Oral drugs for severe, acute nociceptive pain in adults
The oral route of administration for severe, acute nociceptive pain is preferred when prompt analgesia is not required (eg postoperatively when analgesia has been established). Alternative routes of administration should be used if oral absorption is impaired (eg trauma patients). Irrespective of the route of administration used for initial analgesia, oral administration should be used for ongoing analgesia.
For advice on choosing an opioid or the route of administration for severe, acute nociceptive pain, see Approach to managing severe, acute nociceptive pain.
If oral drug regimens are appropriate for severe, acute nociceptive pain due to an acute illness (eg shingles), or following surgery or trauma, as a three-drug regimen, use:
1 paracetamol immediate-release 1 g orally, 4-to 6-hourly. Maximum dose 4 g in 24 hours acute pain, severe (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, severe (adults receiving oral opioids) celecoxib
OR
1 ibuprofen 200 to 400 mg orally, 3 times daily1 acute pain, severe (adults receiving oral opioids) ibuprofen
OR
1 naproxen 250 to 500 mg orally, twice daily2 acute pain, severe (adults receiving oral opioids) naproxen
PLUS ONE OF THE FOLLOWING OPIOIDS
1 morphine immediate-release acute pain, severe (adults) morphine
adults 39 years or younger: 20 to 35 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 40 to 59 years: 15 to 30 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 60 to 69 years: 7.5 to 20 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 70 to 85 years: 7.5 to 10 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults older than 85 years: 3.5 to 7.5 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses 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) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses
OR
1 oxycodone immediate-release acute pain, severe (adults) oxycodone
adults 39 years or younger: 10 to 25 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 40 to 59 years: 10 to 20 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 60 to 69 years: 5 to 15 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults 70 to 85 years: 5 to 10 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses for cachectic or frail patients
adults older than 85 years: 2.5 to 5 mg orally, 2-hourly if required. Use the lower end of the dose range initially for patients whose opioid requirements have not been established. Consider lower initial doses 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) and determine whether pain relief is adequate. See Opioid dose titration in hospital for subsequent management, including top-up doses.