Initial management of pain

First line:

  • Paracetamol (encourage OTC). Low body weight <50 kg consider reducing dose (see link for local advice).
  • Consider NSAID if inflammatory component taking into account patient risk factors. Use lowest effective dose for shortest period of time. Ibuprofen (encourage OTC) or naproxen. Prescribe gastro protection if appropriate - link.
  • For osteoarthritis consider paracetamol and/or topical NSAIDs ahead of oral NSAIDs or opioids (NICE CG 177).
  • For low back pain do NOT offer paracetamol alone. Prescribe oral NSAIDs as above. Consider weak opioids (+/-paracetamol) for acute low back pain only if NSAID is contraindicated, not tolerated or ineffective (NICE NG 59).

Second line:

  • Paracetamol plus separate codeine (easier to titrate than combination preparations). If poor response to codeine, consider dihydrocodeine standard tablets (may be poor metaboliser of codeine).
  • In osteoarthritis, if pain relief is insufficient with first line treatment consider adding oral NSAID or weak opioid. If pain relief ineffective with first line treatment stop treatment and consider oral NSAID (NICE CG 177).


  • Soluble tablets have much higher sodium content than standard tablets and are more expensive.
  • Tramadol is neither more effective nor better tolerated than other weak opioid analgesics for moderate to severe pain (PrescQIPP Bulletin 62); can lead to tolerance, psychological and physical dependence.
  • Nefopam: limited evidence base and adverse effects. Only use if NSAID or opioid is contraindicated or not tolerated.