Essential Pain Management

Question 1

how is a pain assessment performed in practice?

Answer 1

1. Biological/neurophysical aspects: Pain intensity > pain score/scale, visual analogue scale, numeric verbal scale, simple verbal scale, behavioural pain scale, paediatric scales
2. Functional interference: Acute pain (DrEAMS) > drinking, eating, absence of severe pain, mobilising including breathing and coughing, sleeping. Acute and chronic pain > self-efficacy, quality of recovery, quality of life, return to work
3. Psychological distress: How are you doing? Are you comfortable?

Question 2

what are step 1 analgesics used for pain management?

Answer 2

• aspirin
• paracteamol
• NSAID

Question 3

what are step 2 analgesics used for pain management?

Answer 3

• dihydrocodeine
• codeine
• hydrocodone
• tramadol

Question 4

what are step 3 analgesics used for pain management?

Answer 4

• morphine
• oxycodone
• methadone
• levorphanol
• fentanyl

Question 5

what are some multimodal analgesia options?

Answer 5

• locoregional analgesia (central, peripheral blocks)
• ketamine (low ‘anti-hyperalgesic’ doses)
• magnesium sulfate
• alpha-2 agonists: clonidine and dexmedetomidine
• paracetamol
• NSAIDs

Question 6

what is the first line treatment for moderate to severe postoperative/post-trauma pain?

Answer 6

At least 2 regular non-opioids + one opioid (rescue)
e.g. paracetamol + ibuprofen +/- locoregional analgesia + opioid

Question 7

what is the second line treatment for moderate to severe postoperative/post-trauma pain?

Answer 7

If the locoregional technique is adequately working/discussed and an opioid is adequately dosed (e.g. hourly and/or side effects:
- ketamine: if severe (neuropathic) pain and/or resistant to opioids OR
- nefopam: to decrease opioid-induced sedation risk, especially if NSAID contraindication, but risk of nausea/delirium

Question 8

what is the third line treatment for moderate to severe postoperative/post-trauma pain?

Answer 8

• Gabapentin (or pregabalin) only after careful patient selection and clear indication (e.g. after DN4 assessment)
• Or discussion with consultant regarding other advanced techniques
• antiemetic or clonidine to be preferred if nausea, including due to opioid withdrawal is the biggest issue.

Question 9

codeine, tramadol and CYP2D6

Answer 9

10% of the caucasian population are poor metabolisers of CYP2D6 which can cause a reduction of the analgesic effect