Med2Date — Clinical Guidelines
Home Analgesia Multimodal Analgesia

Multimodal Analgesia

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋
  • Multimodal analgesia combines agents acting on different pain pathways (peripheral nociception, central sensitisation, descending modulation) to achieve synergistic pain relief while minimising opioid exposure.
  • Opioid-sparing strategies are now mandated by the ACSQHC Acute Pain Clinical Care Standard and endorsed by RACS — every acute pain plan should include a documented opioid minimisation approach.
  • Paracetamol + NSAID (e.g., paracetamol 1 g QDS + ibuprofen 400 mg TDS) forms the analgesic backbone for most acute pain presentations in Australian emergency departments and surgical wards.
  • Regular (around-the-clock) dosing of nonopioid agents is more effective than PRN dosing for maintaining therapeutic plasma levels and preventing pain escalation.
  • Gabapentinoids (pregabalin, gabapentin) are useful perioperative adjuvants for neuropathic and mixed pain but require dose titration and renal adjustment; avoid routine use in opioid-tolerant patients without clear neuropathic features.
  • Ketamine at sub-anaesthetic doses (0.1–0.25 mg/kg IV) is a valuable NMDA-receptor antagonist adjuvant for opioid-tolerant patients, burns, and acute trauma — use requires cardiorespiratory monitoring.
  • Regional anaesthesia (peripheral nerve blocks, epidural, fascial plane blocks) provides site-specific analgesia with minimal systemic side effects and should be considered early in the pain pathway.
  • Dexamethasone (4–8 mg IV, single dose) as an adjunct to nerve blocks prolongs block duration and provides additional anti-emetic benefit.
  • Lidocaine IV infusion (1–1.5 mg/kg/hr) has evidence for post-operative opioid sparing, particularly in abdominal surgery — requires cardiac monitoring.
  • Renal and hepatic impairment necessitate dose adjustment for NSAIDs, gabapentinoids, and tramadol; always calculate eGFR and assess liver function before prescribing.
  • Aboriginal and Torres Strait Islander patients face barriers including remote access to regional techniques, higher rates of chronic pain, and culturally unsafe pain communication — tailor multimodal plans accordingly.
  • Document the multimodal plan on the medication chart with explicit nonopioid and adjuvant orders; opioid orders should state indication, ceiling dose, and planned review/cessation date.

Introduction & Australian Epidemiology

Multimodal analgesia is the concurrent use of multiple analgesic agents and techniques that act through distinct pharmacological and physiological mechanisms. By targeting different points along the nociceptive and neuropathic pain pathways — from peripheral transduction, through spinal cord transmission, to supraspinal processing and descending modulation — multimodal approaches achieve synergistic or additive analgesia while reducing reliance on any single agent, most notably opioids.

The concept has become a central pillar of contemporary perioperative medicine, emergency medicine, and chronic pain management in Australia. The Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine, the Royal Australasian College of Surgeons (RACS), and the Australian Commission on Safety and Quality in Health Care (ACSQHC) all advocate for multimodal analgesia as first-line practice.

Australian Burden of Acute and Post-Operative Pain

  • Approximately 2.5 million surgical procedures are performed annually in Australian hospitals (AIHW 2022–23), with moderate-to-severe post-operative pain reported by 30–50% of patients in the first 48 hours.
  • Opioid-related harm remains a significant public health concern: Australia recorded 1,237 opioid-induced deaths in 2022 (Penington Institute), with prescription opioids implicated in over 60% of cases.
  • The ACSQHC Acute Pain Clinical Care Standard (2022) requires that all patients with acute pain have a documented pain management plan incorporating non-pharmacological and nonopioid pharmacological strategies.
  • Opioid stewardship programmes are now embedded in over 80% of major Australian tertiary hospitals, supported by state-based QUMAX and NSQHS audits.
  • In regional and remote Australia, access to acute pain services and regional anaesthesia expertise is limited — multimodal nonopioid strategies are especially important in these settings.

