Acute Pain in Adults - Clinical Practice Guideline Assessment, Treatment and Documentation of

Publication: 01/10/2002  
Next review: 03/08/2025  
Clinical Guideline
CURRENT 
ID: 181 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Clinical Practice Guideline for the Assessment, Treatment and Documentation of Acute Pain in Adults, incorporating the Adult Acute Pain Management Analgesic Ladder and Table

  1. Aims
  2. Objectives
  3. Background
  4. Scope of the Guideline
  5. Responsibilities
    5.1 All Healthcare Professionals
    5.2 Wards and Departments
    5.3 Prescribers
    5.4 Pharmacists
    5.5 The Inpatient Pain Management Service
    5.6 The Organisation
  6. Pain Assessment
    6.1 Pre-assessment on admission
    6.2 Pain Assessment Schedules and Documentation
    6.3 Pain Assessment using the 0-3 Pain Intensity Score
    6.4 Functional pain score
    6.5 Using the Analgesic Ladder and Table

Summary of Guideline

This guideline focuses on the assessment and management of acute pain in adults, including the use of the LTHT 0-3 Pain Intensity Score and LTHT Analgesic Ladder and Table.

Effective assessment and documentation of pain should commence on admission to the Trust, this should include the patient’s current pain score, past experiences of pain and any on-going pain issues. The patient should also be asked about any treatments they have received for pain management and which analgesics they utilise.
The responsibility for assessing and appropriately managing pain lies with the individual Healthcare Professional delivering their care.

LTHT supports the use of a 0-3 Pain Intensity Score for the assessment of adult acute pain. This scale is suitable for use by all Healthcare Practitioners for the majority of adult patients experiencing acute pain

Within the Accident and Emergency Department patients are assessed using the 0-10 pain score. Once admitted as an inpatient the 0-3 Pain Intensity Score should be used.

For those patients who are unable to effectively utilise the 0-3 Pain Intensity Score, alternative assessments are available in Appendix 1 and on the Pain Service Intranet Site (alternative assessments scales). Multilingual scales are also available (multilingual assessment scales).
The Inpatient Pain Management Service may be contacted for advice on the selection of appropriate pain scales

The most appropriate pain assessment scale for the individual patient should be used continuously throughout their stay. If this is not the standard 0-3 Pain Intensity Score then clear documentation should exist as to why the preferred scale has been used in the patient’s Specialist Nursing Assessment.

Pain should be assessed at both rest and on movement.

LTHT supports the provision of an Inpatient Pain Management Service (RCOA 2022) to uphold standards, support safe and effective management of acute pain and ensure a positive patient experience.

Advice can be sought from the Inpatient Pain Management Service for patients experiencing pain that is not managed within the LTHT Analgesic Ladder and Table.

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1. Aims

1.1 To provide all adult inpatients with high quality acute pain management, through the effective assessment, treatment and documentation of their acute pain from pre-admission to discharge.
1.2 To provide a framework for the safe prescription and administration of appropriate medications linked to the 0-3 Pain Intensity Score and Analgesic Ladder and Table.

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2. Objectives

2.1 To provide evidence-based recommendations for appropriate assessment and management of acute pain in adults.
2.2 To outline multi-professional responsibilities for the adequate assessment, management and documentation of adult acute pain from pre-admission to discharge.
2.3 To outline the prescriber’s responsibilities for the provision of safe and effective analgesia using the Analgesic Ladder and Table.

