Step 2: Weak Opioids

These opioids have low potency but can be a useful second step for patients with moderate pain. However, there is no pharmacological need for Step 2. Compared to a weak opioid, benefit from low-dose morphine is greater and more rapid.

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 20mg-30mg) should be used, as the lower strength preparations produce opioid side effects with little analgesia.

Codeine

Adult Dose
30mg–60mg 4 hourly | Max 240mg in 24 hours

Dosage Forms
Tablets: 15mg, 30mg, 60mg
Oral solution: 15mg/5mL linctus (sugar-free available),
25mg/5mL oral solution
Injection: 60mg/mL (CD)

Additional Information
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: 30mg/500mg
Oral solution: 30mg/500mg/5ml

Additional Information
Caution in renal impairment / can cause constipation

Tramadol

Adult Dose
50mg–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

Step 1:

Step 2:

Step 3:

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.