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Analgesia and Pain management

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Analgesia

When using opiates always ensure you have access to naloxone for any respiratory depression

Drug	Dose	Comments: Provides analgesia and some sedation
Mild to moderate pain
Paracetamol	500mg-1 g QDS PO/IV.	Use lower dose in those with low weight under 50 kg or low glutathione stores (malnourished. Few side effects unless overdose. Cheap. Antipyretic. Can be taken IV or PO. Do not prescribe this in conjunction with Codydramol or other paracetamol-containing compound preparations. Due to the considerably greater costs, paracetamol IV should be reserved for those patients unable to take by oral route.
Ibuprofen	400-600 mg PO TDS	NSAIDs should be prescribed on a regular (not PRN) basis for maximum benefit. The prescription should be reviewed after 3 days. Contra-indications to NSAIDs - renal impairment peptic ulcer disease (refer to separate parecoxib/etoricoxib guidelines), platelet dysfunction/coagulopathy history of adverse reaction to aspirin or other NSAID. Use NSAIDs with caution in patients with asthma, cardiac failure, those at risk of renal impairment. In elderly postoperative patients and those with hypovolaemia, sepsis or dehydration, NSAIDs are best avoided. Consider adding a PPI.
Codydramol	10/500 contains dihydrocodeine 10mg and paracetamol 500mg	This should be prescribed on a PRN basis for breakthrough pain, to accompany a regular NSAID prescription
Dihydrocodeine	30 mg every 4-6 hrs PO. Can also be given SC/IM as 50 mg 6 hrly	This should be prescribed on a PRN basis for breakthrough pain, to accompany a regular NSAID prescription
Moderate pain
Codeine Phosphate	15-60 mg QDS. Start 30 mg QDS	Approx. 10% of patients will not respond to codeine - try Dihydrocodeine 30mg every 4-6 hrs when required instead
Tramadol	50-100 mg 4-6 hrly. Start at 50 mg QDS	Tramadol is associated with fewer typical opioid side effects leading to less respiratory depression, sedation and constipation. The incidence of nausea and vomiting when given orally is thought to be similar compared to equianalgesic doses of other opioids, but can be severe following intravenous dosing. Some patients may be susceptible to unpleasant psychogenic reactions e.g. agitation, hallucinations, dysphoria, and elderly patients are susceptible to confusion and hallucinations so tramadol should be avoided. Tramadol is a more potent analgesic than dihydrocodeine. 10% of the Caucasian population experience no pain relief from dihydrocodeine due to a lack of the relevant enzyme to convert the prodrug to its active form. Although tramadol may have some benefits over dihydrocodeine, there are some specific potential problems with tramadol and these need to be carefully considered especially in the elderly. Some patients may be susceptible to unpleasant psychogenic reactions e.g. agitation, hallucinations, dysphoria, and elderly patients are susceptible to confusion and hallucinations so tramadol should be avoided. Avoid using tramadol if there is a history of epilepsy, acute head injury, impaired conscious level because the risk of having seizures may be increased in these patients. Avoid using tramadol in pregnancy and breast-feeding. Caution is advised if used in conjunction with tricyclic antidepressants or SSRIs (risk of serotonin syndrome). Do not give in combination with an MAOI antidepressant. Always prescribe a laxative with opioid prescriptions eg. Lactulose 15mls BD or Senna 15-30mg at night
Severe pain
Oral Morphine (oramorph /Zomorph)	10-20 mg 4 hrly and assess 24 hr requirements	Once daily requirements known convert to long acting Zomorph. Always prescribe a laxative with opioid prescriptions eg. Lactulose 15mls BD or Senna 15-30mg at nigh
Oral Morphine MR	Start 10 mg BD and assess requirements	Always prescribe a laxative with opioid prescriptions eg. Lactulose 15mls BD or Senna 15-30mg at nigh
IV Morphine	1-2 mg per minute IV to control acute severe pain	Takes 10-15 mins to work. Always prescribe a laxative with opioid prescriptions eg. Lactulose 15mls BD or Senna 15-30mg at night
Antiemetics	Cyclizine 50mg IM /IV 8 hourly prn plus Prochlorperazine 12.5 mg IM/ PO (not IV) 8 hourly prn 2nd line Ondansetron 4mg IM / IV 8 hourly prn

Advice: Do not offer

Paracetamol on its own for managing low back pain
Opioids for managing ACUTE low back pain. Only prescribe with specialist advice.
Opioids for managing chronic low back pain
Selective serotonin reuptake inhibitors (SSRIs), Serotonin-noradrenaline reuptake inhibitors or tricyclic antidepressants for managing low back pain
Anticonvulsants for managing low back pain

Advice: Do offer

If for OA of hand or knee, consider topical NSAID initially (as per NICE CG177) such as Ibuprofen 5% gel

All analgesic decisions are based on individualized 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.

General Principles

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

About

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

Clinical Assessment

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)
Mild-Moderate	Cocodamol 30/500 One tablet QDS but don't forget it contains Paracetamol if giving PRN Paracetamol
Moderate	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)
Mod-Severe	As above + Morphine (Oramorph) 5-10 mg PRN every 4-6 hours
Severe	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
Advice	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

Reversal

Dilute a standard ampoule containing naloxone 400 microgram to 10ml with sodium chloride 0.9%
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

Adjuvant therapies

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.

References

Dorset NH guidelines

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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