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3. Background

3.1 Pain is an individual, multifactoral experience and can be influenced by previous pain experience, culture and beliefs, mood and the ability to cope. (Long et al, 2012).
3.2 Pain by nature is subjective; therefore wherever possible a patient’s own description/self-report of pain should be used.
3.3 Accurate pain assessment is fundamental in effective pain management. It is essential in order to ensure the selection of appropriate analgesia and in evaluating and modifying pain management strategies (ANZCA, 2020).
3.4 Pain can be acute or chronic in nature. It is now increasingly being recognised that acute and chronic pain may represent a continuum rather than distinct entities (ANZCA 2020).
3.5 Acute pain is relatively brief pain that subsides in a matter of days or weeks as healing takes place. The appropriate management of acute pain may help to reduce the incidence of specific complications and the risk of some patients developing persistent long term chronic pain (ANZCA 2020).
3.6 Chronic pain can be described as “…pain that lasts or recurs for longer than
3 months” (ANZCA 2020) separate guidelines apply to Chronic Pain Management - these guidelines can be found on the LTHT intranet page. Advice on appropriate referral can be found in the Referral Pathway.
3.7 Uncontrolled or unexpected pain requires reassessment of the diagnosis and consideration of alternative causes for the pain (i.e. new surgical/medical diagnosis, neuropathic pain) (ANZCA, 2020).
3.8 Some patients may experience ‘acute on chronic’ pain or complex pain problems requiring specialised assessment and intervention by the Inpatient Pain Management Service (Referral Pathway).

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4. Scope

4.1 This guideline applies to all Clinical Areas/Departments and all Healthcare Practitioners caring for adult patients experiencing acute pain within LTHT.
4.2 This guideline provides information on the use of the Analgesic Ladder and Table for the assessment, treatment and documentation of acute pain in adults only.
4.3 Separate guidelines apply to Chronic Pain Management, Paediatric Pain Management, management of pain in Obstetric Practice guidelines
and the management of pain in Palliative Care. These can all be accessed via the Trust intranet.

4.4 This guideline should be used in conjunction with all current Adult Pain Management Guidelines and;

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5. Responsibilities

5.1 All Healthcare Practitioners

5.1.1 All Healthcare Practitioners in all clinical areas and departments within LTHT should be familiar with the Acute Pain Management in Adults Manual (LTHT) and implement these guidelines in their clinical practice.
5.1.2 All members of the multi-disciplinary team must be aware of and follow the LTHT Guidelines. This includes:

  • Completion of the Nursing Specialist Assessment document on admission and thereafter at least weekly or on change of condition, as per Trust Documentation Guidelines.
  • Completion of an appropriate pain management care plan for all patients who complain of pain. Details of currently available care plans can be found on the Pain Service Intranet site.

5.1.3 It remains the responsibility of the individual practitioner to ensure they have the appropriate skills and knowledge to accurately assess acute pain and to implement effective pain management strategies. It is also the responsibility of the practitioner to discuss individual development and educational requirements with their team leader.
5.1.4 Any member of the multi-disciplinary team (including unregistered practitioners with the agreement of their team leader) may assess a patient’s pain. The individual must have this skill identified as part of their Knowledge and Skills Framework (KSF) and be aware of and follow the relevant pain management guidelines. They must also be able to appropriately report/act on the findings and complete all relevant documentation.
5.1.5 Following appropriate assessment the Healthcare Practitioner should ensure that the patient receives the correct treatment by referring to the Analgesic Ladder and Table and all current Adult Pain Management Guidelines
5.1.6 Patients whose pain cannot be managed within the Analgesic Ladder and Table should be referred to the Adult In-Patient Pain Management Service, there are multiple options: PPM+ referrals, Bleep or Telephone
5.1.7 If a patient has chronic pain requiring intervention they should be referred via their GP to the Chronic Pain Team for outpatient multi-disciplinary assessment.

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5.2 Wards and departments

5.2.1 Wards and departments should ensure there are sufficient numbers of staff who are trained and competent in the management of acute pain to allow effective treatments to take place.
5.2.2 Wards and departments should ensure that Naloxone and antiemetic medications are prescribed alongside strong opioids; and that they are available on the ward and form part of the ward pharmacy stock list.
5.2.3 Wards and departments should ensure that resuscitation equipment is available within the ward or clinical area prior to the prescription or administration of strong opioids.
5.2.4 Wards and departments must ensure they use appropriate Trust documentation for the recording of systemic observations (including AVPU score and Pain Intensity Score) and evaluation of interventions
5.2.5 Clinical areas must ensure that patients have access to relevant patient information leaflets. These are available via print unit, the EIDO Patient Information site, or the Pain Management Intranet Site

