}   Recommended Acute Analgesia for Adult Patients Pain Severity On Movement Assess the level of pain and start at the appropriate point of pain severity 1. Mild 2. Moderate 3. Severe Regular Paracetamol 1g QDS PO/PR. Max 4 gram daily. IV use is restricted to bowel surgery patients who are NBM. If pt wt <50 kg dose IV at 15mg/ kg every 4-6hrs (max 60mg /kg in 24hrs)  Regular NSAID (if not contraindicated *): Ibuprofen 400mg PO TDS Naproxen is preferable to Ibuprofen in patients on aspirin and with a history of cardiovascular disease. Diclofenac PR may be used for patients unable to take oral NSAIDs. *Cautions may include; renal disease, oral anticoagulation, history of hypersensitivity to NSAIDs, history of gastric ulcers, asthma. For a full list refer to the BNF. Regular Weak Opioid: Codeine 30-60mg PO QDS Or Tramadol 50 -100mg PO QDS. Consider a reduced dose in the elderly e.g. 50mg TDS. Tramadol is contraindicated in patients with a history of epilepsy.  Strong Opioid: Either; Regular Zomorph MR PO & PRN breakthrough Oramorph if unsedated. IV titrate aliquots - see protocol PRN IM/PO hourly protocol PCA protocol Epidural protocol With PRN opioid for breakthrough With PRN Oramorph for breakthrough } Titrate dose against pain score to achieve desired therapeutic effect and monitor for signs of adverse events. Caution with dose and frequency in renal impairment. Co-prescribe Naloxone and consider; prophylactic anti-emetic/ laxative. Consider need for adjuvant treatment and/ or referral to specialist pain team where appropriate N.B. Combined regular and PRN prescribing of pain relief is more effective Date Approved: Oct 2011 Review Date: Oct 2012