KERSA HOSPITAL

Pain Management Guideline

2019GC

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Acknowledgments

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Table of Contents

Acknowledgments..........................................................................................................i
List of Abbreviations......................................................................................................2
Foreword.......................................................................................................................3
Users Guide: Purpose and Intended Users..................................................................4
SECTION I: Background...............................................................................................6
1. Introduction............................................................................................................7
2. Scope of the Problem............................................................................................8
SECTION II: Definintion and General Management of Pain.......................................10
3. Definition of Pain..................................................................................................11
4. Classification of Pain...........................................................................................11
5. General Management of Pain..............................................................................13
6. History Taking......................................................................................................14
7. Assessment of Pain.............................................................................................16
8. Pain Treatment....................................................................................................19
SECTION III: Management of Pain in Specific Conditions.........................................28
9. Pain Management in Cancer Patients..............................................................29
10. Pain Management in Patients with HIV/AIDS....................................................32
11. Post Operative Pain Management….................................................................37
12. Pain Management During Pregnancy and Labor..............................................41
13. Pain Management in Children (pediatrics)........................................................45
SECTION IV: Opioids Use in Pain Management........................................................50
14. Opioids Use in Pain Management.....................................................................51
SECTION V: Appendicies...........................................................................................57
Appendix 1: Estimated Relative Potencies and Dosages of Opioids......................58
Appendix 2: Barriers to Effective Pain Management...............................................59
Appendix 3: Steps in the Management of Chronic Pain..........................................60
Appendix 4: Management of Ongoing Chronic Pain...............................................61
Appendix 5: Tips for Using Opioids for Pain Relief.................................................62
Appendix 6: Use of Combination of Drugs in Pain Management............................63
Appendix 7: Drug Management for Special Pain Problem......................................64
Appendix 8: Detailed Evaluation of Pain.................................................................65
Appendix 9: List of Additional Pain Assessment Tools...… ....................................66
Appendix10: Common Pain Problems in Cognitively Impaired Persons….……….67
Appendix11: Drug Formulary for Analgesics...........................................................68
Appendix 12:Kersa hospital action plan for implementation of PFHI…………………….80
Appendix13: Kersa Hospital vital sign sheet template……………………………………81
Appendix14: Pain assessement in advanced dementia scale………………………………82
Glossary......................................................................................................................83
References..................................................................................................................84

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List of Abbreviations

AIDS Acquired Immunodeficiency Syndrome

ATC Around-the-clock
Bid Twelve hourly
DACA Drug Administration and Control Authority
FMOH Federal Ministry of Health
HCW Health care worker
PCA Patient-controlled analgesia
HIV Human Immunodeficiency Virus
ICP Intra-Cranial Pressure
i.m. Intramuscular
i.v. Intravenous
NNRTIs Nonnucleoside reverse transcriptase inhibitors
NSAID Non-steroidal anti-inflammatory drug
HAART High active antiretroviral therapy
PFHI Pain Free Hospital Initiative
PIs Protease inhibitors
Po Oral medication
PLWHA People Living with HIV/AIDS
PRN As needed
Qid Six hourly
SSRIs Selective serotonin reuptake inhibitors (SSRIs)
SVC
Superior Vena Cava syndrome
syndrome
Tid eight hourly
WHO World Health Organization

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Users Guide: Purpose and Intended Users

The guideline covers a range of proven pain management approaches, including

pharmacological and non-pharmacological approaches, which can be applied in
various circumstances and levels of experience. The choice of drugs was made
based on the current policies and guidelines pertaining to procurement and use of
drugs at the levels of primary hospital. Due consideration was made to suggest
improvements when the current policies and guidelines constrain effective
management of pain.

The objectives of the guideline include to:

 Ensure the safety and effectiveness of pain management
 Reduce the risk of adverse outcomes
 Maintain the patient's abilities, physical and psychological well- being
 Improve the quality of life for patients with pain
 Promote rational use of pain management drugs
 Improve access to safe pain management

This guideline is developed to assist the practitioner in making decisions about

health care. It provides useful recommendations that are supported by the current
literature and synthesis of expert opinions. However, this guideline is not intended to
be a rigid procedure. Its use guarantees no specific outcome. The guideline is
subject to revisions as warranted by medical advances. Thus, decisions to adopt any
particular recommendation must be made by the practitioner in light of
circumstances presented by individual patients.

The primary targets of this guideline are health care providers at this hospital but it
could also be a useful reference for health mangers and hospital policy makers.
Recommendations are given for specific population groups such as pregnant women
and children as necessary. Considerations are also given to the level of experts
available here to care for and to have effective implementation of the guideline.

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It is important for health workers to be aware of the following facts in managing
patients with pain:

 Before prescribing any drugs, assess over-the-counter drugs and herbal

preparations that the patient may already be using

 Ask for drug-related fears or misconceptions in order to minimize poor

adherence to any prescription

 Assess the financial resources available to the patient to purchase

medications

 Assess the risks and benefits of the drugs to be used for pain management

 Consider non-drug therapies to maximize pain relief while decreasing side

effects

 While the development of addiction is unlikely during a short course of pain

treatment, careful assessment for indicators of addiction during a course of
opioid therapy is a prudent measure

 Use less invasive and less costly therapies before resorting to more invasive
and costly therapies

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 SECTION I:
BACKGROUND

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1. Introduction

In 2019 Ethiopia had an estimated over 115 million people with an annual
population growth rate of 2.7 percent and life expectancy at birth was 63.4 years for
males and 68.4 for females .(2018/19) 1. Kersa Hospital was established in 2009EC,
to serve people in Munessa Woreda Arsi, based on figures published by the central
statistical agency of Ethiopia, this woreda has an estimated population of 207,422;
according to data published 15yrs back.

The burden of disease in Ethiopia is formidable and affects all segments of the
society though children and women are known to carry the most burdens. Most of
the disease conditions occurring in Ethiopia are accompanied by pain and suffering.
Pain is the most common symptom in all kinds of illnesses but it is particularly
troublesome and long standing in people who live with chronic illness such as AIDS
and cancer. Acute pain in post operative cases and trauma patients is also among
the most unbearable suffering of human kind. According to the latest Ethiopian
Federal Ministry of Health publication the number of people living with HIV/AIDS is
estimated to be 1,320,000, the total number of surgeries performed in a year was
50,515 (2004/05)2. Although the number of patients requiring pain management is
quite enormous, no systematic effort was done to effectively manage pain in
Ethiopia.