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5.3 Prescribers

5.3.1 It remains the responsibility of the prescriber to ensure they are familiar with and understand the correct prescription, side effects and potential complications of any medication to be prescribed, and to refer, where necessary, current Adult Pain Management Guidelines. They must be aware of the physical condition of the patient for whom the prescription is to be written, any allergies, co-morbidities and current medications.
5.3.2 It remains the responsibility of the prescriber to ensure they have an understanding of their professional responsibilities regarding The Medicines Code (LTHT), and the Safe and Effective Prescription and Use of Strong Opioids in the management of acute pain in adult patients.
5.3.3. The patients own Consultant team is responsible for all aspects of the patient’s treatment, including a review of the patient’s prescriptions and as required opioid requirements on a regular basis (daily, wherever possible).
5.3.4 For post operative patients the surgical team and the anaesthetist caring for the patient with acute pain should work collaboratively when prescribing, ensuring there is no duplication.
5.3.5 It is important to recognise that not all acute pain responds to opioid analgesia, for example pain due to nerve injury may be only partially responsive to opioids. This may need a combination of approaches and may require specialist care from the Pain Management Service
5.3.6 It is important that consideration is given to inter-patient variability and the possibility that some patients may not gain any benefit or may experience excessive side effects from two commonly used weak opioids: Codeine Phosphate and Tramadol. Prescribers should refer to the Medicines Code (LTHT) and the BNF. The Pain Management Service/on-call anaesthetist can also offer advice regarding alternative analgesia.

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5.4 Pharmacists

5.4.1 The ward pharmacist should be the first point of contact for advice on the use of medications within the Analgesic Ladder and Table, including the type, dose, and frequency of as required opioids for specific patients.
5.4.2 Pharmacists are responsible for reviewing the prescription charts of individual patients for suitability of dose and frequency of prescribed analgesics.
5.4.3 Pharmacists should endorse all drug prescriptions with the generic name of the drug (if prescribed as the trade name). Brand names may also need to be endorsed on the chart if there is a pharmaceutical need for the brand to be known.
5.4.4 Pharmacists should ensure all the required elements of an "as required" prescription are clearly specified, e.g. dose, route, frequency, reason for use, review date and maximum dose in a 24-hour period as per the guidelines for Safe and Effective Prescription and Use of Strong Opioids.

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5.5. The Pain Management Service

5.5.1 Will maintain evidence based guidelines ensuring regular reviews of the available literature and make changes as necessary. Any changes will be disseminated effectively.
5.5.2 Continually monitor and undertake specific audits to ensure the effective use of the pain management guidelines, pain assessment and documentation within LTHT.
5.5.3 Design and deliver multi-professional, clinically relevant, timely training in a variety of forms to ensure that assessment and documentation of patient’s pain is delivered effectively.
5.5.4 Work closely with the pharmacy department to ensure that the Analgesic Ladder and Table are applied appropriately.
5.5.5 Will ensure that the Pain Management Service complies with the LTHT Clinical Governance Agenda.

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5.6 Organisational

5.6.1 The Trust will ensure that all Healthcare Professionals and clinical support staff have adequate opportunity to attend clinically relevant study days and update sessions.
5.6.2 The Trust will ensure that the Adult Pain Management Service has adequate resources to provide a safe and effective service including resources to perform audit and research, and to provide effective training.

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6. Pain Assessment

In order to provide patients with safe, effective and appropriate individualised pain management, reliable and accurate pain assessment must be carried out at rest and on movement. (ANZCA, 2020)

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6.1 Preassessment/on admission

The Healthcare Practitioner should;

  • Commence the process of pain assessment and documentation at pre-assessment and/or when the patient is first admitted into the hospital. This should include the patient’s current pain intensity, any past experience of pain and any ongoing pain problems and treatments (including medication).
  • Show the patient a copy of the 0-3 Pain Intensity Score and explain how it should be used.
  • Identify if the patient is able to use the 0-3 Pain Intensity Score and if necessary select an appropriate alternative assessment scale.
  • Explain any potential pain management strategies to the patient supported by appropriate documentation.
  • Identify patients whose pain may not be managed within the Analgesic Ladder and Table and refer to the Adult Pain Management Service

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6.2 Pain Assessment Schedules and Documentation

Pain assessment ensures effective treatment with appropriately selected analgesics. All patients within LTHT should undergo some form of pain assessment. Patients self report is still the most effective way to assess the subjective nature of adult acute pain.

The Healthcare Practitioner should;

  • Assess and document pain at rest and on movement (document the higher of the two Pain Intensity Scores)
  • At every medicines round.
  • With every set of observations.
  • With a change in clinical condition.
  • Before the administration of any analgesia.
  • 1 hour after the administration of any analgesia

Assessment should include:

  • Pain Intensity Score.
  • AVPU
  • Other appropriate routine observations, including respiratory status.
  • Analgesic effect and any side effects.
  • This assessment should be documented on the appropriate LTHT observation chart and appropriate actions taken.

If the patient no longer requires regular routine observations, but continues to require analgesia, Pain Intensity Score must continue to be documented regularly. This must be documented on a LTHT designated observation chart and appropriate care plan and occur:

  • At every medicines round.
  • With a change in clinical condition.
  • Before the administration of any analgesia.
  • 1 hour after the administration of any analgesia

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6.3 Assessing Pain Intensity Scores

Assessing Pain Intensity score allows for a more objective pain assessment. The 0-3 Pain Intensity Score used within LTHT is a 4 point Verbal Descriptor Scale. The 0-3 Pain Intensity Score is also linked to the Analgesic Ladder and Table. 

The Healthcare Practitioner should;

  • Ask the patient if they have pain.
  • Ask the patient to describe the pain and its location.
  • Ask the patient to score their pain using the 0-3 Pain Intensity Score.
  • If the patient has a pain intensity score of 0 or 1 at rest, perform a dynamic pain score, (i.e. pain on movement, coughing or deep breathing).

N.B If the patient has a pain intensity score 2 or above at rest a dynamic pain score is not necessary

  • This must be documented on a LTHT designated observation chart.
  • Report any new pain, changes to the character/nature of pain and/or rapid increases in pain intensity to the appropriate medical team as this may indicate additional pathology. This change in condition should be documented in the Nursing Specialist Assessment document.

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6.4 Functional pain score

When required & appropriate to do so the Adult In-Patient Pain Management team may utilise a functional pain score model to assess a patient’s pain alongside the 0 - 3 pain intensity score - this will be on an individual basis.

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6.5 Using the Analgesic Ladder and Table

The Analgesic Ladder and Table promote a structured approach to adult acute pain management through the use of multi modal analgesia. The Analgesic Ladder and Table allow the patient’s Pain Intensity Score to be linked to the most suitable and effective analgesia. The individual patient should be prescribed the most appropriate range of drugs from the Analgesic Ladder and Table throughout their stay to allow effective management of their acute pain.

The Healthcare Practitioner should;

  • Once the Pain Intensity Score has been agreed with the patient consider if simple comfort measures would be appropriate and reassess.
  • Select the appropriate analgesic from the appropriate step on the Analgesic Ladder and Table (i.e. a patient with a Pain Intensity Score of 2 should be administered the appropriate analgesics from step 2 on the analgesic ladder) considering allergies and contraindications.
  • Administer the most appropriate analgesic and document as per the Medicines Code (LTHT).
  • Re-evaluate and document the effectiveness of the analgesia, any side effects experienced and any further treatments after 1 hour following administration.
  • If, on reassessment, the patients Pain Intensity Score have failed to respond to the administered analgesia, proceed to the next prescribed step of the Analgesic Ladder and Table whilst considering simple comfort measures.
  • Refer any Patient whose pain fails to respond to the interventions within the Analgesic Ladder and Table to the appropriate Adult Pain Management Service and / or anaesthetic team

Provenance

Record: 181
Objective:

2.1 To provide evidence-based recommendations for appropriate assessment and management of acute pain in adults.
2.2 To outline multi-professional responsibilities for the adequate assessment, management and documentation of adult acute pain from pre-admission to discharge.
2.3 To outline the prescriber’s responsibilities for the provision of safe and effective analgesia using the Analgesic Ladder and Table.

Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

ANZCA (2020) Acute Pain Management: the Scientific Evidence 5th Edition

LTHT (2019 - present ) Adult Acute Pain Management Guidelines

Royal College Anaesthetist (2022) Chapter 11: Guidelines for the Provision of Anaesthesia Services for Inpatient Pain Management 2022


Evidence base

Evidence sources

ANZCA (2020) Acute Pain Management: the Scientific Evidence 5th Edition

McAffery M and Pasero C (1999) Pain Clinical Manual. 2nd edition.
Mosby Inc, St Louis, Missouri

L. Stephen Long, M.D., William A. Shapiro, M.D., and Jacqueline M. Leung, M.D. (2012)
A brief review of practical preoperative cognitive screening tools.
British Journal of Anaesthesia. 2012 Aug; 59(8): 798–804. 2012 May 26. doi: 10.1007/s12630-012-9737

National Patient Safety Agency (NPSA) (2008)
Rapid response report. Reducing dose errors with opioid medicines. NPSA/2008/RRR05
http://www.npsa.nhs.uk/corporate/news/healthcare-practitioners-alerted-to-concerns-over-incorrect-use-of-powerful-pain-killers/

Nursing & Midwifery Council (2018)
The Code: Professional standards of conduct and behaviour. London, NMC
https://www.nmc.org.uk/standards/code/ The Code: Professional standards of conduct and behaviour.

Palliative Drugs .com (login required)
http://www.palliativedrugs.com/

The British Pain Society
(https://www.britishpainsociety.org/british-pain-society-publications/professional-publications/)

Royal College of Anaesthetists (RCOA 2022). Guidelines for the Provision of Anaesthesia Services for Inpatient Pain Management 2022
https://rcoa.ac.uk/gpas/chapter-11#chapter-1

RCOA (2012) Raising the standard: a compendium of audit recipes. 3rd Edition.
http://www.rcoa.ac.uk/ARB2012

Royal College of Surgeons of England and College of Anaesthetists (1990) (RCS & A) Report of the working party on pain after surgery.
London: Royal College of Surgeons of England and College of Anaesthetists
http://www.rcoa.ac.uk/document-store/commission-the-provision-of-surgical-services-report-of-working-party-pain-after

The British National Formulary (2022) https://bnf.nice.org.uk/

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1:

  • Pain Management Assessment Documents and Tools
  • Adult Acute Pain Analgesic Ladder & Table
  • Adult Acute 0-3 Pain Intensity Score
  • Dermatome Segmental Distribution for Adult Acute Pain Management
  • S-LANSS

Assessment of Patients with Cognitive Impairment

Assessment of patients with cognitive impairment where communication may be limited or difficult can be challenging and complex. Although the Trust recommends the use of the 0-3 Adult Pain Intensity Score, it may not be appropriate for all patients; therefore an appropriate assessment tool must be used. There is limited evidence to suggest that pain has specific behaviours so many of these tools more broadly identify distress. It cannot be presumed that the cause of distress is pain but this MUST be considered.

The Cognitive impairment Assessment tool should be used within Trust as an alternative assessment if the 0-3 Adult Pain Assessment Scale is not appropriate. However, there are other tools available and the most appropriate one must be chosen:

For the assessment of patients with memory problems, The Trust recommends the use of the ‘Know Who I Am’ document which is completed by the patient/carer and provides individualised patient information for staff to refer to. This includes identifying signs of pain (individual to the patient) that can be used in conjunction with other tools to identify pain in patients that may otherwise be unable to communicate this. This is available from the Documentation Index List.
There is also other information that can be referred to when caring for patients with cognitive impairment: Alzheimer’s Society & Social Care Institute for Excellence (Scie),

