4.

2 Pain Management in Adults and Children

Learning Objectives
By the end of this section, participants should be able to:
Describe the non-pharmacological management of pain in adults and children.
Describe the pharmacological management of pain in adults and children.
Explain the WHO three step ladder principles in adults and two step ladder in children.
Discuss the prescription and administration of opioids in pain management.
Identify and manage side effects of opioid administration.

1. Erlewine’s five pain management principles 1

1. Pain assessment and re-assessment is vital for pain management

“If we cannot assess pain, we will never be able to relieve pain.”

Betty Farrel,PhD, FAAN

2. Use appropriate non-drug pain relief measures as well as drug measures

Ø This is often instinctive – the mother that distracts the child from pain, rather
than drawing attention to it or the caregiver that massages the patient’s legs
and feet.

Ø Health professional and caregiver attitudes can make a big difference to

a child or adult in pain.

o Don’t leave them alone when they are in pain; encourage

parents/carers to stay with the patient
o Use familiar items/surroundings: nurse them at home if possible;
allow a child to have their favourite toy, patient their own linen
o Show respect – speak to a child at their level and treat adult patients
like adults, acknowledge the patient as a person when caring for them.

Pain Management Dr Charmaine Blanchard and Dr Julia Ambler 2015 1

 Ø Examples of non-drug measures (Non pharmacological management):

ü Massage, tickling, cuddling A bored child or adult is

more likely to be aware of
ü Acupuncture their pain.
ü TENS machines
ü Reflexology, Aromatherapy

ü Application of heat or cold, a warm face cloth or bean bag

ü Distraction techniques
• playing with a child
• providing music or art
• reading to a patient can take away the focus of their pain

3. Patient and family/caregiver education

It is essential that the patient and family/caregiver is empowered with knowledge

and skills in pain management.

What is causing the pain; understanding the disease.

Assess the family’s understanding of the condition; ask if there is anything

else they would like to ask or know.

Teach them how to use the pain scales; about their medication and why it is
essential to take as scheduled; side effects; drug interactions; signs and
symptoms of disease progression and how it will impact on the pain level;
how to make the patient comfortable.

Alternative methods of pain relief; non-drug measures

How and when to seek further help

4. Ongoing review and updating the patient’s personalised care plan

Remember that the first appointment may be stressful and the parent or
caregiver may not have felt able to ask all their questions. Use open
questions to allow them space to speak freely.

o How is the pain affecting you?

o How is it affecting the family?

Pain Management Dr Charmaine Blanchard and Dr Julia Ambler 2015 2

 o What is it that you find most stressful at the moment?

This kind of insight will help you to improve the care plan appropriately.

5. Team Approach

It is necessary to involve the members of the multi/interdisciplinary team in the

management of the patient.

2. WHO Pain Treatment Principles 2

4 KEY CONCEPTS:

1. By the clock

2. By the appropriate route

3. By the child/adult (Individual)

4. By the WHO ladder (In children – The 2 step approach)

1. By The Clock

For persistent pain, analgesics should be given regularly at a fixed

dose on a fixed schedule. An “as needed” or PRN approach to pain
treatment for persistent pain causes pain intensity to increase and more
difficult to control and means the patient has to be in pain before he or she will be
offered any relief.

2. By the Appropriate Route

- The oral route is best for all analgesics.

- When the patient is unable to talk/swallow, comatose or having incessant

vomiting, other routes will need to be considered.

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 Medications can be given:

Orally – best option for as long as possible

Buccally

Intranasally

Rectally

Intravenously

Subcutaneously

Intramuscularly – to be avoided in children!

Topically

3. By the Patient

• The pain management plan must be individualised for each patient.

• Medications and dosages will need to be adjusted according to the patient’s

response and side –effects.

Remember strong opioids have no ceiling dose – titrate to the response and side
effects of the patient.

4. By the ladder

Classification of Analgesics

Type Name
Non-opioid Paracetamol, Aspirin
Weak Opioid Codeine, Tramadol, Tilidine
Opioid Morphine, Fentanyl, Oxycodone,
Hydromorphone

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The 3 Step WHO pain ladder was first published in 1986 as a tool to improve the
management of cancer pain across the world. Since then we have applied it to other
forms of pain with great success.