Each year in Africa about 2.5 million people die from HIV/AIDS, and more than 0.5
million die from cancer. About 80% of cancer patients will have pain in the terminal
phase of their disease. In Uganda it has been estimated that at least 25% of
HIV/AIDS and 80% of cancer patients have substantial pain during their illness. 3

This Guideline is developed to assist this hospital’s health workers to effectively

alleviate pain and reduce unnecessary suffering of patients. The guideline was
developed largely based on PFHI principles. Mini hospital survey was undertaken
before the preparation of this document to assess baseline pain management
practices in this hospital, by reviewing prior Health record charts: the results have
1
From www.macrotrends.net
2
Health and Health Related Indicators 1998 Eth. Calendar (2005/6). Planning and Programming Department,
FMOH
3
AIDS 6th Report. FMOH 2006

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shown that there was not a coherent and appropriate pain management practices to
say the least.

About PFHI, PFHI is a one-year quality improvement initiative of the FMOH to

integrate effective pain assessment and treatment in to the routine health service
delivery. In this program all hospitals are required to improve patient’s pain
experience and reducing in-patients reporting moderate to severe pain by at least
50%, to avail appropriate pain medication. All Hospitals are expected to train staff
and all hospitals are expected to implement pain as 5 th vital sign, pain management
protocol or guideline.

2. Scope of the Problem

Pain affects the physical, mental, emotional, and spiritual aspects of a patient's life.
Daily non-cancer pain in the elderly has been associated with impaired activities of
daily living, change in mood, and decreased involvement in social activities. Acute
pain can be sign of life threatening conditions and need immediate attention. The
impact of acute and chronic pain on our society is staggering. Throughout the world,
chronic pain is the most frequent cause of suffering and disability that seriously
impair the quality of life. Chronic pain impairs function, can lead to depression, and
can even result in suicidal behavior4. About two third of cancer patients present with
symptoms of pain; 80% complaining one or three sites of pain and 33% complaining
more than three different sites of pain. Pain is also one of the common complaints in
AIDS patients; which is often due to opportunistic infections, neoplasms, or
medication-related neuropathy.

Unrelieved pain can impair all aspects of a person’s life, including appetite, mood,
self-esteem, relationships with others, and even the ability to move. In some
countries, it has been reported that unrelieved pain can lead to the wish for death
and inquiries about euthanasia and assisted suicide. Relief of pain has been

4
Chronic Pain: Barriers to Effective Pain Management, Nicholas Messina http://ezinearticles.com/?Chronic-
Pain:-Barriers-to-Effective-Pain-Management&id=158569 (accessed on April 6, 2007)

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demonstrated to improve quality of life5. However, pain is one of the symptoms that
are poorly managed at the health facilities.

Some of the reasons for poor management of pain include:

 Improper assessment of the cause of pain
 Ignoring the impact of pain on the patient’s quality of life
 Not setting realistic case management goals (a realistic goal has three steps:
initially achieve pain free full night’s sleep, then make patient pain free when
awake and alert, and finally achieving pain free movement)
 Not doing regular re-assessment to detect changes in pain severity
 Fear of using strong analgesics (opioids)
 Misdiagnosis of cause of pain mechanism
 Lack of awareness about the various treatment options by health workers
 Unavailability of drugs and lack of training of health workers
 Not taking a holistic approach to pain management

5
WHO. Narcotic & Psychotropic Drugs Achieving Balance In National Opioids Control Policy, Guidelines For
Assessment World Health Organization, 2000

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 SECTION II:
DEFININTION AND GENERAL
MANAGEMENT OF PAIN

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3. Definition of Pain6

The word "pain" is derived from the Latin word "poena" meaning a penalty 7. Pain is
defined as:
An unpleasant sensory or emotional experience
Associated with actual or potential tissue damage 8.
The unpleasant sensation can range from mild, localized discomfort to agony
depending on the nature of the underlying health problem. Pain could be continuous
(occur without interruption) or intermittent (comes on and off) depending on the
nature of the underlying pathology. Pain has both physical and emotional
components. The physical part of pain results from neural stimulation.

Thus, pain is a warning signal for actual or potential tissue damage in the human
body. As such pain is the commonest symptom patients came to seek medical
advice and demand relief immediately. Pain is highly personal and subjective and is
whatever the patient says it is, existing whenever he/she says it does. Self report of
pain is considered the most reliable indicator of pain 9.

4. Classification of Pain

Pain can be categorized using various criteria. The commonly used classification is
based on the etiology or origin of pain or duration of the symptom. The following
section describes the two commonly used classification systems.
Based on its origin - pain can be categorized into two with further subdivision:

1. Nociceptive pain: The result of tissue damage (eg, postoperative pain).

Nociceptive pain is further subdivided into somatic and visceral pain.

1.1. Somatic pain: It arises from damage to body tissues. It is well localized but
variable in description and experience.

6
http://www.surgeryencyclopedia.com/La-Pa/Pain-Management.html, Pain Management - Definition, Purpose,
Precautions, Description, Preparation, Aftercare, Risks, Normal results, Accessed Feb 20,2007
7
Definition of Pain. http://www.medterms.com/script/main/art.asp?articlekey=4723. Accessed April 25, 2007
8
(International Association for the Study of Pain, 1979; Merskey, 1964)
9
Pain, Assessment and Management Johns Hopkins interdisciplinary clinical practice manual
ttp://www.aacn.org/PalCare/pdfs/pain_assessment_management_jhopkins.pdf (Accessed on April 6, 2007)

12
 1.2. Visceral pain: Is pain arising from the viscera mediated by stretch receptors.
It is poorly localized, deep, dull, and cramping (e.g., appendicitis,
cholecystitis, pleurisy).

2. Neuropathic pain: Is pain arising from abnormal neural activity secondary to

disease or injury of the nervous system. It remains persistent without ongoing
disease (e.g., diabetic neuropathy, trigeminal neuralgia, or thalamic pain
syndrome). Neuropathic pain is further subdivided into the following:

2.1. Sympathetically mediated pain: is pain arising from a peripheral nerve

lesion and associated with autonomic changes (e.g., complex regional pain
syndrome I and II [reflex sympathetic dystrophy and causalgia]).

2.2. Non-sympathetically mediated pain: is due to damage to a peripheral

nerve without autonomic change (e.g., post-herpetic neuralgia, neuroma
formation).

Central pain arises from abnormal central nervous system (CNS) activity (e.g.,
phantom limb pain, pain from spinal cord injuries, and post-stroke pain).

