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Moderate nociceptive pain in adults: first-choice drugs

In patients with moderate nociceptive pain, the first-choice analgesic is paracetamol or, if unsuitable, a NSAID (ibuprofen or naproxen), or else morphine at the lowest effective dose, if necessary.

Nociceptive pain is caused by damage to a tissue or organ, resulting for example from surgery, injury, bone metastasis, or muscle or joint disease. As well as seeking to identify the cause, listening attentively to the patient is the chief approach to evaluating pain in all its complexity and its impact on quality of life.

When drug therapy is needed, paracetamol is the first-choice analgesic for mild to moderate pain. It is often effective, and its adverse effects are rare and less severe than those of other analgesics. The main risk is related to overdoses, causing serious liver and kidney damage. Concomitant use of several drugs containing paracetamol increases the risk of overdose.

When paracetamol is to be avoided or is unsuitable, nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen (not more than 1200 mg per day) and naproxen are the drugs of choice except in pregnant women.

When these analgesics are ineffective against nociceptive pain, an opioid is sometimes justified: morphine at the minimum effective dose is the first choice. Its adverse effects, heightened in cases of renal failure, are mainly intestinal and neuro-psychological, with the risk of addiction and dependence during prolonged treatment. The so-called weak opioids, especially codeine and tramadol, are as risky as morphine, while their efficacy is less certain. Tramadol also exposes patients to additional adverse effects, such as hypoglycaemia and convulsions.

©Prescrire 1 December 2017

"Moderate intensity nociceptive pain in adults. First-choice treatments" Prescrire Int 2017; 26 (188): 297-300. (Pdf, subscribers only).

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See also:

"Weak" opioid analgesics:
codeine, dihydrocodeine
and tramadol are no less
risky than morphine
(February 2016)

Nonsteroidal anti-inflammatory
drugs (NSAIDs): avoid cox-2
inhibitors, diclofenac and
high-dose ibuprofen
(January 2016)