5th November 2024

Principles of pharmacological pain management

Managing pain in palliative care patients is guided by the acuity and the likely cause.

Acute severe pain

• Aim to relieve this immediately with subcutaneous or intravenous strong opioid medication
• Give breakthrough dose of opioid (see section on opioid dose calculations)
• In opioid-naïve patients, consider 5 mg subcutaneous or IV morphine (2.5 mg for elderly or frail patients)

Persistent pain in a non-emergency situation

The WHO (World Health Organisatin) pain ladder, initially developed in 1986, is a stepwise approach for uncontrolled pain. It has been the subject of much debate about its intended use, how effective it is, and whether it is still an appropriate tool. However, it remains widely used as a simple model for acute pain.

• Step 1. Non-opioids, e.g. paracetamol, NSAIDs ± adjuvant therapies, e.g. tricyclic antidepressants for nerve pain
• Step 2. Add weak opioids, e.g. codeine ± non-opioid ± adjuvant therapies
• Step 3. Instead, try strong opioids, e.g. morphine sulphate ± non-opioid ± adjuvant therapies

Managing pain by cause

Below is a table summarising the common causes for pain and how to manage them: