Analgesic Medication

By the clock

Cancer pain is continuous – Use regular analgesia with appropriate dose intervals – not just PRN.

2. By the “Ladder”

Step 1

Non Opioid

e.g. paracetamol

Step 2

Weak Opioid

e.g. codeine for mild to moderate pain + non opioid

Step 3

Strong Opioid

e.g. morphine for moderate to severe pain + non opioid


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, e.g. greater than 300mg PO morphine equivalent /24hrs, or severe side effects, reconsider the cause of the pain, and/or seek specialist palliative care advice.

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.

Use the links below for further information about each Step of the Ladder:

Step 1:

Step 2:

Step 3:


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.