Standard 7 – Pain

  • All patients will be assessed and have their pain score documented at any pre-assessment visit and/or on admission to the Trust, using the appropriate LTH tool.
  • Patients who are unable to effectively utilise these scales will be assessed using an appropriate alternative assessment available from the pain management service intranet site.
  • Staff working within Accident and Emergency will continue to use local guidance.
  • We will regularly assess patient’s pain as per LTHT acute pain management guidelines, and will ensure that pain is assessed before, and evaluated after any analgesia is given.
  • We will ensure that all patients have an approved observation chart in use and that observations are completed in accordance with the pain management guidelines.
  • Once a pain intensity score has been agreed with a patient, we will ensure this is matched against the appropriate step on the analgesic ladder and table to assist in the selection of the most suitable analgesic.
  • We will reassess pain within 30-60 minutes of the administration of analgesia.
  • Patients whose pain fails to respond to the interventions within the analgesic ladder and table will be referred to the appropriate pain management service and / or anaesthetic team
  • We will ensure that as well as pharmacological methods, patients are assessed with regard to their comfort needs, ensuring their preferences for positioning are considered, and that the environment (including at night) is optimised to achieve comfort.
  • We will ensure that patients are able to access relevant patient information leaflets.

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Appendix 2: The prescription and administration of Intravenous Parecoxib. (supporting guidance for the Analgesic Ladder and Table)

Guidance on the use of IV Parecoxib

This Guidance is to be used in conjunction with the LTHT Acute Pain Management in Adults Manual (LTHT) and the LTHT Acute Pain Analgesic Ladder and Table

  • Non selective NSAIDs will be used in preference to COX2 selective drugs unless the use of COX 2 drugs is specifically indicated e.g. high risk of perioperative bleeding
  • The oral or rectal route will be used in preference to the parenteral route for administering perioperative NSAIDs unless there are good reasons not to do this. This may include giving preoperative NSAIDs.
  • The use of parenteral ketorolac will be avoided when specifically prohibited by the current product license, that is intra-operatively and in patients taking anticoagulants including low dose heparin.
  • All COX-2 inhibitors are now contraindicated in patients with ischaemic heart disease or cerebrovascular disease. In addition, the existing contraindication for severe heart failure is now extended to include moderate heart failure (NHYA class II-IV).
  • All COX-2 inhibitors must be used with caution in patients with risk factors for heart disease e.g. hypertension, hyperlipidaemia, diabetes, smoking and peripheral arterial disease.
  • COX-2 inhibitors must be used at the lowest effective dose and for the shortest duration possible.

IV Parecoxib dose guidance

Indications, Contraindications and Cautions can be found in the British National Formulary (BNF)
Dose 40mg slow IV bolus followed every 6 -12 hours by 20-40mg
Maximum daily dose 80mg

Dose Adjustments Elderly: No dosage adjustment is generally necessary in elderly patients (GREATER-THAN OR EQUAL TO (8805) 65 years). However, for elderly patients weighing less than 50 kg, initiate treatment with half the usual recommended dose and reduce the maximum daily dose to 40mg
Renal Impairment: On the basis of pharmacokinetics, no dosage adjustment is necessary in patients with mild to moderate (creatinine clearance of 30-80 ml/min.) or severe (creatinine clearance < 30 ml/min.) renal impairment. However, caution should be observed in patients with renal impairment or patients who may be predisposed to fluid retention
Hepatic impairment: No dosage adjustment is generally necessary in patients with mild hepatic impairment (Child-Pugh score 5-6). Introduce with caution and at half the usual recommended dose in patients with moderate hepatic impairment (Child-Pugh score 7-9) and reduce the maximum daily dose to 40 mg. There is no clinical experience in patients with severe hepatic impairment (Child-Pugh score GREATER-THAN OR EQUAL TO (8805)10), therefore its use is contraindicated in these patients

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Appendix 3: Weak & Strong opioid protocols

The Trust has both weak and strong opioid protocols available to use on eMeds; these were created from RCoA guidance, specifically “Opioids Aware”
They were developed to improve pain management, promote safer prescribing, cease medication duplication and reduce the unnecessary escalation of opioids within the Trust.

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.