Rationale for Multimodal Approach

No single analgesic provides complete pain relief without dose-limiting toxicity. Opioids, while effective for severe nociceptive pain, carry risks of respiratory depression, nausea, constipation, tolerance, opioid-induced hyperalgesia, and dependence. By combining lower doses of multiple agents, clinicians can achieve equianalgesic or superior pain control with fewer adverse effects. The WHO analgesic ladder (1986) has been progressively superseded in acute care by a "multimodal-first" paradigm where nonopioid analgesics are initiated simultaneously rather than sequentially.

Opioid-Sparing Strategy

An opioid-sparing strategy systematically reduces the dose, duration, and reliance on opioid analgesics through structured integration of nonopioid agents, regional techniques, and non-pharmacological interventions. This is not about withholding opioids when genuinely indicated, but about ensuring opioids are not the sole or default analgesic modality.

Core Principles

1
Pre-emptive Analgesia
Administer nonopioid analgesics before the noxious stimulus (pre-incision, pre-procedure) to attenuate central sensitisation. Example: paracetamol 1 g + celecoxib 200 mg PO 1–2 hours pre-operatively.
2
Around-the-Clock Nonopioid Backbone
Schedule paracetamol and/or an NSAID on a fixed-dose basis (not PRN). This provides a steady baseline of analgesia upon which other agents are layered.
3
Targeted Adjuvants
Add mechanism-specific agents (gabapentinoids for neuropathic component, dexamethasone for inflammation/anti-emesis, ketamine for opioid-tolerant patients) based on clinical context.
4
Regional / Local Techniques
Deploy peripheral nerve blocks, fascial plane blocks, epidural analgesia, or wound infiltration catheters wherever anatomically feasible.
5
Rescue Opioid — Low Dose, Defined Ceiling
If breakthrough pain persists despite steps 1–4, use low-dose opioid (e.g., oxycodone 2.5–5 mg PO) with a documented maximum daily dose and planned cessation date.
⚠️
Opioid ceiling and review: All opioid orders in Australian hospitals should specify a maximum 24-hour dose, a review time (typically 24–48 hours), and a planned cessation strategy. Per ACSQHC Acute Pain Standard, ongoing opioid use beyond 5 days requires explicit reassessment and documented rationale.

Quantifying Opioid Sparing

Evidence from meta-analyses demonstrates the following opioid dose reductions when multimodal regimens are employed:

Multimodal Component Opioid Reduction (24h morphine equivalent) Evidence Level
Paracetamol (scheduled QDS) 20–30% Level I (Cochrane)
NSAID (regular dosing) 30–50% Level I (Cochrane)
Perioperative gabapentinoid 15–25% Level I (meta-analysis)
Sub-anaesthetic ketamine 25–40% Level I (Cochrane)
Peripheral nerve block 50–80% Level I
Epidural analgesia 60–90% Level I
IV lidocaine infusion 20–40% Level II
Dexamethasone (single dose) 10–20% Level I

Nonopioid Analgesics

Nonopioid analgesics form the foundation of multimodal regimens. They should be prescribed on a scheduled (around-the-clock) basis rather than PRN for optimal efficacy in acute pain.

Paracetamol (Acetaminophen)

💊
Paracetamol
Panadol® · Panamax® · Dymadon® · Analgesic / antipyretic
Mechanism Central COX inhibition (COX-3 hypothesis), serotonergic pathways, endocannabinoid system modulation; weak peripheral anti-inflammatory activity
Adult dose — oral 500 mg–1 g PO QDS (max 4 g/day); reduce to max 2 g/day in hepatic impairment or body weight <50 kg
Adult dose — IV 1 g IV QDS (infused over 15 min); max 4 g/day; ≤50 kg: 15 mg/kg QDS
Paediatric dose 15 mg/kg PO/IV QDS (max 60 mg/kg/day up to 4 g/day); neonates 10 mg/kg QDS
Renal adjustment eGFR 10–50 mL/min: extend interval to Q6H; eGFR <10: Q8H and max 2 g/day
Hepatic adjustment Max 2 g/day in Child-Pugh A–B; avoid in severe hepatic impairment (Child-Pugh C)
PBS status ✔ PBS General Benefit (oral) ⚑ Authority Required (IV Perfalgan® — authority for inability to take oral)

