Analgesic Ladder in Acute Pain - 3rd Edition

Utilisation of Analgesic Ladder

Use of the analgesic ladder is based on a patient assessment of their pain on a scale of 0-10,
both at rest and during activity such as coughing, deep breathing and on movement. These
equate to staff assessment of mild, moderate or severe pain. The appropriate analgesia should be
given.
Patients with a pain score of 3 to 5 (mild pain) should be treated with regular paracetamol.
Codeine should be used if pain remains uncontrolled. Tramadol may be used as an alternative
to codeine in patients who are intolerant to codeine or where constipation would be a
problem. Use tramadol with caution in patients with a history of epilepsy and those who are
taking antidepressants.
Diclofenac can be added if deemed necessary (if not contraindicated).
Patients with a pain score of 6 to 8 (moderate pain) should be treated with regular
paracetamol, regular codeine and regular diclofenac (if not contraindicated). Morphine
should be used if pain is uncontrolled.
Patients with a pain score 9 to 10 (severe pain) should be treated with morphine regularly
or continuously plus paracetamol regularly.
Diclofenac should also be given regularly (if not contraindicated).

Management of Acute Pain Algorithm

Acute Pain

Assess Pain Level U sing Pain Intensity Scale

Pain Score: 0 - 2 Pain Score 3 - 10 Pain Score 3 - 10

N o pain or pain not Pain of known origin requiring Pain of unknown origin
requiring intervention intervention requiring intervention

Refer to Analgesic Ladder and prescribe appropriate Evaluate patients clinical

Continue regular analgesic. state to identify origin of
assessm ent of pain
pain
N .B . If analgesic ladder fails to control pain, refer to Acute
Pain Service or Duty Anaesthetist

Patient has no additional Treat the underlying

pathology/drug side effects, condition and pain
etc. but is still in pain

Evaluate patients clinical

Is patient still in
state to exclude additional Yes No Continue regular
pain/discom fort after
pathology/drug side effects assessm ent of pain
treatm ent?
etc.

Treat the underlying

condition/drug side effects

Analgesic Ladder in Acute Pain 3rd Edition - Prepared by Acute Pain Team Page 1 of 2
Approved by Medicines Management Committee ......................................... 26th March 2009
Review Date ...................................................................................................... March 2011
 Severe
Pain Score 9-10
& lower if
Analgesic M oderate Regular
uncontrolled

Ladder Pain Score 6-8

& lower if
Patient Controlled Analgesia
or
uncontrolled Epidural
M ild Regular PRN or
Pain Score Morphine
Codeine Morphine
3-5 +
30-60mg QDS 4 hourly
Regular PRN IM/SC/Oral Paracetamol 1g QDS
+
Pain Score Codeine 30- oral/rectal/intravenous
0-2 Paracetamol 60mg QDS Paracetamol 1g
QDS +
1g QDS (4 hourly)
Regular PRN Diclofenac
and/or +
No Medication Paracetamol oral/rectal
1g 4-6 hourly Diclofenac 50mg Diclofenac 50mg up to 150mg in 24 hours
(max QDS) up to TDS TDS

NB
Ibuprofen 1.2g to 2.4g Daily in 3-4 divided doses, may be used as an alternative to Diclofenac.
Tramadol 50mg 100mg QDS, may be used as an alternative to codeine where patient is intolerant to codeine or constipation should be avoided.

NSAIDS
(Diclofenac) Contraindications - Diclofenac should be used with care in patients with thrombocytopenia coagulopathies, asthma and renal, hepatic or
cardiac impairment. It is contraindicated for patients with active peptic ulceration or with a history of sensitivity, eg. wheezing to aspirin or other
NSAIDS. In the elderly (over 75 yrs) consider using a lower dose of Diclofenac (25mg) and buffer those at risk of Gl problems with omeprazole 20mg
each morning, or lansoprazole 30mg each morning.
Formulations Available
Paracetamol - Tablet 500mg, Suspension 500mg/5ml, Suppositories Morphine - Liquid 10mg/5ml, Injection 10mg/1ml, Suppositories 15mg &
1G, intravenous injection 1g 30mg
Codeine - Tablet 30mg, Syrup 25mg/5ml, Injection 60mg Tramadol - Capsule 50mg, intravenous injection 100mg
Diclofenac - Tablet 50mg & 25mg, Dispersible tablets 50mg, Ibuprofen - Tablet 200mg & 400mg, Syrup 100mg/5ml
Suppositories 50mg & 100mg Parecoxib - injection 40mg - perioperative or short-term post-operative use
where oral/rectal diclofenac is not appropriate and a NSAID is needed

Analgesic Ladder in Acute Pain 3rd Edition - Prepared by Acute Pain Team Page 2 of 2
Approved by Medicines Management Committee ......................................... 26th March 2009 Review Date ...................... March 2011
http://www.npsa.nhs.uk/patientsafety/alerts-and-directives

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