188.8.131.52 Non-opioid & compound analgesics
|1st choice||Consider Pain Self-Management|
|Paracetamol tablets 500mg||Dose:|
0.5-1g every 4-6 hours; max 4g daily
|2nd choice||Consider NSAID|
|Consider addition of codeine 15mg tablets|
Prescribe codeine separately from paracetamol to give flexibility
15mg-60mg every 4-6 hours; up to four times daily
Keep dose as low as possible
| 2nd choice |
(alternative option to prescribing codeine separately)
|Co-codamol 8/500 tablets (codeine 8mg with paracetamol 500mg)||Dose:|
Co-codamol 8/500, 1-2 tablets every 4-6 hours; max 8 tablets daily
|Co-codamol 15/500 tablets (codeine 15mg with paracetamol 500mg)||Dose: |
Co-codamol 15/500, 1-2 tablets every 4-6 hours; max 8 tablets daily
|Co-codamol 30/500 tablets (codeine 30mg with paracetamol 500mg)||Co-codamol 30/500, 1-2 tablets every 4-6 hours; max 8 tablets daily|
- See NICE CKS ‘Analgesia mild-to-moderate pain’.
- Encourage self-care/advice from community pharmacist for minor self-limiting conditions and OTC purchase of simple analgesics as appropriate.
- Before prescribing, ask if the person is taking any OTC medicines and remind them not to ‘top up’ prescription medicines with pain relievers bought OTC – seek advice from a doctor or pharmacist and see NI Patient Zone resources.
- Consider need for non-drug interventions e.g. referral to physiotherapy.
- Paracetamol taken regularly appears to be as effective as co-codamol 8/500 with less side-effects.
- Management of postoperative pain should follow hospital acute pain guidelines.
- Codeine is metabolised to morphine to have its analgesic effect e.g. 30mg codeine = 3mg morphine. Codeine is ineffective in approximately 10% of patients who are unable to convert it to morphine. Consider an alternative analgesic in these people.
- In acute pain use opioids for short periods only (3 days or less is usually enough and over 7 days is rarely needed).
- Inform patients about potential harms and risks of dependence with long term use.
- Co-codamol capsules are high cost and should not be prescribed.
- Opioids have the potential to impair driving and anyone who is adversely affected must not drive. If a patient has a condition or is undergoing treatment that could impair their fitness to drive, healthcare professionals should advise them on their legal requirement to notify the DVA. Discuss with the patient and document – for further details see driving information in the Opioid Prescribing for Chronic Pain Resource Pack.
- Some patients may be at increased risk of experiencing toxicity at therapeutic doses of paracetamol, particularly those with a body-weight under 50 kg and those with risk factors for hepatotoxicity. Clinical judgement should be used to adjust the dose of oral and intravenous paracetamol in these patients.
- Each effervescent tablet can contain a sodium content of up to 400mg. Persons on a low sodium diet should be aware of this if they wish to take effervescent tablets as a daily intake can exceed 3g sodium per day. Effervescent tablets are significantly more expensive that tablets/caplet preparations.
- Codeine should not be used by breastfeeding mothers because it can pass to the baby through breast milk and potentially cause respiratory depression.
- Codeine should be avoided in severe renal impairment (eGFR <30).
- Before prescribing any opioid, including codeine, be aware that some patients are at higher risk of developing dependence or addiction. Assess risk e.g. previous history of substance misuse, use of concurrent sedatives or alcohol use. For information on ‘acute pain management for drug misusers’ see here. Acute pain requires full analgesic management in patients dependent on opioids.
- Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression. See MHRA.