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

💊
Ibuprofen
Nurofen® · Brufen® · Non-selective NSAID
Mechanism Non-selective COX-1/COX-2 inhibition; anti-inflammatory, analgesic, antipyretic
Adult dose 200–400 mg PO TDS-QDS (max 1.2 g/day OTC; 2.4 g/day prescription); take with food
Paediatric dose 5–10 mg/kg PO TDS (max 30 mg/kg/day); from 3 months of age
Renal adjustment Avoid if eGFR <30 mL/min; use with caution eGFR 30–60 (short courses only); monitor electrolytes
Key warnings GI bleeding risk (add PPI if age >65 or history); avoid in heart failure (NYHA III–IV); avoid in third trimester of pregnancy
PBS status ✔ PBS General Benefit
💊
Celecoxib
Celebrex® · Selective COX-2 inhibitor
Mechanism Selective COX-2 inhibition; analgesic and anti-inflammatory with reduced GI toxicity vs non-selective NSAIDs
Adult dose 200 mg PO BD or 400 mg stat then 200 mg BD; max 400 mg/day
Renal adjustment Avoid if eGFR <30 mL/min; caution 30–60
Key advantages Lower GI bleed risk than non-selective NSAIDs; suitable for patients on low-dose aspirin; does not inhibit antiplatelet effect of aspirin at doses ≤200 mg/day
PBS status ⚑ PBS Authority Required (for OA, RA, AS, acute gout — where non-selective NSAID contraindicated)
💊
Ketorolac
Toradol® · Potent parenteral NSAID
Adult dose 10–30 mg IV/IM stat (max 30 mg if <65 y; 15 mg if ≥65 y or <50 kg); then 10–15 mg IV Q6H for max 48 hours total
Key indication Acute post-operative pain, renal colic, musculoskeletal trauma — potent opioid-sparing effect
Renal adjustment Contraindicated if eGFR <30 mL/min
Duration limit Maximum 48 hours IV/IM; transition to oral NSAID thereafter
PBS status ⚑ PBS Restricted Benefit (hospital use)
🚨
NSAID safety — contraindications and precautions: Avoid NSAIDs in: active GI bleeding or peptic ulcer disease; severe renal impairment (eGFR <30); heart failure (NYHA III–IV); third trimester of pregnancy (≥28 weeks); concurrent anticoagulation without gastroprotection; coronary artery bypass graft (CABG) perioperative period. Always co-prescribe a PPI (e.g., pantoprazole 40 mg PO daily) for patients with GI risk factors.

Comparative Summary

Agent Route Ceiling Dose Key Advantage Key Limitation
Paracetamol PO / IV / PR 4 g/day (2 g if hepatic risk) Safe, minimal side effects, all ages Weak anti-inflammatory; hepatotoxicity in overdose
Ibuprofen PO 2.4 g/day Potent anti-inflammatory; widely available GI, renal, cardiovascular risks
Celecoxib PO 400 mg/day Reduced GI toxicity; COX-2 selective Cardiovascular risk at high doses; PBS authority needed
Ketorolac IV / IM 120 mg/day (<65 y) Powerful parenteral option; excellent opioid sparing 48-hour limit; renal/GI risks

Adjuvants

Adjuvant analgesics are agents whose primary indication is not analgesia but that provide meaningful pain relief in specific clinical contexts — neuropathic pain, opioid-tolerant states, inflammatory conditions, or central sensitisation. Their use is a hallmark of sophisticated multimodal prescribing.

