Step 2: Weak Opioids

These opioids have low potency but can be a useful second step for patients with moderate pain.

It is seldom useful to change from one weak opioid preparation to another (unless to alter side effects). If regular doses do not provide adequate analgesia, move up the ladder to step 3.

Compound preparations of paracetamol and weak opioids may be useful.

Only preparations with higher doses of opioids (codeine 30mg, dihydrocodeine 20-30mg) should be used, as the lower strength preparations produce opioid side effects with little analgesia.

Codeine

Adult dose:
30–60mg 4 hourly
Max 240mg in 24 hours

Dosage forms
Tablets: 15mg, 30mg, 60mg
Syrup: 25mg/5ml, 15mg/5ml linctus, 25mg/5ml oral solution
Injection: 60mg/ml (CD)

Additional information weak opioids:
Caution in renal impairment / Can cause constipation

Co-codamol 30/500

(Codeine 30mg with Paracetamol 500mg)

Adult dose:
2 tablets 4–6 hourly
Max 8 in 24 hours
(cautions for paracetamol dose apply)

Dosage forms
Tablets, capsules, effervescent tablets and granules: 30/500
Granules: 60/1000 – max 4 sachets daily

Additional information weak opioids:
Caution in renal impairment / Can cause constipation

Dihydrocodeine

Adult dose:
30–40mg 4 hourly
Max 240mg in 24 hours
(higher dose may be associated with more side effects)

Dosage forms
Tablets: 30mg, 40mg
MR tablets: 60mg
Oral solution: 10mg in 5ml
Injection: 50mg/ml (CD)

Additional information weak opioids:
Caution in renal impairment / Can cause constipation

Dihydrocodeine 20mg with Paracetamol 500mg

Adult dose:
2 tablets every 4–6 hours
Max 8 in 24 hours
(cautions for paracetamol dose apply)

Dosage forms
Tablets: 20/500

Additional information:
Caution in renal impairment / Can cause constipation

Dihydrocodeine 30mg with Paracetamol 500mg

Adult dose:
2 tablets every 4–6 hours
Max 8 in 24 hours
(cautions for paracetamol dose apply)

Dosage forms
Tablets: 30/500

Additional information:
Caution in renal impairment / Can cause constipation

Tramadol

Adult dose:
50–100mg 4 hourly
Max 400mg in 24 hours

Dosage forms
Capsules: 50mg (CD)
Soluble tablets: 50mg (CD)
Orodispersible tablets: 50mg (Zamadol Melt®) (CD)
MR 12 hourly tablets: 50mg 100mg, 150mg, 200mg (CD)
MR 24 hourly tablets: 150mg, 200mg, 300mg, 400mg (CD)
Injection: 50mg/ml (CD)

Additional information:
Caution in renal impairment / Can cause constipation

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.