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Scottish Palliative Care Guidelines print pdf

Pain Management


This guideline relates to the management of pain in adult patients with palliative care needs.


  • Assess pain fully before treatment (see Pain assessment guideline)
  • Consider reversible causes.
  • Ask the patient regularly about their pain.
  • Record pain scores. Use a pain assessment tool.


table 1

Step 1: mild pain

1g four times daily

or non-steroidal anti-inflammatory drug (NSAID)
(if not contraindicated - see section"Adjuvant therapies" below))

±other adjuvant

  • Consider reducing paracetamol dose to 500mg four times daily when poor nutritional status, low weight (< 50kg), hepatic impairment and/or chronic alcohol abuse (check local policy for paracetamol and NSAIDs if patient receiving chemotherapy).

Inadequate pain relief

Step 2: mild to moderate pain

weak opioid
Codeine 30 to 60mg four times daily or dihydrocodeine 30 to 60mg four times daily


Alternative :use a combined preparation such as co-codamol 30/500, 2 tablets four times daily (see notes above regarding restrictions)

+ paracetamol
(Dose as above)
(If no benefit stop after 3 to 4 days)

(if not contraindicated)

±other adjuvant

  • Consider prescribing a laxative and anti-emetic

Inadequate pain relief

Step 3: moderate to severe pain

strong opioid

+ paracetamol
(Dose as above)
(stop if no benefit)

(if not contraindicated)

±other adjuvant

Stop any step 2 opioid
Codeine or dihydrocodeine 60mg 4 times daily≈30mg oral morphine in 24 hours

Seek advice:

  • severe pain not responding to treatment
  • unacceptable side effects or toxicity.

If titrating with immediate release oral morphine prescribe 5mg, 4 hourly and as required for breakthrough pain.

If starting with modified release oral morphine prescribe 10 to 15mg, 12 hourly and immediate release morphine 5mg as required for breakthrough pain.

  • Use lower doses and increase dose more slowly if patient is frail, elderly or has renal impairment.
  • In severe renal impairment, an alternative opioid may be needed (see 'Choosing and changing opioids' guideline).


Dose titration for Step 3

  • Increase regular oral morphine dose each day in steps of about 30% (or according to breakthrough doses used) until pain is controlled or side effects develop.
  • Increase laxative dose as needed.
  • Convert to modified release morphine when stable.
  • Divide 24 hour dose of immediate release morphine by 2.
  • Prescribe as modified release morphine, 12 hourly.
  • Prescribe breakthrough analgesia at correct dose (1/10th to 1/6th of 24 hour morphine dose).


Table Pain Management
Regular laxative
(see 'Constipation' guideline)

Metoclopramide 10mg up to three times a day

Senna 2 tablets at night or bisacodyl 5 to 10mg at night + docusate 100mg twice daily

Haloperidol 500 micrograms to 1.5mg daily. Prescribe as required for 5 to 10 days

Macrogol 1 to 3 sachets per day


Subcutaneous (SC) analgesia

  • Usually given in CME T34 syringe pump over 24 hours.
  • Calculate the 24 hour dose of oral morphine.
  • Convert this to SC morphine.
  • Oral morphine 30mg≈SC morphine 15mg.
  • When large doses of breakthrough SC analgesia are required consider SC diamorphine.
  • Prescribe 1/10th to 1/6th of the 24-hour SC opioid dose as required, SC for breakthrough pain.
  • (See Subcutaneous infusion of medication in palliative care guideline).

Breakthrough pain

Defined as a transient exacerbation of pain which occurs either spontaneously or in relation to a specific trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

  • Prescribe immediate release morphine at 1/10th to 1/6th of the regular 24 hour dose, as required.
  • Assess 30 to 60 minutes after a breakthrough dose.
  • If pain persists give a second dose as required.
  • If pain is still not controlled seek advice.
  • Change breakthrough dose if regular dose altered.

Movement or incident related predictable pain

Can be difficult to manage; a dose of short-acting opioid before moving or when pain occurs may help. If pain is short-lived and the patient develops excessive drowsiness seek specialist advice.

Adjuvant therapies

  • NSAID: for bone pain, liver pain, soft tissue infiltration, or inflammatory pain (side effects: gastrointestinal ulceration or bleeding [consider proton pump inhibitor (PPI)], renal impairment, fluid retention).
  • Antidepressant or anticonvulsant: for nerve pain. Start at low dose: titrate slowly. (see Neuropathic pain guideline). No clear difference in efficacy between the two types of medicine for this indication.
    • amitriptyline (side effects: confusion, hypotension) caution in cardiovascular disease.
    • gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
  • Corticosteroids: dexamethasone
    • 16mg daily for raised intracranial pressure.
    • 8mg daily for neuropathic pain; 4 to 8mg/day for liver capsule pain.
    • Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
  • TENS, nerve block, radiotherapy, surgery, bisphosphonates, ketamine (specialist use) and skeletal or smooth muscle relaxants.


Opioid toxicity – seek advice

  • Increasing drowsiness, sedation or delirium.
  • Peripheral shadowing, vivid dreams or hallucinations.
  • Muscle twitching, myoclonus or jerking.
  • Abnormal skin sensitivity to touch.
  • Rarely respiratory depression.
  • If the patient’s pain is controlled reduce opioid dose by one third, ensure patient is well hydrated; consider checking renal function; review and re-titrate analgesia.
  • Consider adjuvant therapies, alternative opioids or both (see Choosing and changing opioids guideline).
  • Previous treatment that may reduce analgesic requirements such as radiotherapy.


Patient/carer information

When prescribing regular analgesia for continuous pain, discuss and resolve any concerns about taking opioids, including:

  • addiction
  • tolerance
  • side effects
  • fears that treatment implies the final stages of life.

Provide information (verbal and written) to the patient:

  • when and why strong opioids are used to treat pain
  • how effective they are likely to be
  • background and breakthrough pain management
  • signs of toxicity
  • strong pain killers and driving
  • follow-up plans.

Further reading

SIGN 106 – Management of pain in adult patients with cancer

Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC.