Pain Management

Question 1

Acute Pain
Pain Level Scores and corresponding Analgesic Step

Answer 1

• MILD Pain = Step 1
  – Non Pharmacological measures
  AND/OR
  – Paracetamol
• MODERATE Pain = Step 2
  – NSAIDS
  AND/OR
  – Oral Opioids
• SEVERE Pain = Step 3
  – Increased dose of oral opioid
  OR
  – IV OPIOID (Morphine or Fentanyl)
  OR
  – SC (morphine)
  or
  – IN FENTANYL

Question 2

Mild acute Pain
Strategies

Answer 2

• Non-pharmacological approaches
• Paracetamol

Question 3

Mild acute Pain
Non-pharmacological measures

Answer 3

• reassurance
• rest (if nonmusculoskeletal pain)
• ice or heat pack

Question 4

Mild acute Pain
PARACETAMOL max daily dose

Answer 4

4 g

Question 5

Moderate acute Pain
(NSAID) Options

Answer 5

1 IBUBROFEN VO

OR (depending on patient comorbidities)

2 DICLOFENAC VO

OR

2 NAPROXEN VO

If symptom relief is not sufficient with paracetamol and there are no contraindications to their use, a (NSAID) can be used instead of, or in addition to, paracetamol

Use the minimum effective dose of the NSAID for the shortest possible time, for a period usually not exceeding 2 weeks. Review the patient at 2 weeks if the acute pain has not resolved.

Question 6

Moderate acute Pain
OPIOIDS Options

Answer 6

1 CODEINE VO

OR

1 TRAMADOL VO

OR

2 OXYCODONE VO

NOTE: Codeine is a prodrug and requires conversion by the cytochrome P450 (CYP) 2D6 isoenzyme to morphine

Question 7

Severe acute Pain
IV options

In most cases of severe acute pain (eg myocardial infarction, renal colic), the intravenous route is indicated to achieve a rapid and predictable effect.

Answer 7

• MORPHINE
• FENTANYL

A small dose is given and doses repeated at intervals of about 5 minutes until analgesia is achieved or sedation and/or respiratory depression contraindicate further opioid administration

Carefully monitor the sedation score in all patients receiving intravenous opioids (IDEALLY < 2)

SEDATION SCORE
0 = awake, alert
1 = mild sedation, easy to rouse
2 = moderate sedation, easy to rouse, unable to remain awake
3 = difficult to rouse

Question 8

Severe acute Pain
SC options

Answer 8

MORPHINE

The subcutaneous route is preferred to intramuscular administration because it is less painful and less likely to cause damage to muscle and other structures. The subcutaneous route is not appropriate in patients with poor peripheral perfusion or oedema.

Consider other methods of delivering maintenance opioid if more than one dose of subcutaneous morphine is required.

Question 9

Severe acute Pain
IN options

Answer 9

FENTANYL

Intranasal administration has been evaluated as an alternative to IV
administration in burns, paediatric emergencies and some-times in paediatric postoperative patients, and in palliative care. It is also widely used by paramedics in the prehospital setting.

An intranasal delivery device is required to deliver a fine mist of solution quickly into the nasal cavity.

The intranasal route avoids the need for IV cannulation and may provide more rapid analgesia than IV administration if an IV line is not available. IN administration should be avoided in patients with nasal
congestion, occlusion or epistaxis.

Answer 10

Note 1: Codeine should not be used in breastfeeding women, patients known to be ultrarapid metabolisers, in
children younger than 12 years, and in children 12 to 18 years who have recently had a tonsillectomy and/or
adenoidectomy for obstructive sleep apnoea. For more information, see the TGA Medicines Safety Update