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Use this flow chart (algorithm) for online advice about using pain relief medication for conditions like back pain, period pain, toothache and arthritis. Most of the medicines mentioned in this analgesic ladder can be bought over the counter (paracetamol, the anti-inflammatory ibuprofen, cocodamol 8/500).
  • 2010 - Managing your pain effectively using "Over The Counter" (OTC) Medicines

If you require strong narcotic prescription pain relieving drugs, you will need to make an appointment with your family doctor.

Let your mouse hover some of the drug names for simple analgesic dosing recommendations (route of administration, dose, frequency etc).

Rate your pain as Mild, Moderate or Severe, and choose the correct starting place in the left hand column.

Analgesic Advice
Start with regular paracetamol

See Pain Types and Medication Types for advice about which analgesics are best for particular types of pain.

Change to regular paracetamol plus an NSAID (e.g. ibuprofen)

Be aware of the side effects and contra-indications of NSAIDs


Change to regular cocodamol 8/500 plus an NSAID (e.g. ibuprofen)

Be aware of the side effects and contra-indications of NSAIDs, and codeine. All these medications can be bought over the counter at your local pharmacy. Always read the instruction leaflet about dose and frequency. If you are taking any other medication from your doctor or you are pregnant, please ask your pharmacist or GP for further advice.

See your doctor to change to regular cocodamol 30/500 plus an NSAID (e.g. ibuprofen)

7% of the population can't convert codeine to morphine in the liver, making codeine totally ineffective for them. Consider Tramadol / Tapentadol / Buprenorphine / Morphine instead.

See your doctor to change to regular paracetamol plus an NSAID (e.g. ibuprofen) plus either dihydrocodeine OR tramadol / tapentadol
Dihydrocodeine and Tramadol are both available in normal release and slow release preparations.
See your doctor to change to regular paracetamol plus an NSAID (e.g. ibuprofen) plus oral morphine (10 mg 4 hourly)

If you have nerve type pain, see your doctor about medications specific for that type of pain (see Anti-depressants, Anti-convulsants, Nerve Pain).


Calculate the 24 hour dose of morphine and convert if necessary to twice daily slow release oral morphine (MST).

Use normal release morphine 4 hourly for breakthrough pain (single dose = 1/6th total daily dose).

If necessary the daily morphine dose can be increased by 50-100% as smaller dose increases may not produce any clinically noticeable effect.

Alternatives to morphine include oxycodone, hydromorphone, fentanyl patches, and buprenorphine (patches and sublingually). Avoid oral pethidine as it only lasts 1.5 hours.

Remember that morphine (and any other morphine-like drug) causes constipation. The best cure for this is lactulose (for lubrication) plus senna (for movement).

Nausea and vomiting can be troublesome initially but usually passes with acclimatisation. If you are actively vomiting then anti-emetics by mouth will be ineffective. Some anti-emetics are available sublingually or by suppository and can therefore bypass this problem.

Consider Pain Clinic referral for specific non-drug interventions e.g. nerve blocks, epidural injections, joint injections etc.

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