The 3 Steps are as follows:

If pain occurs, there should be prompt oral administration of drugs in the following
order:

Step 1 Non opioids (Aspirin and Paracetamol) and if this does not relieve pain then
Step 2 Mild opioids (Codeine) and if this does not relieve pain, stop and then
Step 3 Strong opioids such as morphine, until the patient is free of pain.

To calm fears and anxiety, additional drugs – “adjuvants or co-analgesics” – should

be used.

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Children’s Two Step Approach 3

In 2012, new guidelines for the management of persisting pain in children were
published and describe the use of a two-step strategy.

For children, this three step ladder has been abandoned now in favour of a two-step
approach.

For mild pain Paracetamol and/or NSAID (ibuprofen) should be offered first
For moderate to severe pain the second step now advocated is a strong
opioid, such as Morphine, thus leaving out the original “step 2”, weak opioids
such as Codeine or Tramadol.

The reason for this is that there is insufficient evidence supporting the use
and safety of Tramadol in children and the metabolism of Codeine is complex
and variable. Codeine is a prodrug that needs to be metabolized to Morphine.
It has been shown that many young children are not able to convert codeine
and hence may not enjoy the analgesic effects.

Some children are ultra-rapid metabolisers of codeine and therefore run the
risk of toxicity. Overall it is believed that codeine not be used for managing
persisting pain in children.

Tilidine (Valoron) is a weak opioid that comes as a liquid with a dropper. It is

popular in South Africa and can be useful for procedural pain. It is not ideal
for persistent pain and the recommendation is to use a strong opioid.

Aspirin should not be used for children under 12 years because of its
association with Reye syndrome (fatty infiltration of the liver and
encephalopathy associated with a high mortality rate).

IM Pethidine is not recommended for use in children.

Weak and strong opioids should never be combined as they are

competitive agonists at the same receptors. Combining a weak opioid

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 with a strong opioid decreases the efficacy of the strong opioid. Stop the
weak opioid before starting the strong opioid.

Codeine phosphate is commonly available as a combination formulation with

Paracetamol and sometimes other ingredients, (for example, Spectrapain,
Paracod).

o If unsure, check the formulation. The dose of codeine in these

combinations is less than the usual analgesic dose, (typically
8mg/tablet).

When prescribing a combination tablet with Paracetamol as an

ingredient, do not add Paracetamol.

Strong Opioids (Morphine)

Morphine is the strong opioid of choice.
There is no maximum dose of morphine in management of chronic pain.

Initiating Morphine Treatment

Always explore any concerns that the patient or family may have and also
explain the need for regular dosing for pain control and the need to prn
dosing for breakthrough pain.
If necessary, provide a written dosing schedule decided by the patient to
assist them with remembering.
Start with immediate release morphine syrup 10mg in 5mls (10mg/5ml). The
concentration may differ between institutions. Always be sure and note the
strength of morphine syrup. (KZN use 10mg/1ml)
Prescription: Morphine syrup (10mg/5ml), 5ml PO 4 hourly plus 5ml prn as
a rescue dose (breakthrough pain)
Note 60mg morphine PO is equivalent to 180mg codeine phosphate/400mg
Tramal
In frail elderly patients or in renal failure, start with 2,5mg - 5mg 4 hourly.

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 In children we commence 0.2mg/kg/dose 4 hourly. The dose is less in
neonates.
Titrate the dose upward as follows:
o After 24 hours, add up the total morphine required and divide by 6 to
get the new dose required.
o Or, increase the dose by 30-50% and review regularly.
If the pain is not responding to morphine and the patient is increasingly
drowsy, assess whether pain is fully opioid responsive. An adjuvant (co-
analgesic) may be required.
Once established pain control, or if circumstances require, prescribe MST:
o Calculate the total 24-hour intake of morphine: divide by 2 to get the
12 hourly dosing of MST, and divide by 6, to get the rescue dose of
morphine syrup.
o For example, should the patient be taking morphine syrup 10mg/5ml
4hourly (6 doses), = 60mg in 24 hours. Divide by 2, = MST 30mg 12
hourly. Divide by 6 = morphine syrup 10mg/5ml PRN for breakthrough
pain.
o Children also respond well to MST if they are able to swallow tablets

Do the
and nottotal
crush or dose
daily BREAK MST tablets. Review regularly
is big enough to be converted.

