PAIN MANAGEMENT

AIM
Background understanding on types of pain.

Understand the different types of analgesia

available and their side effects, use and
counselling.
Current optimal practice for label requirements
of analgesic medication.

PAIN
The World Health Organisation (WHO) defines pain as:

An unpleasant sensory or
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.

BACKGROUND
Pain Types
Nociceptive Pain activation of normal pain fibres in
response to a stimulus (e.g. injury, disease or
inflammation)
Neuropathic Pain injury or disease affecting the
peripheral or central nervous system or both (e.g.
phantom limb, spinal cord injury)

BACKGROUND
Measuring Pain
Numerical Rating Scale

Visual Analogue Scale

BACKGROUND
Classification of Pain
Acute Pain Identifiable cause with defined pattern
of onset and duration. Aim is to relieve suffering
and assist rehab by mobilisation.

Chronic/ Persistent Pain Persists for >3 months or

after healing is expected to be complete. Aim is to
reduce the pain to a level that allows functioning.

TYPES OF ANALGESIA
Regular Baseline pain management
PRN When required

Opioids

Non-Opioids

Adjuvant

Morphine
Oxycodone
Tramadol
Fentanyl

Paracetamol
NSAIDs
Ibuprofen

Gabapentin
Amitriptyline
Pregabalin

OPIOIDS
Use
Treatment of moderate to severe pain.

Side Effects & Management

Drowsiness monitor (better pain management e.g. panadol should
reduce this side effect)
Nausea and vomiting metoclopramide (first line at PAH)
Constipation coloxyl & senna, movicol (regular or prn while on opioid)
Counselling
Avoid alcohol
Can make you dizzy when standing up too quickly (care in elderly)

OXYCODONE
Label

Take ONE to TWO tablets every

FOUR to SIX hours when necessary
for relief of severe pain.
WHEN REQUIRED
Should be on regular paracetamol to
limit opioid use.

Swallow whole ONE tablet TWICE a

day (every TWELVE hours)
REGULAR
Also available with naloxone as
Targin to prevent constipation

MORPHINE
Most Common Formulations
CR tablets MS Contin, Momex SR
Oral Liquid Ordine

Labels
CR tablets Take ONE tablet TWICE a day (every TWELVE hours).
**TO BE SWALLOWED WHOLE** **DO NOT CRUSH OR CHEW**
Liquid by metric measure

Counselling
Avoid alcohol

Patches

FENTANYL

Used for chronic pain

Label

Apply ONE patch to clean dry skin and replace

every SEVENTY-TWO hours. Carefully remove,
fold and discard used patch.
iPharmacy code fen72

Counselling

Write date & time on the patch on application

Do not use if patch is damaged or cut
Remove after 3 days and put new patch in a
different place
Do not use in opioid-nave patients

BUPRENORPHINE
Use

Patch

Sublingual Tablets

Chronic moderate to severe pain

Moderate to severe pain or opioid

dependence

Label Apply ONE (1) patch to clean, dry

Place ONE (1) tablet under the tongue
skin and replace ONCE a WEEK on and keep in place until dissolved. Do
the same day. Carefully remove,
not chew or swallow the tablet.
fold and discard used patch.

Counselling

Write date & time on the patch on application

Remove after 7 days and put new patch in a different area
Do not wear more than 2 patches at any time
Do not cut or divide patches

NON-OPIOIDS
Use
Mild moderate pain

Taken at regular doses to reduce baseline

moderate to severe pain hence reduce opioid
usage

Types
Paracetamol, Aspirin, NSAIDs.

PARACETAMOL
Label

Take ONE to TWO tablets FOUR times a day (when required).

Maximum of EIGHT paracetamol containing tablets in 24 hours.

Other

Can cause liver damage if too much is taken

Care with alcohol

Side Effects

Paracetamol is preferred to NSAIDs as it has fewer adverse effects

NSAIDS
Examples

Ibuprofen (Nurofen), Diclofenac (Voltaren), Naproxen, Indomethacin

Label

Doses vary
Take with or soon after food

Counselling

Do not take aspirin with NSAIDs

Side Effects/Management

Nausea take with food

GI bleeding/ulceration may be taken with PPI (e.g. omeprazole)
Hypertension often contraindicated in patients with cardiovascular disease

ADJUVANT
Examples
Anticonvulsants
Gabapentin
Pregabalin
Carbamazepine
Antidepressants
Amitriptyline
Duloxetine
Use
Treatment of neuropathic (nerve) pain

ANTICONVULSANTS
Most commonly
Gabapentin
Pregabalin Now on PBS for neuropathic pain (not first line)
Side Effects
Sedation, dizziness, weight gain, rash
Pregabalin has more than Gabapentin
Counselling
Drowsiness avoid driving til you know how it affects you
Do not stop taking abruptly

ANTIDEPRESSANTS
Most Common
Amitriptyline (often lower dose than depression, usually 10-25mg at night)

Side effects
Sedation, dry mouth, blurred vision, constipation, dizziness.
Counselling
Drowsiness avoid driving until you know how it affects you
Most common side effects lessen after 7 days
Get up gradually from sitting or lying down to prevent dizziness or falls
Can increase the effects of alcohol
Do not stop suddenly

QUESTIONS?