Based on its duration, pain can be divided into two categories:

1. Acute pain: A vital body protective mechanism. Pain that is transmitted by

nociceptors is typically called acute pain. It is associated with injury, headaches,
and many other disease conditions. Response to acute pain is made by the
sympathetic nervous system. It normally resolves once the condition that
precipitated it is resolved.

2. Chronic pain: It serves no such physiologic role and is itself not a symptom but a
disease state. It is usually defined as pain which lasts beyond the average
duration of time that an injury to the body needs to heal, which is commonly four
to six weeks. Chronic pain often responds less favorably than acute pain to
treatment, the prognosis unpredictable and cause significant psychological
stress.

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5. General Management of Pain

Management of pain includes taking proper history, examining the patient,

assessment of pain and provision of appropriate treatment in order to relieve pain.
Pain relief requires thorough thinking and good planning especially if long term
therapy is needed. This section deals on how to assess pain by taking relevant
history from patients; and the various treatment modalities that include
psychological, pharmacological (drug) and surgical measures. Another very
important component of management of pain is to identify the underlying cause and
provide appropriate specific treatment, if it is possible, this approach must be
comprehensive to relieve the presenting symptom and address the underlying
cause. Pain management requires a careful understanding of the circumstances
surrounding the patient and the family to create a cooperative atmosphere that help
achieve better control of pain. The points outlined below in Table 1 need to be
addressed systematically.

Table 1. ABCDE for Pain Assessment and Management 10

A Ask about pain regularity

B Believe the patient and family in their reports of pain and what relieves it.

C Choose pain control options appropriate for the patient, family, and
setting.

D Deliver interventions in a timely, logical, and coordinated fashion.

E Educate and empower patients and their family. Enable them to control
their course to the greatest extent possible.

The goal of chronic pain management must be clearly delineated to the patient (what
is the patient’s role in goal setting here? Palliative Care generally emphasizes the
goals-of-care as expressed by the patient/family as facilitated by the HCW) and the

Jacox AK, Carr DB, Payne R et al. Management of Cancer Pain. Clinical Practice
10

Guideline. No.9. AHCPR Publication No.940592. Rockville, MD:Agency for Health

Care Policy and Research, Public Health Service, US Department of Health and
Human Services; March 1994.

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family. Having a clear treatment goal also improves the effectiveness of treatment.
The following are general goals to chronic pain management:

 Decreasing the frequency and/or severity of the pain

 Improving the general sense of feeling better

 Achieving increased level of physical activity

 Achieving level of comfort that allow the patient back to work

 Decreasing health care utilization

 Eliminating or reducing use of medication

 Allowing pain relief so the patient may address emotional, family, and spiritual
issues

 Allowing a comfortable and peaceful death process; in terminal cases

6. History Taking

As in any patient management in a clinical setting, history taking is an important

aspect of pain management (see also Appendix 8). Without proper history taking and
complete physical examination followed by appropriate laboratory and other
diagnostic investigations the management of pain may not be complete and
successful. Careful assessment of patient history and physical examination must be
done with particular emphasis on:

 Patient perceptions

 Physiological responses

 Behavioral responses

 Cognitive attempts by the patient to manage pain

The pain history should systematically inquire detailed information about the nature
of the pain including the following11:

11
http://www.surgeryencyclopedia.com/La-Pa/Pain-Management.html, Pain Management - Definition, Purpose,
Precautions, Description, Preparation, Aftercare, Risks, Normal results, Accessed on Feb 20,2007

15
Table 2: PQRST for Pain History

P Precipitating and relieving factors

Q Quality of pain; whether the pain is sharp or dull; shooting, burning or

gripping; or cramping

R Radiation

S Site and severity

T Time course; whether pain is continuous or intermittent (recurring

predictably on movement or weight bearing; recurring unpredictably);
how long pain lasts; does pain start suddenly or gradually; associated
syptoms such as par aesthesia or vomiting

Then ask more detailed questions:

 Does the person know of anything that triggers the pain, or makes it worse?
 Does the person have other symptoms (nausea, dizziness, blurred vision,
etc.) during or after the pain?
 What pain medications or other measures has the person found to help in
easing the pain?
 How does the pain affect the person's ability to carry on normal activities?
 What does it mean to the person that he or she is experiencing pain?
 What is the patient's attitude toward and use of medications, including any
history of substance abuse?
 What is the patient’s typical coping responses for stress or pain? Including
more broadly, the presence or absence of psychiatric disorders such as
depression, anxiety, or psychosis.
 What are the family expectations and beliefs concerning pain, stress, and the
course of illness?

After taking a detailed history, a careful clinical examination is necessary to

determine the cause of the pain. Investigation should be reserved for cases with
uncertain diagnosis and cause of pain or when precise localization of the disease is

16
difficult. Some of the commonly used diagnostic investigations ranges from a simple
stool examination to high level investigation that include radiography, blood
electrolytes, mylogram, and CT-scan (or MRI). It is also important to note that pain
relief will not obscure the search for the cause; thus analgesics should not be
withheld while the cause of pain is being established. In fact, use of analgesics
markedly improves the patient’s ability to undergo necessary investigation.

7. Assessment of Pain

It is important to note from the outset that the single most reliable indicator of the
existence and intensity of acute pain (and any resultant affective discomfort or
distress) is the patient's self-report. Although physiological responses such as
increased heart rate, blood pressure, and respiratory rate can provide useful
information they can not substitute for a self-report. Patients may be experiencing
excruciating pain even while smiling, using laughter as coping mechanisms, in the
absence of the above mentioned physiological signs. Further some chronic pain
patients may use sleep to avoid the conscious experience of the pain. In mentally
retarded/altered individuals and children, assessment of pain must involve care
givers and close family members; their description can provide useful clue as to the
cause and nature of the pain. (See Appendix 10 for assessing pain in old patients)

Pain assessment includes determining the type of pain: nociceptive or neuropathic.

 Nociceptive pain: occurs as a result of tissue injury (somatic) or activation of

nociceptors resulting from stretching, distention, or inflammation of the
internal organs of the body. Nociceptive pain usually is well localized; may be
described as sharp, dull, aching, throbbing, or gnawing in nature; and typically
involves bones, joints, and soft tissue.
 Neuropathic pain: occurs from injury to peripheral nerves or central nervous
system structures. Neuropathic pain may be described as burning, shooting,
tingling, stabbing, or like a vise or electric shock; it involves the brain, central
nervous system, nerve plexuses, nerve roots, or peripheral nerves.

