Pain E-book

Question 1

Adjuvant analgesics

Answer 1

• Adjuvant analgesics (also known as co-analgesics) are drugs with a primary
  indication other than pain which are used for analgesia.
• Adjuvants may be used in both acute and chronic pain and are recommended by
  WHO at all stages of the pain ladder (see stage 3 pain module and section 4 of this
  eBook). They are of particular value in neuropathic, post-operative and cancer pain.

Question 2

Types of adjuvant

analgesics & examples

Answer 2

-Alpha-2 agonists Clonidine

-Antidepressants Amitriptyline
Duloxetine

-Anticonvulsants Gabapentin
Pregabalin
Carbamazepine

-Bisphosphonates Pamidronate
Zoledronic acid

-Corticosteroids Dexamethasone
Prednisolone

-NMDA receptor
antagonists
Ketamine

-Topical agents Capsaicin

Question 3

Neuropathic pain

Answer 3

Neuropathic pain occurs when there is damage to, or a change within, the central or
peripheral nervous systems. This may occur with Herpes zoster infections (the pain
of shingles), direct damage to, or compression of, a nerve (e.g. sciatica), tumour
infiltration of a nerve or as the result of chemotherapy for cancer. The pain may be
continuous or consist of unpredictable episodes, the latter often being likened to
having an electric shock.

Question 4

Neuropathic pain is often described as:

Answer 4

• Tingling
• Burning
• Electrical
• Stabbing
• Pins & needles
• Itching

Question 5

Tactile allodynia

Answer 5

This is when even a very light touch on the skin of the patient will result in the sensation of severe pain in the area and the patient may find the touch of clothing or bedclothes intolerable.

Question 6

Neuropathic pain often responds very poorly to

Answer 6

conventional analgesia and drugs
which work centrally may be more effective. These include (not an exhaustive list):
amitriptyline, carbamazepine, duloxetine gabapentin, pregabalin, tramadol.

Question 7

Phantom Limb Pain

Answer 7

Phantom Limb Pain (PLP) affects 50-80% of amputees. It is often confused with
residual-limb or stump pain or amputation pain. These are nociceptive types of pain,
whereas PLP is a neuropathic pain. Pressure on the residual limb, certain times of
the day and the weather can make the pain worse, as can emotional stress. The
pain is often described as sharp, cramping, burning, electric, jumping, crushing and
cramping. Often the pain is associated with particular movements or positions of the
phantom limb. It differs from phantom limb sensation, which is a normal
phenomenon for almost all amputees, but unlike PLP, is not distressing. Phantom sensation has been described as itchiness, tingling or pins and needles, squeezing
and toe crossing.

Question 8

Post-operative Pain operative P

Answer 8

Post-operative pain is usually acute and usually decreases in the days following
surgery. Inadequate control of pain within the post-operative period can lead to the
pain becoming chronic

The WHO pain ladder (refer back to your stage 3 pain module) is used to treat acute
pain such as post-operative pain

Question 9

WHOs pain relief ladder

Answer 9

1 (mild pain) Paracetamol and NSAIDs

2 (mild – moderate pain) Paracetamol and NSAIDs plus weak opioid
e.g. codeine or dihydrocodeine

3 (severe pain) paracetamol and NSAIDs plus strong opioids
(eg morphine, alfentanil, diamorphine,
fentanyl, or oxycodone)

Question 10

Non-opioids used may include

Answer 10

paracetamol or NSAIDs e.g. ibuprofen. Non-opioids
are administered orally or rectally (although rectal adsorption of paracetamol can
often lead to sub-therapeutic levels).

Question 11

Opioids used may include (amongst others):

Answer 11

• Codeine (weak opioid)
• Dihydrocodeine (weak opioid)
• Tramadol (moderate opioid)
• Morphine (strong opioid)
• Diamorphine (strong opioid)
• Oxycodone (strong opioid)
• Fentanyl (strong opioid)
• Buprenorphine (strong opioid)
• Pentazocine (strong opioid)
• Tapentadol (strong opioid)

Question 12

Patient controlled analgesia (PCA)

Answer 12

PCA allows a patient to administer their own pain relief; a syringe containing the
chosen drug is inserted into the computerised pump. The pump can be set to
administer prescribed doses of the drug when the patient presses the button on the
pump, there will be a ‘lock-out’ period whereby if the patient presses the button they
will not receive any further doses thus minimising the risk of overdose. Alternatively
the pump can be set to administer a small constant flow of analgesia; additional
doses can also be administered by the patient pressing the button. The usual route
for PCA is IV. The video in the recommended reading shows a PCA being used in
adolescent patients.