Opioid (Morphine) side effects

Constipation is a constant side effect of opioids. When prescribing opioids,
always prescribe laxatives. It is good practice to prescribe a “pusher” and
a “softener”, such as Senakot 2 tablets at night and liquid paraffin 10-20ml at
night. An alternative if these are not available is lactulose 20ml-30ml at night.
Often patients experience nausea with opioids and metoclopramide 10mg
three times a day may be necessary. (100mcg/kg TDS in children)
If a patient becomes increasingly drowsy and has a decreasing respiratory
rate, review the pain assessment and consider reducing the dose or missing
a dose. If the patient does not improve and pain returns, it may then be due to
deterioration of their condition.

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Common myths about Morphine

“Patients will become addicted to morphine” if given to them for pain.

This is false. If morphine dose is titrated against pain, the patient will not
become addicted.
Patients will become “zombies” if given morphine. False. Patients may
experience some drowsiness when first starting morphine or when the dose
is increased, but this passes after a few days and patients can be fully
cognitive.
“Morphine is only given when the patient is close to death”. False.
Morphine is given to treat pain when it is needed and not only at the time of
death.
“Morphine can hasten death”. False. Morphine used correctly does not
hasten death. If a patient is close to dying and is given morphine correctly
for pain, the morphine relieves pain and death may occur as a natural
consequence of their condition.
If morphine is given and pain is not controlled, there is nothing more to be
given, so morphine should be saved “for the end”. No. Morphine has no
ceiling dose. As pain increases the morphine can be increased.
“Morphine causes life threatening respiratory depression”. False.
Morphine given according to the WHO guidelines will not cause a fatal
respiratory depression.
“Morphine is only for cancer patients”. False. Morphine can be given to
any patient with severe pain that is not controlled with weaker opioids.

Non-nutritive Sucking in the Newborn 4

This is one of the most extensively studied interventions used to decrease pain associated
with minor procedures in newborns (21 studies, 1616 infants). It describes the technique of
using a dummy dipped in sucrose solution, given 2 minutes prior to a painful procedure. It
is the most effective pain reduction method for minor painful procedures, more effective
than Emla anaesthetic cream.

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Co-analgesics
Previously known as adjuvant analgesics, these medications were not invented to treat
pain but have other uses. Over the years they have been discovered to have analgesic
effects.

The medications may be used alone but are usually more effective used in combination
with analgesic medications as described in the WHO Pain Ladder.

Co-analgesics

For further information, please refer to HPCA guidelines in separate PDF

Class Main Indications for Use Examples

Corticosteroids Nerve pain Prednisolone

Betamethasone
Pain associated with oedema Dexamethasone
(swelling) and inflammation
Headache due to raised
intracranial pressure. Bone
pain.
Antidepressants Nerve injury pain Amitriptyline

Anti-convulsants Nerve injury pain Carbamazepine

Gabapentin

NMDA-receptor Pain with poor response to Methadone

channel Morphine and other standard Ketamine
blockers therapies;
Severe nerve pain
Antispasmodics Bowel and renal colic Hyoscine Butylbromide

Muscle relaxants Muscle spasms Diazepam

Tension headache Baclofen

Anxiolytics Anxiety-related pain Diazepam, Lorazepam

Bisphosphonates Severe metastatic bone pain Zoledronic acid

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References

1. Erlewine, S., Nursing Care at the End of Life. Part 2: Pain Management
http://erlewinedesign.com/end-of-life-care/207principles.htm accessed 7 April 2015

2. WHO Cancer Pain Ladder for Adults

http://www.who.int/cancer/palliative/painladder/en/

3. WHO guidelines on persisting pain in children

http://www.who.int/medicines/areas/quality_safety/guide_perspainchild/en/

4. Pinelli J and Symington A.(2004) Non-nutritive sucking for promoting physiological

stability and nutrition in preterm infants.Cochrane review, The Cochrane Library
Issue 3. Association for Paediatric Palliative Medicine Formulary at
www.appm.org.uk

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