analgesics in palliative care

Last edited 08/2020

This section covers:

  • drugs used in palliative care to relieve pain

  • management of some specific types of pain encountered in palliative care
    • consider three main types of cancer related pain:
      • visceral/soft tissue pain
        • • opioid sensitive - use the "ladder"
      • bone pain
        • NSAID sensitive
        • partly opioid sensitive
        • radiotherapy may help
      • nerve related
        • partly opioid sensitive
        • adjuvant analgesics may often be needed
      • also consider incident pain
        • exacerbations of pain on movement, may require fast acting analgesia

  • use of syringe drivers and how to set them up in the patient's home

The concept of the pain relief 'ladder' is one that is used in palliative care:

Step 3 - strong opioid e.g. morphine +/- non-opioid
Step 2 - weak opioid e.g. codeine +/- non opioid
Step 1 - Non opioid e.g. paracetamol, NSAID

The steps of the pain ladder are traversed 1 to 3 and the decision to go to the next step is based on whether pain persists or increases whilst at a particular step.

The ladder has no "top rung" as there is no maximum dose for strong opioids. If pain is still a problem with high doses of strong opioid (>300mg morphine equivalent/24 hours) or severe side effects, reconsider the cause of the pain - for example, bone pain may be better helped by NSAIDs - or seek specialist advice (1).


  • many pains are not cancer related but may be:
    • treatment related e.g. constipation, post radiotherapy
    • coincident illness or condition e.g. arthritis, migraine. Many factors influence the perception of pain. e.g. fear, loneliness, boredom


  1. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.
  2. St Elizabeth Hospice Guidelines, Ipswich, 1997