Question 13

Adjuvant therapies that might be used may include (amongst others):

Answer 13

• Entonox (50% nitrous oxide 50% oxygen)
• Antidepressants e.g. amitriptyline
• Anticonvulsants e.g. gabapentin, pregabalin
• NMDA-receptor antagonists e.g. ketamine

Question 14

more likely to be used in the immediate

post-operative period

Answer 14

Entonox and ketamine

Question 15

antidepressants and anticonvulsants are more likely to be

added

Answer 15

if other first line options are not adequately controlling a patients’ pain.

Question 16

Pain associated with burns can originate in many different ways. For example:

Answer 16

• Pain associated with the burn itself
• Dressing changes
• Donor graft sites
• Nerve regrowth

Question 17

useful for dressing changes.

Answer 17

Remifentanil, is a very short acting opioid, which is useful for dressing changes

Question 18

used for procedural pain

Answer 18

Ketamine or inhaled nitrous oxide

Question 19

The pain from fractures may be described as a deep, intense ache. Some people
also experience sharp pain with broken bones. Patients may also feel:

Answer 19

• Bruising
• Stiffness
• Swelling
• Warmth
• Weakness.

Question 20

The pain
associated with non-complex fractures of the arm or leg bones in adults is managed
with:

Answer 20

• oral paracetamol for mild pain
• oral paracetamol and codeine for moderate pain
• intravenous paracetamol supplemented with intravenous morphine titrated to
effect for severe pain.

Question 21

NSAIDs should not be considered in

Answer 21

frail or older adults due to

the risk of NSAIDs impeding the bone healing process

Question 22

The pain associated with non-complex fractures of the arm or leg bones in children
under 16 is managed with:

Answer 22

• oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
• intranasal or intravenous opioids for moderate to severe pain (use intravenous
opioids if intravenous access has been established).

Question 23

suspected displaced femoral fractures

Answer 23

A femoral nerve block or fascia iliaca block may be used in the emergency
department for children (under 16s) with suspected displaced femoral fractures.

Question 24

Complex fractures

Answer 24

IV Morphine should be used as first line

with ketamine as second line.

Question 25

ACS includes:

Answer 25

• Unstable angina
• Non-ST elevation myocardial infarction (NSTEMI)
• ST elevation myocardial infarction (STEMI).

Question 26

ACS pain relief

Answer 26

Pain relief should be provided as soon as possible. Buccal or sublingual GTN may
provide this relief however IV opioids e.g. morphine or diamorphine should be
offered, particularly in STEMI or NSTEMI

Question 27

Treatment for

All neuropathic pain (except trigeminal neuralgia)

Answer 27

Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia.

If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

Consider tramadol only if acute rescue therapy is needed.

Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Question 28

Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so:

Answer 28

cannabis sativa extract

capsaicin patch

lacosamide

lamotrigine

levetiracetam

morphine

oxcarbazepine

topiramate

tramadol (long-term use)

venlafaxine

sodium valproate

Question 29

Trigeminal neuralgia treatment

Answer 29

Offer carbamazepine as initial treatment for trigeminal neuralgia.

If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.

Question 30

For patients with major trauma, use

Answer 30

intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.

If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.

Consider ketamine in analgesic doses as a second‑line agent.

Question 31

patients presenting at hospital with suspected hip fracture - treatment

Answer 31

Offer immediate analgesia

Offer paracetamol every 6 hours preoperatively unless contraindicated.

Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief.

Question 32

Fractures (non-complex) - Initial pharmacological management of pain in adults (16 or over)

Answer 32

For the initial management of pain in adults (16 or over) with suspected long bone fractures of the legs (tibia, fibula) or arms (humerus, radius, ulna), offer:

• oral paracetamol for mild pain
• oral paracetamol and codeine for moderate pain
• intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.

Use intravenous opioids with caution in frail or older adults.

Do not offer non‑steroidal anti‑inflammatory drugs (NSAIDs) to frail or older adults with fractures.

Consider NSAIDs to supplement the pain relief except for frail or older adults.

Question 33

Fractures (non-complex) -Initial pharmacological management of pain in children (under 16s)

Answer 33

For the initial management of pain in children (under 16s) with suspected long bone fractures of the legs (femur, tibia, fibula) or arms (humerus, radius, ulna), offer:

• oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
• intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).

Question 34

Fractures (complex)

Answer 34

intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.

If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.

Consider ketamine in analgesic doses as a second‑line agent.

(same treatment as major trauma)

Question 35

Immediate management of a suspected acute coronary syndrome (ACS)

Answer 35

Offer pain relief as soon as possible. This may be achieved with GTN (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected.

Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.

If aspirin is given before arrival at hospital, send a written record that it has been given with the person.

Only offer other antiplatelet agents in hospital.