Oral drugs for moderate, acute nociceptive pain in adults

The oral route of administration is preferred for moderate, acute nociceptive pain in adults; if the oral route is not appropriate, see Approach to managing moderate, acute nociceptive pain. Paracetamol and an NSAID may provide adequate pain relief in some patients for moderate, acute nociceptive pain; however, an immediate-release opioid is often required¹.

Tapentadol or tramadol may be preferred to other opioids for moderate, acute nociceptive pain because they are less likely to cause excessive sedation and opioid-induced ventilatory impairment. Do not use modified-release opioids for acute pain because they cannot be safely or rapidly titrated. For further information on commonly used opioids, see Overview of opioids commonly used in pain management.

If oral drug regimens are appropriate for moderate, acute nociceptive pain due to an acute illness (eg uncomplicated appendicitis), or following surgery or trauma, as a two- or three-drug regimen, use:

1 paracetamol immediate-release 1 g orally, 4-to 6-hourly. Maximum dose 4 g in 24 hours acute pain, moderate (adults receiving oral opioids) paracetamol

OR

1 paracetamol modified-release 1.33 g orally, 8-hourly. Maximum dose 4 g in 24 hours paracetamol

PLUS ONE OF THE FOLLOWING NSAIDS

1 celecoxib 100 to 200 mg orally, twice daily acute pain, moderate (adults receiving oral opioids) celecoxib

OR

1 ibuprofen 200 to 400 mg orally, 3 times daily² acute pain, moderate (adults receiving oral opioids) ibuprofen

OR

1 naproxen 250 to 500 mg orally, twice daily³ acute pain, moderate (adults receiving oral opioids) naproxen

PLUS (if pain is not expected to be relieved with paracetamol plus an NSAID) ONE OF THE FOLLOWING OPIOIDS

1 tapentadol immediate-release⁴ acute pain, moderate (adults) tapentadol

adults 75 years or younger: 50 mg orally, 4-to 6-hourly if required. If adequate pain relief is not achieved with a 50 mg dose, increase the dose to 100 mg orally, 4-to 6-hourly if required

adults older than 75 years: 50 mg orally, 4-to 6-hourly if required

OR

1 tramadol immediate-release⁵ acute pain, moderate (adults) tramadol

adults 75 years or younger: 50 mg orally, 4-to 6-hourly if required. If adequate pain relief is not achieved with a 50 mg dose, increase the dose to 100 mg orally, 4-to 6-hourly if required

adults older than 75 years: 50 mg orally, 4-to 6-hourly if required

OR

2 morphine immediate-release⁶ acute pain, moderate (adults) morphine

adults 49 years or younger: 7.5 to 20 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

adults 50 to 75 years: 7.5 to 15 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

adults older than 75 years: 3.5 to 7.5 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁷ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital

OR

2 oxycodone immediate-release acute pain, moderate (adults) oxycodone

adults 49 years or younger: 5 to 15 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

adults 50 to 75 years: 5 to 10 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

adults older than 75 years: 2.5 to 5 mg orally, 4-hourly if required. Use the lower end of the dose range for patients treated in the community, and for cachectic or frail patients

after each dose, wait 1 hour then assess the patient for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate)⁷ and determine whether pain relief is adequate. Subsequent management depends on whether the patient is treated in the community or in hospital.

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

² Avoid ibuprofen in patients at increased risk of bleeding or gastrointestinal toxicity. In these patients, celecoxib is preferred. See Nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management for further advice on adverse effects and contraindications.Return

³ Avoid naproxen in patients at increased risk of bleeding or gastrointestinal toxicity. In these patients, celecoxib is preferred. See Nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management for further advice on adverse effects and contraindications.Return

⁴ At the time of writing, immediate-release tapentadol tablets are not available on the Pharmaceutical Benefits Scheme (PBS) for the treatment of acute pain. See the PBS website for current information.Return

⁵ Concurrent use of tramadol with other serotonergic drugs increases the risk of serotonin toxicity (see Drugs most commonly associated with serotonergic toxidrome for drugs associated with serotonin toxicity).Return

⁶ At the time of writing, immediate-release morphine tablets are not available on the Pharmaceutical Benefits Scheme (PBS) for this indication. See the PBS website for current information. Avoid using immediate-release morphine liquid in patients treated in the community because dose errors are common.Return

⁷ If the patient cannot be monitored (eg is being treated with oral opioids at home), they should be educated about opioid-induced ventilatory impairment and how to safely use an opioid for acute pain at home; see How to use an opioid for acute pain at home.Return