Gabapentinoids

💊
Pregabalin
Lyrica® · α2δ ligand / gabapentinoid
Mechanism Binds α2δ subunit of voltage-gated calcium channels → reduces presynaptic neurotransmitter release (glutamate, substance P, noradrenaline)
Adult dose — perioperative 75–150 mg PO pre-operatively, then 75–150 mg PO BD for 2–5 days post-operatively
Adult dose — neuropathic pain 75 mg PO BD, titrate to 150–300 mg PO BD over 1–2 weeks; max 600 mg/day
Renal adjustment eGFR 30–60: max 150 mg BD; eGFR 15–30: 25–75 mg OD-BD; eGFR <15: 25 mg OD
Key warnings Sedation, dizziness, visual disturbance, peripheral oedema; avoid abrupt cessation (risk of seizure, anxiety, insomnia); drug of dependence potential — S8 in some states
PBS status ⚑ PBS Authority Required (neuropathic pain — trial of treatment; not PBS-listed for acute perioperative use)
💊
Gabapentin
Neurontin® · Gabapentin Sandoz® · α2δ ligand / gabapentinoid
Adult dose — perioperative 300–600 mg PO 1–2 hours pre-operatively
Adult dose — neuropathic pain 300 mg OD Day 1, 300 mg BD Day 2, 300 mg TDS Day 3; titrate to 300–600 mg TDS; max 3.6 g/day
Renal adjustment eGFR 30–60: 200–700 mg BD; eGFR 15–30: 200–300 mg daily; eGFR <15: 100–300 mg daily
PBS status ⚑ PBS Authority Required (neuropathic pain)

Ketamine (Sub-Anaesthetic Dose)

💊
Ketamine
Ketalar® · NMDA-receptor antagonist
Mechanism Non-competitive NMDA-receptor antagonism → reduces wind-up, central sensitisation, and opioid-induced hyperalgesia; also interacts with opioid receptors, monoamine systems, and anti-inflammatory cholinergic pathways
Adult dose — sub-anaesthetic IV bolus: 0.1–0.25 mg/kg over 10–15 min, may repeat Q4–6H; Infusion: 0.1–0.2 mg/kg/hr for 24–72 hours
Key indications Opioid-tolerant patients; burns/procedural pain; acute trauma (particularly rib fractures); refractory post-operative pain; opioid-induced hyperalgesia
Monitoring required Continuous pulse oximetry; BP and HR Q15 min during bolus; sedation score; psychomimetic side effects (hallucinations, dysphoria) — co-administer midazolam 0.5–1 mg IV PRN
Contraindications Uncontrolled hypertension; raised intracranial pressure; severe psychiatric disorder; porphyria; pregnancy (relative)
PBS status ⚑ PBS Restricted Benefit (hospital use; authority required for outpatient subcutaneous use in palliative care)

Dexamethasone

💊
Dexamethasone
Dexamethasone Sodium Phosphate · Corticosteroid / anti-inflammatory
Adult dose — perioperative adjunct 4–8 mg IV at induction (single dose); 8–16 mg IV for major surgery or chemotherapy-induced nausea
Paediatric dose 0.1–0.15 mg/kg IV (max 8 mg) at induction
Analgesic benefits Anti-inflammatory; reduces post-operative nausea and vomiting (PONV); prolongs peripheral nerve block duration by 4–8 hours; may reduce acute post-operative opioid consumption
Key caution Single perioperative dose generally safe for diabetics (may cause transient hyperglycaemia 4–6 hr); avoid repeated doses in uncontrolled diabetes; monitor BGL
PBS status ✔ PBS General Benefit

IV Lidocaine (Lignocaine) Infusion

💊
Lidocaine (Lignocaine)
Xylocard® · Sodium channel blocker / local anaesthetic (systemic)
Adult dose — perioperative Bolus: 1–1.5 mg/kg IV over 10 min at induction; Infusion: 1–1.5 mg/kg/hr for 24 hours (some protocols extend to 48 hr)
Key indications Abdominal surgery (laparoscopic and open); opioid-induced hyperalgesia; refractory acute pain; ERAS protocols
Monitoring Continuous ECG; BP Q15 min during bolus; lidocaine levels if available (therapeutic 1.5–5 µg/mL); observe for CNS toxicity (perioral numbness, tinnitus, seizures)
Renal adjustment Reduce infusion rate by 50% if eGFR <30 (active metabolites accumulate); avoid bolus load in severe heart failure
PBS status ✔ PBS General Benefit (injectable; hospital use)

