefined variable $nameCategory in /home/docthand/public_html/wp-content/themes/docthand/single-post_handbook.php on line 42

Warning: Attempt to read property "term_id" on null in /home/docthand/public_html/wp-content/themes/docthand/single-post_handbook.php on line 42
Home | Articles | Assessment & Management of Acute Pain

Assessment & Management of Acute Pain

Last updated 4th March 2024

This guide is specifically for Acute ‘Nociceptive’ Pain that is not resulting from cancer.
Our Analgesic Ladder represents initial safe starting drugs and doses in acute pain.

Pain can be categorised into the following:

  1. Acute, Acute-on-chronic or Chronic
  2. Cancer related or Non-cancer related
  3. Nociceptive or Neuropathic

We advocate the following steps in before prescribing Analgesia:

Step 1 – Assess the Pain

Step 2 – Categorise the Pain

Step 3 – Prescribe Analgesia (See Analgesic Ladder)

Step 4 – Anticipate and Manage the Opioid Side-effects

Step 5 – Reassess the pain

Step 6 – Prepare for the Analgesic Plan on Discharge from Hospital

Step 1: Assessment of Pain


History – Questions not to forget


Presenting complaint:

  1. What does the pain feel like (e.g. ‘aching’, ‘burning’, ‘throbbing’, ‘stabbing’)?
  2. What is the effect on physical function?
    • Can they cough?
    • Can they deep breathe?
    • Can they get out of bed or reposition in bed?
    • Can they sleep?

Drug History:

  1. What is the current analgesic strategy? What has helped/not helped so far?
  2. Was the patient taking opioids or other analgesics pre-hospital? Has this been considered in their current prescription?

Assessment of Severity:

  1. Assessment of severity is important because it:
    • Helps guide initial choice of treatment
    • Helps to measure response to treatment
  2. We recommend that you choose one of the following pain assessment tools. Remember pain should be assessed together with the NEWS observation at rest AND on movement (e.g. deep breathing/coughing/repositioning):
    • The Verbal Rating Scale should be used in patients who can understand the use of the tool and verbalise their pain. (e.g. 0 to 10)
    • A 4-point Categorical Rating Scale (none, mild, moderate, severe) should be used in patients who can understand the use of the tool and verbalise their pain, but may not understand the VRS.  (e.g. none, mild, moderate or severe)
    • The Abbey Pain Assessment Tool should be used in patients who have cognitive impairment and/or are unable to verbalise their pain. There is a section on the NEWS chart to guide you in the use of this. (See below). Also available on – Abbey Pain Scale.

Document the Severity

Any member of medical, nursing or allied-health professional staff can assess pain using one of the above tools. It is important that the severity score is documented appropriately on the NEWS chart. See below.

Step 2 – Categorise Pain

“Not all pain is the same”. 

  1.  It is important to classify the pain (make a pain diagnosis) because this helps us to choose the best treatment.
  2. Pain can be classified in many ways, but it is helpful to classify pain using three main questions:
    • How long has the patient had pain?
    • What is the cause?
    • What is the pain mechanism?

Acute versus chronic pain (duration)

  1. Pain can be acute (pain for less than 3 months) or chronic (pain for more than 3 months or pain persisting after an injury heals). Sometimes, a patient with chronic pain may experience additional acute pain (acute on chronic pain). NB: This guideline is targeted at Acute pain and Acute-on-chronic pain only.

Cancer versus non-cancer pain (cause)


Cancer pain

NB: This guideline is targeted at Non-cancer pain. If you think your patient has Cancer-related pain, then you may wish to refer to the Scottish Palliative Care Guidelines or contact the in-hospital Palliative Care Team.

Non-cancer pain

  1. There are many different causes, including:
    • Surgery or injury
    • Surgical pathology (e.g. appendicitis, pancreatitis)
    • Degenerative disease (e.g. arthritis)
    • Childbirth
    • Nerve compression or injury (e.g. sciatica, neuralgia)
  2. Pain may be acute and last for a limited time or may become chronic.
  3. The cause may or may not be obvious.

Nociceptive versus neuropathic pain (mechanism)

Pain can also be classified by mechanism (the physiological or pathological way the pain is produced). The pain can either be nociceptive, neuropathic or mixed (both nociceptive and neuropathic).

Nociceptive pain

  1. Commonest type of pain following tissue injury.
  2. Sometimes called physiological or inflammatory pain.
  3. Caused by stimulation of pain receptors in the tissues that have been injured.
  4. Has a protective function.
  5. Patients describe pain as sharp, throbbing or aching, and it is usually well localised (the patient is able to point to exactly where the pain is).
  6. Examples: Pain due to a fracture, appendicitis, burn.

