Pain Management

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.

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

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.