Tramadol

💊
Tramadol
Tramal® · Tramadol Sandoz® · Weak opioid + SNRI
Mechanism Weak µ-opioid agonist + serotonin/noradrenaline reuptake inhibitor (dual mechanism) — useful for mixed nociceptive/neuropathic pain
Adult dose 50–100 mg PO/IV Q4–6H; max 400 mg/day (200 mg/day if age >75 or eGFR <30)
Renal adjustment eGFR <30: extend interval to Q12H, max 200 mg/day; avoid in eGFR <15
Hepatic adjustment Avoid in severe hepatic impairment (Child-Pugh C); reduce dose in moderate impairment
Key warnings Seizure risk (especially with SSRIs, TCAs, antipsychotics); serotonin syndrome risk; CYP2D6 polymorphism — ultra-rapid metabolisers at risk of toxicity; slow metabolisers get reduced efficacy
PBS status ✔ PBS General Benefit

Other Adjuvant Agents

Agent Class Indication Dose Notes
Amitriptyline TCA Neuropathic pain (chronic) 10–25 mg nocte, titrate to 50–75 mg Anticholinergic side effects; caution in elderly; PBS Authority Required
Duloxetine SNRI Neuropathic pain; chronic musculoskeletal 30 mg PO daily × 1 week → 60 mg daily Avoid in severe hepatic/renal impairment; PBS Authority Required
Clonidine α2-agonist Neuraxial / regional adjunct; refractory pain 75–150 µg epidural or perineural; 100–200 µg PO BD Hypotension, bradycardia, sedation; monitor BP
Magnesium NMDA antagonist (mild) Perioperative adjunct 30–50 mg/kg IV bolus over 15 min → 5–10 mg/kg/hr infusion Monitor for hypotension, flushing; check serum Mg²⁺; adjust in renal impairment
Paracetamol/codeine combination Weak opioid combination Moderate acute pain (step-down from stronger opioids) Paracetamol 500 mg/codeine 30 mg: 1–2 tabs PO Q4–6H (max 8 tabs/day limited by paracetamol) S4 — pharmacist only; codeine causes constipation; CYP2D6 variation
Tapentadol µ-opioid agonist + NRI Moderate-severe acute/chronic pain; neuropathic component 50–100 mg PO Q4–6H; max 500 mg/day (immediate release) S8; lower seizure risk than tramadol; PBS Authority Required

Regional Techniques

Regional anaesthesia delivers local anaesthetic (± adjuvants) to specific neural targets, providing potent site-specific analgesia with minimal systemic drug exposure. Regional techniques are a cornerstone of multimodal analgesia for surgical, traumatic, and chronic pain states.

Peripheral Nerve Blocks

Block Indication Local Anaesthetic Regimen Duration
Interscalene brachial plexus Shoulder surgery (arthroplasty, rotator cuff repair) Ropivacaine 0.375% 20–30 mL (single shot) or 0.2% infusion 5–8 mL/hr via catheter 12–18 hr (single shot); 48–72 hr (catheter)
Supraclavicular / infraclavicular Elbow, forearm, hand surgery Ropivacaine 0.375% 20–30 mL 12–16 hr
Femoral nerve block Femoral shaft fracture; total knee arthroplasty (in combination with sciatic) Ropivacaine 0.2% 20 mL bolus → 0.2% infusion 5–10 mL/hr 24–72 hr (catheter)
Adductor canal block Knee arthroplasty (preserves quadriceps strength vs femoral block) Ropivacaine 0.2% 15–20 mL ± catheter 12–24 hr (single); 48–72 hr (catheter)
Sciatic nerve block (popliteal) Foot and ankle surgery; combined with saphenous/adductor for below-knee procedures Ropivacaine 0.2–0.375% 20–30 mL 12–24 hr
Ankle block Foot surgery (forefoot, toes) Ropivacaine 0.2% or lignocaine 1% 20–30 mL total (five nerves) 4–8 hr