Neuropathic pain

  1. Caused by a lesion or disease of the sensory nervous system.
  2. Sometimes called pathological pain.
  3. Tissue injury may not be obvious.
  4. Does not have a protective function.
  5. Patients describe neuropathic pain as ‘burning’ or ‘shooting’. They may also complain of numbness or pins and needles. The pain is often not well localised.
  6. Examples: Post-amputation pain, pain associated with diabetes, sciatica.

NB: This guideline is targeted at Nociceptive pain. If you think your patient has Neuropathic pain, then you may wish to refer to the Acute Pain Team. Alternatively, there is an Algorithm for Management of Neuropathic Pain available on the NHSD&G Adult Joint Formulary 2022.

Step 3: Prescribe Analgesics

  1. If after Step 1 and Step 2 you are sure you are treating acute (or acute-on-chronic), nociceptive, non-cancer pain, then please refer to the Analgesic Ladder. This represents initial safe starting drugs and doses in acute pain.
  2. Before using this ladder, you need the following information:
    • Is the oral route available?
    • Patient’s Weight.
    • Is your patient in a ‘Special Group’: Renal or Hepatic Impairment, Poor Nutritional Status; Frailty; Opioid use disorder, Chronic Pain.

NB: patients with a history of either chronic pain or chronic opioid analgesics may need either higher doses of opioid analgesics or alternative analgesics. For complex patients such as these, please seek help from the Acute Pain Team.

Analgesic Ladder for Adults in Acute Pain

Oral Route
No Oral Route
Mild Pain
(see mild pain protocol on HEPMA)
- Oral Paracetamol 1g regularly four times a day
( 500mg four times a day if <50kg or in hepatic impairment/nutritional deficiency)
- ± 3 days of Oral Ibuprofen 400mg three times a day (check for contraindications)
- IV Paracetamol 1g regularly four times a day
(500mg four times a day if <50kg or hepatic impairment/nutritional deficiency)
Moderate Pain
(see moderate pain protocol on HEPMA)
- Oral Paracetamol 1g 500mg four times-a-day if <50kg or hepatic impairment/nutritional deficiency)
- Oramorph: 5mg five times-a-day
+ hourly PRN
(2.5mg five times-a-day if elderly)
- ± 3 days of Oral Ibuprofen 400mg three times-a-day
(check for contraindications)

If renal impairment change Morphine to:
- Oxynorm 2.5mg
five times-a-day + hourly PRN
(1.25mg five times-a-day if elderly)
-IV Paracetamol 1g four times-a-day
(500mg four times-a -day if <50kg or hepatic impairment/nutritional deficiency)
-Subcutaneous Morphine 2.5mg five times-a-day + hourly PRN
(1.25mg five times-a-day if elderly)

If renal impairment change Morphine to:
- Subcutaneous Oxynorm 1.25mg
five times-a-day + hourly PRN
(0.675mg five times-a-day if elderly)
Severe Pain
(see severe pain protocol on HEPMA)
- Regular Paracetamol +/- Ibuprofen (see above) If no oral route IV Diclofenac 75mg twice daily can be used (check for contraindications and d/w Acute Pain Team. Diclofenac is given as an IV infusion).
- Titrate: IV Fentanyl or Morphine (avoid Morphine in renal impairment)
- Intravenous PCA: Protocol E-Fentanyl OR Protocol A-Morphine (avoid Morphine in renal impairment) Please seek advice from pain team before modifying the bolus dose or background rate on a PCA.
- If unable to control pain using this regime then please call the Acute Pain team

  1. We recommend that the prescription is reviewed daily in accordance with pain assessment.  The prescription should be de-escalated as soon as it is clinically indicated to do so and a clear deprescribing plan for opioids should be in place at the time of discharge from hospital.
  2. Please note the following additional resources that should be consulted when indicated:

Step 4: Management of the Side Effects of Opioids



    1. Within the BNF, there is a helpful treatment summary on Constipation which the authors of this guideline encourage you to refer to. Important points to highlight include:
      • Opioid-induced constipation (OIC) is a common side effect of opioids and thus treatment for this should begin with the commencement of opioids. Treatments for OIC include:
      • Non-pharmacological – Increase in dietary fibre, increase in oral fluid intake, increase in physical activity.
      • Pharmacological – Laxatives
    2. Before prescribing laxatives, make sure that the patient is constipated due to opioids and that it is not secondary to an underlying undiagnosed complaint.
    3. Contraindications to laxatives include: intestinal obstruction, intestinal perforation, paralytic ileus and inflammatory conditions of the intestinal tract.
    4. In patients with opioid-induced constipation, an osmotic laxative and a stimulant laxative are recommended. Bulk-forming laxatives should be avoided.