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Pain measurement should include both the time-frame and the clinical context of the
pain. Patient with acute pain are usually asked to describe their pain ‘right now” and
may be asked about the average intensity over fixed period of time in order to
provide information on the course of the pain. With chronic pain, experts find it useful
to inquire about pain over the previous month, and obtain separate measures for
pain “on average”, “pain at a worst” and” pain at least”.

Assessment of pain requires rating its severity, which can be done in a number of
ways. The following are the common ways of assessing the severity of pain in a
clinical setting (see also Appendix 9)

1. Numeric Rating Scale (NRS): rating pain on a 0-10 scale by the patient (0 = no
pain and 10 = worst imaginable pain). Pain ratings >3 usually indicate pain that
interferes with daily activities. Use the same scale for evaluation of treatment
response. It is important to note that assessing pain intensity and pattern of pain
occurrence is a good guide to therapy: for example, if presenting pain is 9/10 but
occurs only for 2 hours twice a day one may consider using immediate release
opioid as a PRN dose while if pain is always 4/10 with exacerbations to 9/10 then
long acting or RTC medication along with break through medications ought to be
used. The following is a simple NRS:

0 ——1——2———3———4——5——6———7———8———9————10

Pain rating using Numeric Rating Scale

2. Visual analogue scale (VAS): pain severity is indicated by marking along the
line from no pain to maximum possible pain.

No pain Max. Possible pain

________________________________________________________________

Pain rating using Visual Analogue Scale

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3. Verbal Rating Scale (VRS): this is a categorical scale for rating pain based on
the patient’s description. The response range is: none, mild, moderate, or severe.
In the Ethiopian context this is probably the most common approach to pain
assessment.

4. Pediatric face pain scale: rating pain by observing the child face (when verbal
or language abilities are absent).

SOURCE: WHO Guidelines for Palliative Care12

12
WHO. Palliative Care: Symptom Management and End-of-Life Care. Integrated Management of
Adolescent And Adult Illness. Interim Guidelines for First-Level Facility Health Workers.
WHO/CDS/IMAI/2004.4

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8. Pain Treatment

Effective treatment of pain is one of the challenges in patient care at outpatient and
inpatient level as well as following medical interventions and procedures. It is
important to pay particular attention in identifying the underlying cause of pain for
effective pain relief; this is particularly important in acute pain as that could be
associated with life threatening situations. Management of pain is a very critical
aspect of therapy for individuals suffering from chronic diseases such as AIDS and
cancer. Treatment of pain in patients with chronic illness could be a huge
psychological and economic burden for themselves and their families. Thus, it is
important to consider a relatively inexpensive yet effective approach for relieving
pain.

Older people are more sensitive to analgesic properties, especially those of opioid
but are safe and effective for use by this population. They are more likely to
experience side effects of analgesic medications. However, the older population is
heterogeneous, optimum dosage and side effects are difficult to predict.
Recommendations for age-adjusted dosing are not available for most analgesics.

It is advised to start low dose and go slow. Dosing for old patients requires careful
titration, including frequent assessment and dosage adjustments, to optimize pain
relief while monitoring and managing side effects.

Pharmacologic therapy in old patients is most effective when combined. The use of
more than one agent to affect a therapeutic endpoint may be necessary to minimize
dose-limiting adverse effects of a particular drug. It is recognized that there are major
potential problems with multiple drug use by older patients. However analgesic drugs
should also supplement other medications directed at definitive treatment or
optimum management of underlying disease.
In this section general principles of pain management and detailed approaches in
choice of therapy are outlined.

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8.1. General Principles of Drug Administration:
Table 3.

Type Description
If possible, analgesics should be given by mouth. Consider other
Give treatment routes if the patient is not able to take by mouth. Rectal suppositories
“By Mouth” are useful in patients with dysphagia, uncontrolled vomiting or
gastrointestinal obstruction and in pediatric age group.

Patients with persistent pain should be given analgesics regularly at a

fixed interval of time based on the known pharmacokinetics of the
drug in use. The next dose should be given before the effect of the
previous one has fully worn off. In this way, it is possible to relive pain
Give treatment continuously. The dose of analgesia should be adjusted against the
“By the Clock” severity of pain; increase dose gradually (25-100% depending on
pain severity) until the patient is comfortable. Some patients may
need to take “rescue” doses in addition to the regular doses for
severe intermittent pain, in which case the dose of analgesia should
be 50-100% of the regular four-hourly dose. Breakthrough dosing is
generally recommended to be 10% of the 24hourly dose orally.

The sequential use of the drugs as shown in figure 1 and Table 3 is

very useful for the patient; economical and systematic. Use only one
drug from each of the groups at the same time. Adjuvant drugs
Give treatment
should be given for specific conditions. If a drug ceases to be
“By the Ladder”
effective do not switch to an alternative drug of similar efficacy but
prescribe a drug that is of stronger efficacy (e.g. morphine). It may
also be necessary to start treatment any where in the ladder
depending on the type and severity of pain.
There are no standard doses for Opioid drugs; the “right dose is the
Adjust treatment
dose that relieves the patient’s pain”. The range for oral morphine, for
“For the
example, can be from as little as 5 mg to more than 1000mg every
Individual”
four hours.
Provide full information on dose and schedules and emphasize the
need for regular administration of pain relief drugs to the patient and
In planning pain families. Ideally, the patient’s drug regimens should be written out in
treatment pay full for the patient and his or her family, including names of drugs,
“Attention to reason for use, dose and number of times per day. If multiple doses
Detail” are prescribed it is good to schedule the first and last doses of the
drug to the patient’s waking and bed time. The patient should be
warned about possible adverse effects.

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8.2. General Approaches to Treatment

Table 4 provides an overview of the options for treating pain. Details on pain
medication choice and use are given in the following section.

Table 4. Pain Treatment Options

Type Description
There are a number of non-drug interventions to relieve pain
Non-drug
which are broadly categorized as follows:
Treatment
 Patient and care giver education
 Psychological- Behavioural and CBT
 Physical and rehabilitative therapies
 Complimentary and alternative medicine
 Other physical and invasive modalities

It is important to refer patients to the right professionals for non-

drug therapy. In addition, meditation can be used as adjunctive
therapy at any step in the treatment plan.

Drug There is a range of medications for effective treatment of pain

(Pharmacologic) for various illnesses and specific conditions. The drug
Interventions treatment that is recommended by the World Health
Organization (WHO) is fully described in the following section.

Adjunctive The addition of antidepressant medications can improve pain

Treatments management, especially for chronic pain syndromes. These
agents, and anticonvulsants, are usually used to treat
neuropathic pain (discussed in more detail below), but should
be considered for other chronic pain syndromes as well.