Fascial Plane Blocks

Block Indication Volume / Agent Advantages
Transversus abdominis plane (TAP) Abdominal surgery (laparoscopic, open, caesarean section) Ropivacaine 0.375% 15–20 mL per side (US-guided) Technically simple; low complication rate; can be performed under US at bedside
Rectus sheath block Midline laparotomy; umbilical hernia repair Ropivacaine 0.25% 10–15 mL per side Good analgesia for midline incisions; easy US landmarking
Erector spinae plane (ESP) Thoracic / rib fracture pain; thoracotomy; posterior spinal surgery Ropivacaine 0.2% 20–30 mL ± catheter infusion Safe alternative to epidural; low pneumothorax risk
Serratus anterior plane (SAP) Lateral chest wall pain; breast surgery; rib fractures Ropivacaine 0.25% 20–30 mL Superficial; low risk; suitable for anticoagulated patients
Pectoral nerve blocks (PECS I & II) Breast surgery (mastectomy, augmentation, reconstruction) PECS I: ropivacaine 0.25% 10 mL; PECS II: 0.25% 20 mL Reduces opioid consumption significantly after breast surgery

Neuraxial Techniques

💉
Epidural Analgesia
Thoracic or lumbar epidural catheter · Continuous or PCEA
Indications Major thoracic surgery (thoracotomy, oesophagectomy); major abdominal surgery (open); vascular surgery (aortic); rib fractures (≥3 unilateral); labour analgesia
Typical regimen Ropivacaine 0.2% + fentanyl 2 µg/mL at 4–10 mL/hr; or bupivacaine 0.1% + fentanyl 2 µg/mL; patient-controlled bolus 2–4 mL Q15 min lockout
Duration 48–72 hours post-operatively (some protocols 96 hr); remove catheter and assess
Contraindications Absolute: patient refusal, infection at insertion site, severe coagulopathy (INR >1.5, platelets <80), raised ICP. Relative: anticoagulation (check ANZCA guidelines re: timing relative to LMWH)
Monitoring Sensory level Q4H; motor block assessment (Bromage scale); BP Q1H × 4 then Q4H; urinary catheter required; ECG post-initiation; manage hypotension with IV fluids + vasopressor PRN

Adjuvants for Regional Blocks

Adjuvant Dose (perineural) Effect Evidence
Dexamethasone 4 mg perineural or IV (equivalent effect) Prolongs block duration by 4–8 hours; reduces PONV Level I — multiple RCTs and meta-analyses
Dexmedetomidine 0.5–1 µg/kg perineural Prolongs block duration; sedation — use caution Level II; not PBS-listed for perineural use
Clonidine 75–150 µg perineural Mild prolongation; may cause hypotension and sedation Level II
Bicarbonate 1 mEq per 10 mL of LA (raise pH) Speeds onset of block Level III; routine practice in many centres
ℹ️
MBS items for regional anaesthesia: Peripheral nerve block and epidural insertion are funded under Medicare Benefits Schedule (MBS) when performed by an anaesthetist in a hospital setting. MBS items include epidural catheter insertion (item 18220–18225), peripheral nerve block (item 18200–18215), and continuous infusion via catheter (item 18260). Pain service consultation items (e.g., 5010–5012) apply to chronic pain assessments.

Special Populations

🤰

Pregnancy

Paracetamol First-line analgesic in pregnancy; safe in all trimesters at standard doses (max 4 g/day).
NSAIDs Avoid after 28 weeks' gestation (risk of premature closure of ductus arteriosus, oligohydramnios). Short courses <28 weeks may be used under specialist guidance.
Gabapentinoids Category B3 — avoid in pregnancy and breastfeeding unless benefit clearly outweighs risk. Limited safety data.
Ketamine Avoid in early pregnancy (teratogenicity uncertain); may be used for procedural sedation when benefits justify.
Regional techniques Neuraxial (epidural/spinal) analgesia is standard of care for labour and caesarean section. TAP blocks are safe and effective for post-caesarean analgesia.
Tramadol / opioids Use lowest effective dose for shortest duration; risk of neonatal respiratory depression; avoid prolonged use near term.
👶

