RANKED BY CLINICAL EFFICACY12
(see also ranking of opioids, p. 338)
• Non-narcotic (nonopioid) analgesics or NSAIDs, e.g. paracetamol, ibuprofen, diclofenac.13 (Ch. 15) Where these fail after using the full dose range, proceed to drugs for:
• Narcotic (opioid) analgesics, low-efficacy opioids, e.g. codeine, dihydrocodeine, dextropropoxyphene, pentazocine.
• Combined therapy of NSAIDs plus low-efficacy opioid, either as a fixed-dose formulation, which is convenient for acute pain or separately to find the optimum dose of each, which may be preferable for chronic pain though less convenient.
Where these fail proceed to drugs for:
• High-efficacy opioids, e.g. morphine, diamorphine, pethidine, buprenorphine. An added NSAID is useful if there is an additional tissue injury component, e.g. gout, bone metastasis.
12 Based on Twycross R G 1978 In: Saunders Cicely M (ed) The management of terminal disease. Arnold, London. The work of this author contributes much to this chapter.
13 Paracetamol is sometimes not classed as an NSAID because its anti-inflammatory pattern differs substantially from most, i.e. it is central rather than peripheral, as witness its weak anti-inflammatory efficacy in rheumatoid arthritis.
Where these fail proceed to drugs for: Overwhelming acute pain
• High efficacy opioid plus a sedative /anxiolytic (diazepam) or a phenothiazine tranquilliser, e.g. chlorpromazine, levomepromazine (methotrimeprazine) (which also has analgesic effect).
Note: adjuvant drugs (p. 331) may be useful in all grades of pain.
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