Approach to managing severe, acute nociceptive pain

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

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

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

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

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

To achieve adequate pain relief, immediate-release opioids are required in addition to paracetamol and a nonsteroidal anti-inflammatory drug (NSAID). 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 of paracetamol and an NSAID is preferred for severe, 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 that are full mu-receptor agonists (eg morphine) are preferred for severe, acute nociceptive pain; tramadol or tapentadol are unlikely to provide adequate relief of severe pain because their dosing is limited by effects at other receptors. For further information on commonly used opioids, see Overview of opioids commonly used in pain management.

High or frequent doses of opioids may be required for severe, acute nociceptive pain, which increases the risk of opioid-induced ventilatory impairment. Severe, acute pain should be managed in hospitals with staffing and resources that allow immediate resuscitation of a patient with opioid-induced ventilatory impairment; see Using opioids in hospital.

Note: Severe acute pain should be managed in hospitals with staffing and resources that allow immediate resuscitation of a patient with opioid-induced ventilatory impairment.

Intravenous or intranasal opioid administration is preferred to oral or subcutaneous opioid administration for severe, acute nociceptive pain because the fast onset of effect provides prompt analgesia. Intravenous or intranasal opioids are uncommonly used outside of critical care areas (eg emergency departments, intensive care units, postoperative recovery units) because there is a high risk of opioid-induced ventilatory impairment. Intranasal opioid administration is not appropriate for ongoing analgesia.

In adults, subcutaneous opioid administration for severe, acute nociceptive pain is an alternative when intravenous or intranasal administration is not appropriate. In children, the use of subcutaneous opioids is usually limited to postoperative pain.

Oral administration of opioids is preferred when prompt analgesia is not required (eg postoperatively when analgesia has been established), provided oral absorption is not impaired; trauma patients may have impaired oral absorption.

Irrespective of the route of administration used for initial treatment, oral administration 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 via patient-controlled analgesia (PCA) (seek expert advice). 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.