Paediatrics

Paracetamol 15 mg/kg QDS; weight-based dosing critical. IV formulation available for unable-to-take-oral children.
Ibuprofen 5–10 mg/kg TDS from 3 months of age; avoid in dehydration, renal impairment, and chickenpox (risk of invasive Group A strep).
Gabapentinoids Limited paediatric data for perioperative use; pregabalin not approved <18 years for most indications in Australia.
Ketamine Widely used for procedural sedation in paediatric ED at 1–2 mg/kg IV or 4–5 mg/kg IM; sub-anaesthetic doses for analgesia 0.25–0.5 mg/kg IV.
Regional techniques Caudal epidural (bupivacaine 0.25% 1 mL/kg, max 20 mL) is the workhorse for lower-body paediatric surgery. Peripheral nerve blocks increasingly used under US guidance.
Codeine Contraindicated <12 years and in obese children <18 years (TGA 2015) — CYP2D6 ultra-rapid metaboliser risk of fatal respiratory depression.
👴

Elderly (≥65 years)

Paracetamol Standard dosing (max 4 g/day); consider max 2–3 g/day if low body weight or hepatic concerns.
NSAIDs Use with extreme caution; lowest dose, shortest course; co-prescribe PPI; avoid if eGFR <30, heart failure, or concurrent anticoagulant. Prefer celecoxib over non-selective if NSAID essential.
Gabapentinoids Start low (pregabalin 25–50 mg nocte; gabapentin 100 mg nocte); increased risk of falls, sedation, and cognitive impairment.
Opioids Reduce starting dose by 25–50%; "start low, go slow"; increased half-life; monitor for delirium, falls, constipation, respiratory depression.
Regional techniques Highly beneficial — esp. hip fracture (fascia iliaca block in ED reduces opioid need and delirium incidence). Consider frailty assessment (clinical frailty score) when planning analgesia.
🫘

Renal Impairment

Paracetamol Safe at adjusted doses: eGFR 10–50 → Q6H; eGFR <10 → Q8H, max 2 g/day.
NSAIDs Avoid if eGFR <30 mL/min. If essential (eGFR 30–60): short course (<5 days), monitor creatinine and electrolytes at Day 3.
Gabapentinoids Both renally cleared — mandatory dose adjustment; gabapentin accumulates significantly; pregabalin requires dose reduction at eGFR <60.
Tramadol Active metabolite (M1) accumulates in renal failure; reduce dose and extend interval; avoid if eGFR <15.
Morphine Avoid in severe renal impairment (active metabolite M6G accumulates → respiratory depression). Prefer fentanyl or hydromorphone.
Regional techniques First-line in CKD patients; excellent opioid-sparing strategy. Monitor for LA toxicity if hypoalbuminaemia.
🫁

Hepatic Impairment

Paracetamol Max 2 g/day in moderate impairment (Child-Pugh A–B); avoid in severe impairment (Child-Pugh C).
NSAIDs Avoid in severe hepatic impairment — increased GI bleeding risk, fluid retention, hepatorenal physiology.
Tramadol Extensively hepatically metabolised — reduce dose; avoid in Child-Pugh C.
Gabapentin Not hepatically metabolised — safe in hepatic impairment (dose-adjust for renal function only).
Regional techniques Excellent choice; coagulopathy must be assessed (check INR, platelets) before neuraxial procedures. Peripheral blocks generally safe.
🛡️

Immunocompromised

NSAIDs Use with caution in neutropenic patients (masking fever); generally avoid in sepsis or DIC.
Ketamine Safe in immunocompromised; no immune suppression; useful when opioids are causing excessive sedation in ICU patients.
Regional techniques Neuraxial techniques: risk-benefit assessment required in thrombocytopenia (platelets <80 contraindicated for epidural). Peripheral blocks generally safe. Strict asepsis essential.
Opioid considerations Opioids have immunosuppressive effects (µ-receptor-mediated NK cell suppression) — minimise duration; multimodal approach especially valuable in this population.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience disproportionately high rates of acute and chronic pain, surgical procedures, trauma, and opioid-related harm. Multimodal analgesia planning must address systemic barriers and embed culturally safe practice.

