Professional Documents
Culture Documents
Pain is a symptom
Pain is subjective
Pain is influenced by many factors
Localised pain may have different source
Nature and causes of pain are heterogenous
Other therapy outside of analgesia may be
required
Nerves
MYELINATED NERVES
Reflex action - quick response
UNMYELINATED NERVES
Secondary pain
Chronic pain - no response
ANALGESIA
Non-opioids - paracetamol, compound
preps and NSAIDs including aspirin
Opioids (narcotics)
Examples of opioids
Codeine
Dihydrocodeine
Alfentanil, fentanyl and remifentanil
Morphine, diamorphine
Pethidine
As narcotics they have to be locked and
registered
Acute pain
Arises from injury, trauma, disease or
spasm
involve both types of nerves
intensity proportional to damage
Limited duration
Intensity dec with healing
Visceral pain
Diffuse, dull, aching
Usual at onset/early disease stage
Chronic pain
Persists beyond injury
Usually malignancy OR non-malignant ex.
Neuropathic
Not always an objective cause
Pyshological damage
Dosing - 24 hour demands
Chronic pain
Selection of drug depends on nature of pain
Evaluation of pain - PQRST model:
Palliative pain?
Quality of pain?
Region of pain?
Severity of pain?
Time-related?
Post-operative pain
Palliative care and cancer pain
Headache
Migraine
Post-operative pain
Post-operative pain
Avoid pethidine repeated adm esp with
renal dysfunction
Post-op pain started before or at onset of
pain? Controversial
Intravenous analgesia - bolus opioid,
continous inf opioid or Patient Controlled
Analgesia (PCA)
Post-operative pain
Bolus administration opioid
Theatre and recovery rooms
Small boli till controlled
Constant supervision needed - not practical
Post-operative pain
Patient controlled analgesia (PCA)
Post-operative pain
Oral dosing opioids
Not immed post-op because
Dose req too large
Post-op nausea
GI Surgery
Cancer pain
Pain assessment:
Initially and regularly
Change in nature of pain
Pharmacological intervals
Cancer pain
WHO analgesic ladder:
Step 1: non-opioid analgesia
Step 2: Weak opioid + non-opioid
Step 3: Strong opioid +/- non-opioid
Cancer pain
Long term - consider break through pain
Step1: non-opioids
paracetamol, NSAIDs esp bone pain, tendons,
muscle pain, visceral pain.
No relief after 1 week try other NSAID before
moving up ladder
Cancer pain
Step 2: weak opioids
Codeine and dihydrocodeine and
dextropropoxyphene
Convenient non-opioid plus weak opioid
formulations - Co-proxamol
Inc. doses of weak opioids before moving up
ladder if combination prods used
Tramadol
Cancer pain
Step 3: Opioids
Oral morphine
Dependence not an issue in these patients
Initially start with syrup, start inc dose by 50%
daily till total pain control
Then calculate daily dose and give as Oral
Morphine Sustained release tablets twice dly
Keep oral syrup for breakthrough pain
Cancer pain
Consider other routes of adm if:
Severe dysphagia
Intractable nausea and vomiting
Head and neck cancer
Intestinal obstruction
Comatose or semiconscious patient
Rapid onset is required due to acute pain
SC pref to IM
Continous IV may be req - maybe PCA
Fentanyl transdermal patch
Cancer pain
Adjuvant analgesia
Corticosteroids - mood elevation, anti emetic
Anti-epileptic - lancinating/stabbing pain,
carbamazepine, gabapentin
Tricyclic antidepressants - Burning discomfort
used at lower doses ex. amitriptyline
Migraine
Phases of migraine headache involve:
Prodromal phase 1-2 days before
Auras 1-2 hours before - visual changes,
dizziness, drowsiness
Post-dromal phase - after headache subsided for
a day or two
Migraine
Trigger Factors:
Management of Migraine
Avoid triggers
Analgesia
GI S/E major concern
Larger doses than normal
Often combined with metoclopramide
Triptans
Mimic 5-HT involved in migraine
Only indicated for migraine pain