All analgesic decisions are based on individualised patient assessment and the experience of the practitioner. Take senior help if unsure. Revise and reduce or increase as needed. Opiate overdose should be reversed with Naloxone. Use lower doses in the elderly.
- Ensure that patient expectations are managed - acute onset pain should only require a short period of analgesia/treatment.
- Acute severe pain can be managed but is often resolving and analgesia may need reducing
- Chronic pain is not about cure but management. Total pain relief is not often achieved.
- Consider non-pharmacological factors e.g., anxiety, lack of information, TENS, need for physiotherapy and role of alternative therapies.
- Acute pain due to fracture or other cause often reduces so reduce analgesics with time
- Pain is unpleasant by definition but is a useful clinical sign that alerts us to problems
- Generates secondary issues limiting mobility, eating, drinking, breathing, work, depression
- Pain is very subjective. The aim should be to reduce pain as far as possible
- All significant pain medications are associated with significant side effects which need weighed up
- Where is the pain, what is the cause, are more investigations needed
- Is this a short term pain e.g. a fracture or one that will need ongoing analgesia
- Is drug toxicity increased - elderly, poor renal function
- Are there drug interactions e.g. NSAIDs and Warfarin
- What routes are available - orally, PR, IV, IM, Transdermal
Analgesic Choices: Always time limit and review dose and need
|Mild Intermittent||Paracetamol 1g QDS (oral or PR or NG tube) written up as PRN |
|Mild Constant||Regular Paracetamol 1g QDS (PO or PR) |
Cocodamol 30/500 One tablet QDS but don't forget it contains Paracetamol if giving PRN Paracetamol|
Paracetamol (US Tylenol) 1g QDS (oral or PR) AND ONE OF THE FOLLOWING. Up to 4 mg/day
Ibuprofen 400mg TDS PO or if unable to tolerate oral medications PR Diclofenac 50mg TDS
Codeine Phosphate 30 to 60 mg QDS (Weak Opiate)
Tramadol 50-100 mg 6 hrly (Weak Opiate)
Dihydrocodeine 30 mg 6 hrly (Weak Opiate)
As above + Morphine (Oramorph) 5-10 mg PRN every 4-6 hours
Regular PO/IV Paracetamol (US Tylenol) 1g qds
Consider NSAID: Ibuprofen 400mg TDS PO or if unable to tolerate oral medications PR Diclofenac 50mg tds
Start Morphine LONG ACTING 10 mg BD 12 hourly + PRN Morphine (Oramorph) 5-10 mg PRN every four hours
Acute Severe e.g. MI : Diamorphine 2.5-5 mg IV or Morphine IV 5-10 mg
Consider IV Morphine protocol OR Patient-Controlled Analgesia / Epidural analgesia
Give laxatives and an antiemetic in those on Codeine or Morphine e.g. Lactulose, Metoclopramide or Cyclizine
Respiratory depression is the greatest concern in those on Opiates and can be reversed with naloxone
Avoid NSAIDs in those with renal disease, Active GI ulceration or bleeding, Severe heart failure, hepatic failure, coagulopathy, pregnancy
Caution with codeine or opiates with bowel surgery patients and severe constipation
- Dilute a standard ampoule containing naloxone 400 microgram to 10ml with sodium
- Administer 0.5ml (20 microgram) IV every 2 minutes until the patient respiratory
status is satisfactory
|Specific pain issues and suggested management|
|Neuropathic pain || Amitriptyline is used commonly to treat neuropathic pain usually as a single dose at bedtime. Carbamazepine and Gabapentin also used. Very severe pain Ketamine may be used under specialist advice. |
|Bone Metastases || Orthopaedic Surgery for pathological fractures and Bisphosphonates |
|Liver capsule pain || Steroids useful in palliative car for liver capsule pain related to metastases. |
|Headache and Raised ICP || Codeine, Steroids (Dexamethasone) often used in those with brain malignancy and raised Intracranial pressure. |
|Muscle spasm || Baclofen but side affects can be significant. Use Consider Botulinum toxin for localised increased spasm. |
|Intestinal colic || Antispasmodics e.g. Hyoscine |
- Acknowledgement of mild pain and explanation and simple strategies to reduce it may be all that a person is looking for. Not all patients expect analgesics or take the ones prescribed.
- Complementary therapies may be of some use in Mild pain - Aromatherapy, massage and Hypnosis may all be tried.
- Physiotherapy - mobilisation, splinting joints, exercise to improve muscle strength, management of seating can all help. TENS may be useful. Hydrotherapy can help build up muscle strength.
- Psychological support - useful especially for non-malignant chronic pain syndromes
- Acupuncture - increases spinal cord endorphins and has used. Transcutaneous electrical nerve stimulation may work similarly.
- Radiotherapy - primarily for bone metastases. May be useful for reducing tumour bulk elsewhere.