8.2.1. Patient Education

In pain management, patients should give feedback to allow the best treatment
decisions. If pain persists or interferes with daily life, patients should call, so that their
health care provider can change the plan and try additional measures if needed. In
the short run, patients should not expect full pain relief in most cases, but enough
relief that they can perform their daily activities.

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"Mild" pain medications (e.g., NSAIDs, aspirin, and acetaminophen) usually are
continued even after "stronger" medications are started because their mechanism of
action is different from that of opiates. This combination of pain medication has
additive effects, so that pain may be controllable with a lower narcotic dosage.
Patients taking "around the clock" medications should take them on schedule. Those
taking "as needed" medications should take them between doses if they have
breakthrough pain.

Opiates are noted for causing severe constipation. Patients must remain hydrated
and may need stool softeners, laxatives, or other measures. They should call their
health care provider quickly if constipation persists in spite of the above measures.
Patients should avoid recreational drugs or alcohol when taking opiates because
opiates can interact with them or cause additive adverse effects, possibly resulting in
central nervous system depression, coma, or death. Patients taking opiates should
also avoid driving and operating machinery. Once patients are on a regular schedule
of opioid medication, tolerance frequently allows for the safe resumption of operation
of such machinery, unless sedation is present.

23
8.2.2. Dosing Principles for Pain Treatment

Scheduling the dose of pain treatment is dependent on the type and severity of pain.
Thus although there are general approaches that are described below, dosing must
be individualized. Common dosing approaches are shown below.

Table 5. Dosing Approaches

Type Description

‘As needed’ Beneficial when rapid dose escalation is needed or for patients
(PRN) dosing who have rapidly decreasing analgesic requirement or intermittent
pains separated by pain-free intervals. The “PRN” orders have a
delayed effect; some times due to inaccessibility of the drugs
needed for the treatment because some drugs are kept in a
locked cabinet.

‘Around-the- Beneficial for patients with continuous or frequent pain; provides

clock’ (ATC) the patient with continuous relief by preventing the pain from
dosing recurring. Dosing interval is adjusted based on the plasma half life
of the drug selected for treatment; the aim is to maintain constant
blood level of the drug around the clock. The delay of effect in
“PRN” order can be eliminated by administering analgesics on a
regular time schedule. Give opioids around-the-clock instead of
“PRN.”

Controlled Controlled release preparations of oral opioids can lessen the

release drug inconvenience associated with the use of ‘around-the-clock’
formulations administration of drugs with a short duration of action.

Patient- A technique of parenteral drug administration in which the patient

controlled controls an infusion device that may deliver a continuous infusion
analgesia and a bolus of analgesic drug ‘on demand’ according to
(PCA) parameters set by the physician.

24
 8.3. Step-wise Approach to Management of Pain
The step-wise approach to management of pain developed by the WHO 13 is currently
used worldwide (Figure 1). The WHO guideline recommends a three-step ladder
approach:

Step 1: For mild pain, use non opioids drugs like acetaminophen and non-
steroidal anti-inflammatory drug (NSAID) such as aspirin and
ibuprofen.

Step 2: For mild to moderate Pain, use combination of NSAID and mild
opioids such as codeine.

Step 3: For moderate to severe pain, use combination of NSAID and strong
opioids such as morphine (See side effects of opioids in Table 4).

Figure 1. Step-wise Approach for Pain Management

13
http://www.surgeryencyclopedia.com/La-Pa/Pain-Management.html, Pain Management - Definition, Purpose,
Precautions, Description, Preparation, Aftercare, Risks, Normal results, Accessed Feb 20,2007

25
8.4. Drugs Used in Pain Treatment

Table 6. Drugs Used for Step-by-step Analgesia

STEP 1

NSAIDs Usual Adult Dose Pediatric Dose Comments

Acetaminophen* 500-1000 mg q 4-6hr PO
Aspirin 300-900 mg q 4-6hr PO
Diclofenac 50 mg q 8hrs orally (max
200 mg per day),
100 mg per rectum every
16 hours
75mg IM q 12hrly
Ibuprofen 400 mg q 4-6 hr PO
Indomethacin 50-200mg/daily PO
divided 12hrly
100mg suppository 12hrly
10-15 mg/kg q 4 hr PO No peripheral anti-
inflammatory activity
10-15 mg/kg q 4 hr PO Inhibits platelet
aggregation; may cause
postoperative bleeding
Children:5–10 years: Diclofenac should not be
25mg supp. or IM used in children below 5
Children:10– 14 years: years old. Diclofenac is
50mg supp.s or i.m not for i.v. injection
10 mg/kg q 6-8 hr Available as oral
suspension
not recommended for 3-11hrs Elim ½ life
Children

Ketorolac 15 or 30 mg IM/IV q 6 hrly Intramuscular dose not to

Oral dose following IM exceed 5 days
dosage:10 mg q 6-8 hr
stat dose-60mg IM
STEP 2

Mild Opioids Recommended starting Recommended starting

dose (adults more than dose (children and
50kg ) adults less than 50kg )
Codeine 60 mg q 3-4 hr PO 1 mg/kg 3-4 hr
Not recommended for
60 mg q 2 hr IM/SCU im, iv
Tramadol PO 50-100 mg q 6hrs Max. Not recommended for
400 g/day children
IM/IV 50-100 mg q 4-6hrs
Max. 600 g/day
Pentazocine** 50 mg q 4-6 hr po 3 -12 yrs- 0.5
30-60 mg IM/scu 30 mg, mg/kg/dose IV, maxi.
IV, q 3-4 hourly. Maximum Single doses 1 mg/kg
total daily dose, 360 mg. up to a maximum of 30
mg/dose. IM or Scu
STEP 3

Strong Opioids Recommended starting dose Recommended starting dose (children and
(adults more than 50kg ) adults less than 50kg )
Oral Parenteral Oral Parenteral
Morphine 30 mg q 3-4 hr 10 mg q 3-4 0.3 mg/kg q 3-4 0.1 mg/kg q 3-4 hr
hr hr
Meperidine *** Not 100 mg q 3 Not 0.75 mg/kg q 2-3 hr
recommended hr recommended

* Generally accepted max dose of acetaminophen is 4g/d and 3g/day in elderly.

** Pentazocine is a mixed agonist antagonist. It is no longer recommended for chronic pain
management. It has a ceiling effect and can induce withdrawal if given with pure opioids.
*** meperidine is contraindicated for chronic pain management due to the accumulation of
Normeperidine and risk of seizures.

