Approach to managing moderate, acute nociceptive pain

For the management of moderate, acute nociceptive pain in patients whose goals of care are palliative, see Principles of managing pain in palliative care.

For the management of moderate, acute nociceptive pain anticipated during a procedure; see Procedural sedation and analgesia.

For the management of moderate, acute nociceptive pain in children younger than 1 year, seek expert advice.

Moderate, acute nociceptive pain due to an acute illness, or following surgery or trauma (eg minor fracture) is treated with multimodal analgesia and nonpharmacological interventions.

For advice on assessing moderate, acute nociceptive pain, see:

Paracetamol and a nonsteroidal anti-inflammatory drug (NSAID) may provide adequate pain relief in some patients for moderate, acute nociceptive pain; however, an immediate-release opioid is often required1. Do not use modified-release opioids (including transdermal patches) for acute pain because they cannot be safely or rapidly titrated; modified-release formulations have a slow onset and long duration of action.
Note: Do not use modified-release opioids for acute pain because they cannot be safely or rapidly titrated.

Oral administration is preferred for moderate, acute nociceptive pain unless the patient cannot take oral drugs or has impaired gastrointestinal absorption. Paracetamol or an NSAID can be administered parenterally or rectally if required; see Alternative routes of administration if oral paracetamol or NSAIDs cannot be used. Opioids may be administered subcutaneously, but repeat doses should only be administered in hospital. In children, the use of subcutaneous opioids is usually limited to postoperative pain.

Inhaled methoxyflurane has a fast onset and offset of action, and lower risk of adverse effects than opioids. It can be used when prompt, time-limited analgesia is required (eg pain associated with a dressing change) or for prompt pain relief before opioid analgesia can be established (eg before hospital transfer).

Oral opioids should be used for ongoing analgesia. If the oral route is not suitable in adults, opioids may be administered subcutaneously via a subcutaneous cannula, or seek expert advice on the administration of opioids via patient-controlled analgesia (PCA). If the oral route is not appropriate in children, refer to local protocols—nurse- or patient-controlled analgesia may be considered, seek expert advice. Always have a plan for reassessment, and tapering and stopping analgesics; analgesics should not be continued after the acute illness or injury has resolved.

For drug regimens used in adults, see:

For drug regimens used in children, see:

NSAIDs can cause significant adverse effects, so use the lowest effective dose for the shortest possible time, for a period usually not exceeding 5 days. For further information on paracetamol and NSAIDs, including adverse effects and contraindications, see Nonopioid analgesics in pain management. For further information on opioids, including individual opioid characteristics, equianalgesic doses and opioid-related harms, see Opioids in pain management.

1 There is no universal definition of moderate acute pain. The definition used in these guidelines may differ to definitions used by other organisations (including the Therapeutic Goods Administration) and literature. Return