1. By the clock

Cancer pain is continuous – Use regular analgesia appropriate dose intervals – not just p.r.n.

2. By the ‘ladder’

If pain is still a problem with high doses of strong opioid, (greater than 300mg morphine equivalent /24hrs), or severe side effects, reconsider the cause of the pain, and/or seek specialist palliative care adviceThe ‘ladder’ has no ‘top rung’ as there is no maximum dose for strong opioids

3. By the mouth

The oral route is preferred for all steps of the analgesic ‘ladder’ unless there is a clinical reason why absorption of drugs given orally will not be effective


Adult Dose

Oral: 200-400mg TDS

Dosage Forms

  • Tablet: 200mg, 400mg, 600mg
  • MR tablet: 800mg od
  • MR capsule: 300mg bd
  • Suspension: 100mg/5ml
  • Granules: 600mg sachet
  • Gel for topical use

Additional Information

Current evidence suggests an increased risk of cardiovascular thrombotic events with NSAIDs.

For those at risk consider naproxen or low dose ibuprofen (1200mg or less/24h)


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.