26
SSRI Tricyclic antidepressants (TCAs)
Title?? Starting Dose Maintenance Adverse Adult/Child Comments
Dose Effects Dose
Amitriptyline 10-25 mg at 25-150 mg
bedtime
Desipramine 25 mg 25-250 mg at
bedtime
Nortriptyline 10 mg at bedtime 20-150 mg at Fewer Titrate upward
bedtime anticholinergic every 3-5 days,
side effects as tolerated
than the
others

Fluoxetine 20 mg to a
maximum of 80
mg
Anticonvulsants

Phenytoin 100 mg three

times a day
Carbamazepine 100 mg Bid increased Elderly
gradually reduce initial
according to dose, Child
response to 10–20
dose of 0.8–1.2 mg/kg daily
g daily in in divided
divided doses doses
Gabapentin 100-300 mg 1,200-3,600 Somnolence, Monitor
2 or 3 times daily mg/day in dizziness, response,
divided doses fatigue, and increase the
nausea dosage every 1-
2 weeks by 300-
600 mg/day
Lamotrigine 25 mg twice daily 50-300 mg/day sedation, Slow dose
in divided dizziness, escalation is
doses ataxia, important to
confusion, prevent rash
nausea,
blurred vision,
and rash
Valproic Acid 500 mg twice 500-1,500 mg 2 Weight gain, Monitor valproic
daily or 3 times daily sedation, acid serum
ataxia, levels
nausea, and
diarrhea
Hyoscine Adult Dose Child Dose
Antispasmodics

(scopolamine) Oral, 0.3 mg 30 min before a journey for Oral, aged 4 to 10 years 75 to 150 mg and
Hydrobromide motion sickness then 0.3 mg every 6 those over 10 years, 150 to 300 mg;
hours up to a maximum of 3 doses in 24 IM, IV, o SC, 0.006 mg/Kg or 0.2 mg/m2
hours; IM, IV, o SC, 0.3 to 0.6 mg; the
dose may be repeated 3 or 4 times daily
Ergotamine Oral, 1 to 2 mg at first sign of attack,
Tartrate maximum 4mg in 24 hours; do not repeat
at intervals of less than 4 days maximum
8mg in any one week; not to be used
more than twice in a month
Table 7. Title??
NOTE:

27
Although phenytoin and carbamazepine have some effectiveness in treating
neuropathy, they have significant drug interactions with Anti-AIDS drugs such
as protease inhibitors and non-nucleoside reverse transcriptase inhibitors,
and their use in HIV-infected patients is limited.
Give only one drug from the opioid and non-opioid group at a time except: If
no codeine, aspirin every 4 hours can be combined with paracetamol every 4
hours—overlap so one is given every 2 hours. Use both anticonvulsant with
antidepressants in difficult to control cases.

28
 SECTION III:
MANAGEMENT OF PAIN
IN SPECIFIC CONDITIONS

29
9. Pain Management in Cancer Patients

The suffering of cancer patients from pain associated with the disease is so huge
that their life is often miserable without proper control of pain. Up to 70% of cancer
patients suffer from pain. Causes of chronic pain syndromes in patients with cancer
can be tumor related and/or treatment related (see Appendix 3 & 4). Options
available for palliative treatment of common cancer conditions are given in Table 8.
The use of corticosteroids in cancer treatment is summarized in Table 9. The
following steps are recommended in the management of pain in cancer patients:

1. Increasing pain tolerance: the initial therapy for pain in cancer patients should
address their emotional distress and low moral by providing appropriate
counseling. Treatment with anxiolytics and antidepressants as well as referring
to other non-drug therapy centers such as relaxation and aromatherapy, when
available, could be useful.
2. Modification of the tumor pathology: pain arising from edema, inflammation,
obstruction, and compression due to the tumor growth may be able to be relieved
by appropriate treatment such as radiotherapy, hormonal therapy,
Chemotherapy, and surgery.
 Radiation therapy helps to decrease edema, inflammation, tumor size and
slows progression of tumor growth
 Hormone therapy helps to relive pain in cancer patients by down regulation of
the hypothalamus pituitary gonadal axis, blocking hormone receptor, and
inhibition of adrenal steroid genesis
 Chemotherapy helps by relieving obstruction, shrinking the mass/volume size
of the tumor, relieving infiltration, avoiding compression and correcting
hypercalcaemia

3. Modulation of pain transmission: pain in cancer patients can also be

effectively controlled by modulation of pain transmission using the Step-wise
Approach (Figure 1). Explain pain management protocol and use of Entonox (a
mixture of 50% nitrous oxide and 50% oxygen). Interruption (medical and
surgical) of pain pathways: another option for pain management in cancer
patients is nerve blocks.

30
4. Surgery: pain in cancer patients can sometimes be relieved by surgical
decompression. Careful interdisciplinary evaluation should precede contemplated
procedures.

Table 8. Palliative Pain Treatment for Common Malignant Condition

Type of Treatment Indications

Palliative Radiotherapy Impending pathological fracture of weight bearing bone,

pathological fracture, bone erosion, cord compression,
SVC Syndrome, cerebral metastases, bleeding, offensive
discharge

Chemotherapy SVC Syndrome, metastasis to visceral organ and causes

tumor related symptoms, metastatic mass causes
obstruction, bleeding due to malignancy, malignant
pleural and, cardiac effusion or ascites, metastasis to
bone

Hormonal Therapy Advanced Prostate ca, advanced breast ca, increased

intracranial pressure, cord compression and or SVCS
with extensive disease

Surgery Cord compression, intestinal obstruction 2nd to mass,

dysphagia due to head neck tumors or esophageal ca,
dyspnea, pathological fracture

Miscellaneous Diffuse bone metastasis, renal cell ca

31
Table 9. Potential Uses and Indications of Corticosteroids in Advanced Cancer
Cases
General Uses
 To improve appetite
 To enhance sense of well-being
 To improve strength
 To relieve pain caused by:
 raised intracranial pressure
 nerve compression
 spinal cord compression
 metastatic arthralgia
 bone metastasis
Specific indications
 Spinal cord compression
 Nerve compression
 Dyspnoea due to pneumonitis (after
radiotherapy), Carcinomatous lymphangitis,
tracheal compression/stridor
 Superior vena caval obstruction
 Pericardial effusion
 Haemoptysis
 Obstruction of hollow viscus:bronchus,
ureter, intestine
 Hypercalceaemia (in lymphoma, myeloma)
 Radiation-induced inflammation
 Leukoerythroblastic anaemia
 Rectal discharge (give per rectum)
 Sweating
32
10. Pain Management in Patients with HIV/AIDS

Pain is one of the common complaints among AIDS patients; about 40-90% of
patients with AIDS complain of pain. WHO also estimated that about 50% of People
Living with HIV/AIDS suffers from severe chronic pain (9). Although the cause and
type of pain among AIDS patients is diverse the most common ones are peripheral
neuropathy, headaches especially in cryptococcal meningitis, and gastro-intestinal
pain.

