• Argyll & Bute HSCP and Highland HSCP
  • Primary and Secondary Care

Quick reference guide


  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) 

Non-steroidal anti-inflammatory analgesia

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).

Opioid analgesia

  • 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:

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.

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)


  • 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.


Abbreviation Meaning 
ACE inhibitorsAngiotensin-converting-enzyme inhibitors
AKI Acute kidney injury 
 eGFR Estimated glomerular filtration rate 
IRImmediate release 

Last reviewed: 31/10/2022

Next review date: 31/10/2025

Author(s): Acute Pain Team.

Approved By: Approved TAMSG of the ADTC

Reviewer name(s): Louise Reid, Claire Wright .

Document Id: TAM100

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Related resources

Further information for Health Care Professionals

(Scroll down to see all references)

  • BNF
  • eg SIGN
  • eg NICE
  • Other reference

Further information for Patients

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Self-management information