Peri-operative analgesia
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Adults >50kg: 1g every 4-6 hours; max 4g daily.
Adults <50kg: 500mg every 4-6 hours.
Refer to specialist advice.
Refer to specialist advice.
Refer to specialist advice
Refer to specialist advice.
Refer to specialist advice.
In-patient use only. Tramadol or oral liquid morphine, with or without a NSAID.
Initially 50-100mg, then 50-100mg every 4-6 hours; Usual maximum 400mg/24 hours.
Limit to 3-5 days. Maximum 7 days at discharge.
Refer to local board guidance on preferred preparation of morphine sulfate solution for Patient Controlled Analgesia (PCA) .
Initially 5-10mg every 4-6 hours (5mg in elderly patients), adjusted according to response.
Limit supply to 3-5 days only at discharge.
Refer to BNF for dosing
NSAID choices – Ibuprofen, diclofenac sodium or etoricoxib.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
Rectally, 75–150 mg daily in divided doses.
120mg daily for 2 days, followed by 90mg daily for 5 days; or 90mg daily for 7 days.
120mg daily for 2 days, followed by 90mg daily for 5 days; or 90mg daily for 7 days.
Specialist peri-operative analgesia.
Refer to BNF/product information.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight adults.
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Prolonged-release opioids should not be used for the treatment of acute pain following surgery. Immediate-release opioids are preferred in the management of postoperative pain (to decrease risk of respiratory impairment and long-term continuation), when simple analgesics such as paracetamol or NSAIDs are not effective enough to allow the achievement of agreed functional goals.
- Patients undergoing surgery whose pain is managed with opioids pre-operatively should have their treatment reviewed before and after surgery in line with Best Practice Guidelines. See Guidelines and Resources | Centre for Perioperative Care Surgery and Opioids: Best Practice Guidelines 2021.
- On discharge from hospital following surgery, only prescribe and supply a sufficient amount of immediate-release opioids to treat acute post-operative pain and communicate the pain management plan on discharge to primary care.
- Avoid concomitant use of two or more opioids.
- Tramadol is considered to be a strong opioid (approximately twice as potent as codeine) and is associated with important safety considerations.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. Combination of a stimulant and softening laxative is recommended.
- Elderly patients are particularly susceptible to side effects of opioids e.g. respiratory depression and constipation.
History Notes
12/01/2026
Updates to prescribing information, ERWG October 2025.
27/10/2022
East Region Formulary content agreed.
Intravenous paracetamol is restricted to use for the short-term treatment of moderate pain, when administration by the intravenous route is clinically justified.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
In-patient use only. Oral liquid morphine or tramadol, with or without a NSAID.
Refer to local board guidance on preferred preparation of morphine sulfate solution for Patient Controlled Analgesia (PCA)
Limit supply at discharge.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Tramadol may be considered in those with side effects or poor analgesic effect from other opioids.
Limit supply at discharge.
For dose, refer to BNF for Children.
NSAID choices – Ibuprofen or diclofenac sodium.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Inpatient use only. Restricted to use in the acute post operative setting in RHCYP under the specialist supervision of paediatric anaesthesia and pain teams within established peri-operative care pathways. Used in combination with paracetamol, with or without NSAID (ibuprofen or diclofenac sodium).
As per specialist.
Restricted to use under the management of the paediatric pain team in the acute post operative setting (RHCYP). Oxycodone may be considered in those with side effects or poor analgesic effect from other opioids. Used in combination with paracetamol, with or without NSAID (ibuprofen or diclofenac sodium). Refer to individual product information for licence status.
As per specialist.
As per specialist.
As per specialist.
As per specialist.
Prescribing Notes:
- Patients who are malnourished or with significant weight loss may be more susceptible to paracetamol induced liver damage even at appropriate doses. It is also important to consider the need for weight-based dosing in underweight children.
- In acute pain management, it will often be appropriate to initiate treatment with potent opioids plus non-opiates and then gradually wean these as the symptoms improve.
- Except for fentanyl patches in established RHCYP care pathways only under the direct supervision of specialists in paediatric pain management in RHCYP, prolonged-release opioids should not be used for the treatment of acute pain following surgery. Immediate-release opioids are preferred in the management of postoperative pain (to decrease risk of respiratory impairment and long-term continuation), when simple analgesics such as paracetamol or NSAIDs are not effective enough to allow the achievement of agreed functional goals.
- Patients undergoing surgery whose pain is managed with opioids pre-operatively should have their treatment reviewed before and after surgery in line with Best Practice Guidelines. See Guidelines and Resources | Centre for Perioperative Care Surgery and Opioids:Best Practice Guidelines 2021.
- On discharge from hospital following surgery, only prescribe and supply a sufficient amount of immediate-release opioids to treat acute post-operative pain and communicate the pain management plan on discharge to primary care.
- Post-operative patients may be discharged with an appropriate short term course of morphine, as detailed in the NHS Lothian intranet discharge analgesia guideline. This should not routinely be continued beyond this period.
- See the NHS Lothian intranet discharge analgesia guideline available on the Children’s Services Policies and Guidelines page.
- Avoid concomitant use of two or more opioids.
- Tramadol is considered to be a strong opioid (approximately twice as potent as codeine) and is associated with important safety considerations.
- Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.
- Patients prescribed a strong opioid should have access to regular prophylactic laxatives. Combination of a stimulant and softening laxative is recommended.
History Notes
31/07/2025
Prescribing information updated, ERWG July 2025.
09/07/2024
Paracetamol 60mg suppositories discontinued
09/11/2023
East Region Formulary content agreed.