The effectiveness of a balanced analgesia with buprenorphine ketoprofen-propacetamol for pain control during extracorporeal shock wave lithotripsy (ESWL) was evaluated in order to reduce the requirements for general anaesthesia. Two hundred and ninety-one consecutive patients were included in a randomized, placebo-controlled, double-blind study. Patients in each group received midazolam 5 mg pre-operatively as premedication. The subjects then received either placebo (group 1), buprenorphine 0.3 mg (group 2) or the combination buprenorphine 0.3 mg plus ketoprofen 100 mg and propacetamol 2 g (group 3) intravenously (i.v.) at a constant rate. The treatment was started 45 min prior to ESWL. Pain was assessed using a three-point verbal scale: (0)no pain; (1) moderate pain; and (2) intense pain needing general anaesthesia. The patients assessed their pain intensity on a 0–100 mm visual analogue scale. Only 69% of group 1 patients received ESWL with midazolam premedication. Buprenorphine provided good analgesia in 87% of group 2 patients, while the combination buprenorphine-ketoprofen-propacetamol was effective in 99% of group 3 patients (P<0.05). The incidence of nausea and vomiting was similar in the buprenorphine groups. No respiratory depression was reported. In conclusion, the buprenorphine-ketoprofen-propacetamol combination provided effective analgesia, allowing ESWL to be performed without the need for general anaesthesia.