NB: This does not apply to patients on the Enhanced Recovery after Surgery (ERAS) pathway. Please seek advice from the surgical team before prescribing laxatives for ERAS patients.


Patients receiving regular opioids should be prescribe a PRN anti-emetic in anticipation of this common side effect. First line agents are Ondansetron and Cyclizine. NB: Constipation is a common side effect of ondansetron.  

Respiratory Depression

Respiratory depression is a much-feared but thankfully rare harm associated with the use of opioids. However, fear of this side effect must not prevent the patient receiving adequate analgesia.

To reduce the risk of harm from respiratory depression, we recommend awareness of the following points:

  1. Choice of appropriate analgesic in at-risk patients, such as Renal Impairment, as per the Analgesic Ladder.
  2. Deepening levels of sedation usually precede respiratory depression and should be a trigger for suspending opioids pending further assessment.
  3. A Respiratory Rate of <12/minute in a patient who is not physiologically asleep is highly sensitive of opioid overdose, especially if constricted pupils or stupor are present
  4. Naloxone is the antidote to opioids. For guidance on how to safely administer Naloxone, please refer to our Flowchart for Intravenous Opioids

Step 5: Reassess Pain

  1. We recommend pain be reviewed at least daily by the Parent Team.
  2. Assess the patient. Are they still in acute pain?
  3. What is the severity of their pain in each of the following:
    • at rest
    • on deep breathing
    • with coughing/movement?

Mild Pain0-3'Mild Pain'3-7
Moderate Pain4-6'Moderate Pain'8-13
Severe Pain7-10'Severe Pain'≥14

VRS=Verbal Rating Scale, CRS= Categorical Rating Scale, APAT=Abbey Pain Assessment Tool

Has the pain severity improved from their previous documented severity category?
If ‘Yes’ in all three of the above - DE-ESCALATE the prescription
-Move to the lower rung in the analgesic ladder whilst continuing PRN opioids
If ‘No’ in any of the above three - ESCALATE the prescription.
Consider the following:
- If new severe pain, refer to the Analgesic Ladder for the Management of Severe Pain (above).
- Does the patient require IV titration to manage acute severe pain? If so, refer to Administration of IV Opioids Flowchart.

Or, if requiring >2 doses of PRN analgesia per 24hr period, consider the following:
- Increasing the regular and PRN oral opioid dose by 50-100%
- Stopping the regular and PRN immediate-release oral opioid and prescribing a long-acting opioid*

Long-acting oral opioids should not be prescribed in patients with post-operative paralytic ileus. They should be used in caution in patients with AKI/CKD and hepatic impairment.

NB Pain that is not responding tro treastment may be a sinister sign of missed pathology.  Have a low threshold for seeking senior review if you are concerned about this.

It is also important to taper or stop the opioid regimen if:

    • the underlying painful condition resolves
    • opioid medication is not providing useful pain relief.
    • the patient develops intolerable side effects

Increasing opioid load above 90mg oral morphine equivalent/24hours dose is unlikely to yield further benefits but exposes the patient to increased harm.

Step 6: Discharge from Hospital

  1. On discharge from hospital, the discharge letter must include accurate details of all analgesia provided.
  2. The prescription of any opioid analgesia for use post-discharge must include a de-prescribing plan. 

Paracetamol – Important Points

Paracetamol should be used with caution in cases of:

  1. hepatocellular insufficiency
  2. severe renal insufficiency (please refer to the Renal Handbook via the Clinical Handbook page on Beacon)
  3. chronic alcoholism
  4. chronic malnutrition (low reserves of hepatic glutathione)
  5. dehydration

Safe Dosing of Paracetamol

Patient WeightDose per AdministrationMaximum Dose in 24 Hours
33-50kg15mg/kg60mg/kg *not exceeding 3g
>50kg and additional risk factors for hepatotoxicity1g3g
>50kg and no risk factors for hepatotoxicity1g4g
(extrapolated from the SmPC ( Accessed 28/6/22

NSAIDs – Important Points

  1. Check for contra-indications to Non-Steroidal Anti-Inflammatory Drugs before prescribing them
    1. Consider Renal, Cardiac and Hepatic impairment,
    2. Suspected/high risk of haemorrhage,
    3. coagulation abnormalities,
    4. hypersensitivity to aspirin,
    5. previous/active peptic ulceration etc.


Content by Duncan Thomson, Libby Jardine, Alasdair Hay