Effective management of pain requires fairly accurate determination of the site and
severity of the pain14. It is also important to note that many analgesics,
anticonvulsants, and psychiatric drugs may have drug interactions with drugs used
as anti-retroviral treatment; for example non-nucleoside reverse transcriptase
inhibitors and protease inhibitors. Clinically, only ritonavir and delavirdine are likely to
cause meaningful interactions with these drugs. Extensive clinical experience,
especially with ritonavir, has shown that CVP3A4-metabolized drugs such as
methadone often need no dose adjustment15.

Pain control in AIDS patients ought to be achieved step-by-step. Chronic pain is

better treated by analgesia given by mouth and on a regular basis. Like other causes
of pain it is advisable to start with mild analgesia and progress in step-wise to more
potent analgesics and opioids, if necessary (Figure 1). The dose of drugs should be
increased to levels that control pain. However if pain is severe at the outset, starting
with step 2 or 3 medications is strongly suggested.

14
HIV/AIDS Treatment and Care WHO protocols for CIS countries World Health Organization 2004
15
Symptom Management Guidelines HIV In Site Knowledge Base Chapter
July 2004 Lisa Capaldini, MD, University of California San Francisco (http://hivinsite.ucsf.edu/InSite?
page=kb-03-01-06, accessed on April 9, 2007

33
10. 1. Common Causes of Pain in HIV/AIDS and their Management 16

Headache:
Headache is very common in advanced HIV/AIDS patients. In patients with severe
headache and no lateralizing symptoms or signs of hemiplegia or hemiparesis in the
sub-Saharan Africa, Cryptocoocal Meningitis comes top in the differential diagnosis.
This infection causes raised intra-cranial pressure that produces the worst
headache. This headache due to the raised intracranial pressure can be effectively
treated using the analgesic ladder. Unlike ICP due to brain tumors, the headache
associated with ICP due to cryptoccal meningitis does not respond well to
dexamethasone.
Treatment:
 Regular analgesia such as morphine
 Treating the infection
 In hospitalized patients: therapeutic lumbar punctures – remove up to 30ml
of CSF once or twice a day

Neuropathic Pain:
This type of pain can also be treated effectively using the analgesic ladder. If patient
is commencing on morphine for another pain, wait a few days and reassess nerve
pain as it may be somewhat relieved.

 Paraesthesia or abnormal sensation: treat with amitryptiline starting with 12.5

mgs bid or 25mgs at night. There is a window effect in some patients so larger
doses may not effect the pain. Pain should be relieved in 1-5 days

 If sharp or shooting in character, commence anticonvulsant phenytoin

100mgs bid to 200mgs tds, but be aware of potential drug interactions- start
with the lower dose. Pain should be relieved within 24 hours; if not or
response is poor try amitryptiline

Oesophageal and Mouth Ulceration:

HIV/AIDS patients commonly have pain in the mouth, odynophagia or severe pain
during swallowing. Identifying the cause of oesophageal and mouth ulceration is
16
Pain and Symptom Control In Cancer and/or AIDS Patient In Uganda and Other African
Countries,Hospice Africa, Uganda, Fourth Edition,2006,

34
often difficult but it always has an element of candidiasis and Herpes infection. Many
patients are extremely emaciated because of failure to eat for several weeks.

Treatment of such symptoms can be life saving and may include:

 Reducing inflammation using steroids:
 Dexamethasone 6mgs IV initially. By the second day the patient
can usually swallow. Then give orally so that the dexamethasone
can actually touch off the ulceration and remove the inflammation.
Reduce dose by 2 mgs daily
 Always give antifungals along with steroids
 Use analgesic ladder to treat pain initially. Pain often subsides after the first
day of steroid treatment
 Gentle mouthwash using a simple antiseptic like 0.05% chlorhexidene can aid
oral hygiene

Perianal and Vulval Ulceration:

This is very painful and usually due to the herpes simplex virus. The treatment for
this is:

 A solution containing: 5mls of nystatin (500,000 units), 2 tablets crushed of

metronidazole (400 mgs) and 1 capsule of acyclovir, can be painted to the
ulcers twice daily. Pain is usually relieved by the second day and healing
follows. This is often affordable

 Acyclovir can reduce the healing time if available and affordable. Oral and
topical preparations are available. Apply to the ulcer

 If none of the above is available then crush a tablet of prednisolone and apply
the powder to the affected part to relieve the pain

Herpes and Post Herpetic Neuralgia (PHN):

Both acute zoster and PHN can be severe conditions associated with profound
psychosocial dysfunction, including impaired sleep, decreased appetite, and
diminished libido. Patients with PHN often demonstrate areas of anesthesia, as well
as deficits of thermal, tactile, pinprick, and vibration sensation within the affected

35
dermatomes. The contralateral, uninvolved side tests normally. Sensory deficits may
extend beyond dermatomal margins. It has been suggested that allodynia is most
prominent in areas of relatively preserved sensation, while spontaneous pain is felt
predominately within the area of lost or impaired sensation. PHN most often
represents a continuum of pain that never resolved following an acute episode of
herpes zoster.

Prevention of PHN:

 For patients with acute herpes zoster rash, treatment with amitriptyline 25 mg
daily or nortriptyline 25 mg daily for 90 days as preventive therapy for
postherpetic neuralgia (PHN), in addition to acute antiviral treatment.

 For patients who cannot tolerate amitriptyline or nortriptyline, early therapy

with gabapentin 1800 mg daily for 90 days in addition to acute antiviral
treatment.

 Antiviral treatment of acute zoster is also helpful in ophthalmic zoster

particularly.

Treatment of PHN:
 Antidepressants
 Analgesic drugs using the step-ladder
 Topical anesthetics
 Anticonvulsants
 Intrathecal corticosteroids
 Cryotherapy
 Surgery

36
 17
10.2 Drug Interactions in Pain Management of HIV/AIDS Patients
Although phenytoin and carbamazepine have some effectiveness in treating
neuropathy, they have significant drug interactions with Anti-AIDS drugs such as
protease inhibitors and non-nucleoside reverse transcriptase inhibitors, and their use
in HIV-infected patients is limited. They are potent CYP450 inducers that can
potentially render some PIs and NNRTIs ineffective. Certain PIs, including lopinavir,
can also decrease phenytoin levels. More suitable alternatives for use with HAART
include divalproex sodium, gabapentin, lamotrigine, and levetiracetam.