Pain burden
Indigenous Australians report chronic pain at 1.5–2× the rate of non-Indigenous Australians (AIHW 2023). Higher rates of musculoskeletal injury, dental pain, renal disease-related pain, and post-surgical pain contribute to an elevated analgesic burden.
Opioid harm
Indigenous Australians are hospitalised for opioid-related harm at 2.5× the non-Indigenous rate. Prescription opioid dependence and codeine misuse are growing concerns in regional and remote communities. Multimodal nonopioid strategies should be prioritised to minimise opioid initiation.
Remote and rural access
Access to acute pain services, regional anaesthesia expertise (peripheral nerve blocks, epidural), and specialist pain physicians is severely limited in remote NT, WA, QLD, and SA communities. Health professionals in these settings should maximise oral multimodal regimens, wound infiltration, and telehealth-supported pain service consultations.
Culturally safe pain communication
Pain expression may differ culturally; numerical rating scales may not be well understood — use visual analogue scales, Wong-Baker FACES (paediatrics), or culturally adapted tools. Involve Aboriginal Health Workers/Practitioners (AHW/AHPs) in pain assessment, education, and shared decision-making. Avoid assumptions about pain behaviour or stoicism.
Medication availability
Essential nonopioid analgesics (paracetamol, ibuprofen) are available through remote area health centres and Aboriginal Community Controlled Health Organisations (ACCHOs). IV paracetamol, gabapentinoids, and injectable regional anaesthesia agents may require drug repatriation or Royal Flying Doctor Service (RFDS) coordination.
Continuity of care
Patient transfer between remote clinics, regional hospitals, and tertiary centres can interrupt multimodal analgesia plans. Ensure clear pain management plans are documented in shared electronic records (e.g., My Health Record, Communicare, Primary Care Information System) and communicated to receiving teams.

📚 References

  1. 1. Australian and New Zealand College of Anaesthetists (ANZCA). Acute Pain Management: Scientific Evidence. 5th ed. Melbourne: ANZCA; 2020.
  2. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Acute Pain Clinical Care Standard. Sydney: ACSQHC; 2022.
  3. 3. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J. Acute pain management: scientific evidence, fourth edition, 2015. Anaesthesia and Intensive Care. 2015;43(4):455–468.
  4. 4. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surgery. 2017;152(7):691–697.
  5. 5. Bajwa SJS, Kaur J. Perioperative multimodal analgesia: a concise review. Indian Journal of Anaesthesia. 2022;66(Suppl 1):S34–S41.
  6. 6. Derry S, Wiffen PJ, Moore RA, McNicol ED, Bell RF, Blyth FM, et al. Oral nonsteroidal anti-inflammatory drugs for acute postoperative pain in adults — an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2023;(6):CD008466.
  7. 7. Mishriky BM, Waldron NH, Habib AS. Impact of pregabalin on acute and persistent postoperative pain: a systematic review and meta-analysis. British Journal of Anaesthesia. 2015;114(1):10–31.
  8. 8. Brinck ECV, Tiippana E, Heesen M, Bell RF, Straube S, Moore RA, et al. Perioperative intravenous ketamine for acute postoperative pain in adults. Cochrane Database of Systematic Reviews. 2018;(12):CD012033.
  9. 9. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of ultrasound-guided transversus abdominis plane block in adult patients: a meta-analysis. Anesthesia & Analgesia. 2015;121(6):1640–1654.
  10. 10. De Oliveira GS Jr, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane infiltration to improve postoperative analgesia after laparoscopic inguinal hernia repair: a systematic review and meta-analysis. Anesthesia & Analgesia. 2014;118(1):140–148.
  11. 11. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
  12. 12. Gaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database of Systematic Reviews. 2009;(3):CD002763.
  13. 13. McNicol ED, Ferguson MC, Haroutounian S, Carr DB, Schumann R. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database of Systematic Reviews. 2016;(5):CD007126.
  14. 14. Penington Institute. Australia's Annual Overdose Report 2023. Melbourne: Penington Institute; 2023.
  15. 15. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia. The Journal of Pain. 2016;17(2):131–157.
  16. 16. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part B — Opioids. Melbourne: RACGP; 2022.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).