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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).