1. Use the oral route whenever possible.
2. Give paracetamol and NSAIDS regularly and opioids PRN.  
3. Avoid the use of compound analgesia e.g. co-codamol
4. Review analgesia regularly, at least once a day 
5. When changing from one route of administration to another, use "step-over" doses (equipotent) until you can assess the effect.  Later you can change to "step-down" drugs (less potent) 

Please remember the side-effects of NSAIDs and stop them if the patient develops dyspepsia or renal impairment. 

Part 1 

Part 2 

Please refer to NSAID guidelines (see resources).

• In the elderly use a reduced dose and longer dosing interval.
• Patients with moderate to severe renal impairment (see acute pain management in adults with renal impairment) or liver impairment may need a reduced dose and a longer dosing interval.

Remember unexpected pain must be investigated for other causes, especially if the analgesia prescribed becomes ineffective. The patient's condition can change.

Oral Opioids

• Combination of opioids should not be prescribed or given.
• If you need to change opioids seek advice from Acute Pain Team and/or see Opioid Conversion Chart in theBNForPalliative Care Formulary.
• The most common side effects of opioids are:

Constipation:
Laxatives may need to be prescribed. Use with caution if patient has had bowel surgery. Encourage a high fibre diet and adequate fluid intake. Assess for other causes. Older adult inpatient management of constipation. 

Nausea and vomiting:
An anti-emetic should be prescribed and administered. See PONV guidelines.

Itching:
Assess cause – may not be opioid. Ondansetron can help or low dose naloxone.

Respiratory depression:
If respiratory rate is less than 7 per minute and/or sedation score is 3:

• Contact medical staff, clinical nurse practitioner or the Acute Pain Nurse.
• Administer 10litres/min of oxygen via Hudson face mask.
• Give naloxone (see naloxone guidance)

CAUTION WITH THE FOLLOWING PATIENTS

• Use a reduced dose with a longer dosing interval in the elderly.
• Refer to the acute pain management in adults with renal impairment
• Contact acute pain team for advice on patients with severe liver impairment.

At Raigmore Hospital the Acute Pain Team includes:
Consultant Anaesthetist - Department of Anaesthesia
Clinical Nurse Specialists, Acute Pain Service
Senior Pharmacist - Pharmacy Department
Advice can be sought in office hours - 08.00 – 16.00 (page 1003 or 6056)
Out of hours please contact the ITU anaesthetist.