Among the benzodiazepines, a class of sedatives used to treat anxiety and

insomnia, midazolam and triazolam may reach dangerously high concentrations
when used with CYP450 inhibitors, potentially causing fatal respiratory depression.
Caution is also warranted concerning alprazolam, diazepam, and zolpidem. Safer
alternatives include lorazepam and temazepam.

Tricyclic antidepressant classes are most likely to be involved in CYP450-mediated

interactions. Levels of the more commonly used selective serotonin reuptake
inhibitors (SSRIs) -- including fluoxetine, paroxetine sertraline, and escitalopram --
may also be increased by CYP450 inhibitors; excessive SSRI levels can cause
symptoms such as seizures, heart rhythm abnormalities, and coma. When taken with
PIs, especially ritonavir, antidepressant drug doses may need to be reduced.

PIs can increase plasma levels of ergot alkaloid derivatives (e.g., Cafergot, Migranal)
used to treat migraine headaches; co administration of these drugs should be
avoided.

17
SF AIDS Fdn Drug Interactions and Anti-HIV Therapy.htm accessed on May 19, 2007

37
11. Postoperative Pain Management18
Postoperative pain contributes to patient discomfort, longer recovery periods, and
greater use of scarce health care resources and may compromise patient outcomes.
Routine orders for intramuscular injections of opioid as needed (PRN) is the modality
used and it has been reported to lead to unrelieved pain in over 50% of patients.

Importance of Effective Postoperative Pain Control:

Stress response to surgery: Surgery results in tissue trauma and activation of this
“stress response” leads to an increase in metabolic rate, water retention and
triggering of a ‘fight or flight’ reaction with autonomic features .These responses
result in pain and surgical morbidity including cardiovascular and respiratory
complications which may be particularly pronounced in elderly patients and patients
with pre-existing cardio-respiratory disease

Adverse cardiovascular effects including hypertension, tachycardia and increased

cardiac work may result from unrelieved pain. Pain may also lead to shallow
breathing and cough suppression increasing the risk of retained pulmonary
secretions and chest infection

11.1. Postoperative Analgesic Drugs

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are not sufficiently effective as the sole agent after major surgery. They are
often effective after minor or moderate surgery though. NSAIDs often decrease
opioid requirement.

Typical dosing schedules include the following:

 Diclofenac:: 50 mg 3 x / day PO (max 200 mg / day), or 100 mg per
rectum every 16 hours
 Ibuprofen: 400 mg 3x per day orally
 Ketorolac:: 10-30 mg orally or intravenously every 6 hours

18
Guidelines on Pain Management, F. Francesca (chair), P. Bader, D. Echtle, F. Giunta, J. Williams, M. Fall (chair), A. Baranowski, C.
Fowler, V. Lepinard, J. Malone-Lee, E.J. Messelink, F. Oberpenning, J.L. Osborne, S. Schumacher, © European Association of Urology
2006, Accessed
on Feb 26,2007

38
Paracetamol and Combinations of Paracetamol with Codeine

These drugs are commonly prescribed after minor procedures when the patient is
able to take oral medications. Alternatively a rectal preparation is available.

Contraindications are relatively few; some patients may be allergic to these

preparations or sensitive to the constipating effects of codeine.

Typical dosing schedules include the following:

 Paracetamol: 1 g orally or rectally every 6 hours

 Combination therapy: 500 mg paracetamol and codeine 2 tablets every 6

hours. 32.5mg dextropropoxyphene + 325 mg paracetamol + 2codeine
tablets every 6 hours

Opioids: Oral, Intravenous, Subcutaneous and Intramuscular

Tramadol is a weak opioid analgesic which is commonly used in postoperative pain

control. It can be given orally or intravenously. Efficacy in postoperative pain has
been widely reported. Adverse effects include dizziness, sleepiness and nausea.

Typical dosing schedules include the following:

 Tramadol: 50-100 mg orally or intravenously, every 6 hours or

continuously

 Loading dose: 100 mg + 0.2 mg/kg/hr as maintenance

Other Opioids

Opioids can be given orally, intravenously, intramuscularly or subcutaneously after

surgery. Systemic administration of opioids may be by using the fixed interval
schedule or ‘around-the-clock’ dosing. Opioids are first line treatment for severe
acute pain. The key principle for safe and effective use is to titrate the dose against
the desired pain relief and minimize unwanted effects .The subcutaneous route is
comparable to intravenous. Oral route is the most feasible, easy and efficacious

39
Side effects include major problems such as respiratory depression, and more minor
problems such as hypotension, sleepiness, nausea and constipation. As part of this
schedule, a patient's pain should be assessed at regular intervals to determine the
efficacy of the drug intervention, the presence of side effects, or the need for dosage
adjustment or supplemental doses for breakthrough pain. Effective use of opioid
analgesics should facilitate routine postoperative activities, e.g., coughing and deep
breathing exercises, ambulation, and physical therapy. The opioid should be
withheld if the patient is sedated when awake or whenever there is respiratory
depression (usually fewer than 10 breaths /minute).

Typical dosing schedules include the following: (The dosage schedule for opioids
needs to be individualized).

 Oral morphine: 5-10 mg every 3-4 hours. This is the preferred route of
delivery, but requires return of gastric motility.

 Intravenous or subcutaneous morphine infusions: (usually managed

in a high dependency area) up to 10 mg/hour, but titrated for individual
patients to determine both effect and side effects.

 Meperidine: 25-50mg slow IV 4 hourly.

 Intermittent IM injections of morphine: 10 mg every 3 hours. Adult daily

dosage = (20-70 yrs old) 100 minus patient age. Child daily dosage= 0.01-
0.04 mg/kg/h.

 Meperidine (Pethidine): 75-100mg q 3 hourly or 0.75mg/kg q 3 hours.

Patient Controlled Analgesia (PCA)

PCA-machines allow the patient to self-medicate opioid by pressing a button which

results in the delivery of the drug directly into the bloodstream. The potential
advantage is patient control and immediate drug delivery. PCA allows patients to
adjust the degree of pain relief to their own desired level of comfort and tolerance of
side effects. Morphine is the usual drug used in PCA machines, but other opioids
could be used such as fentanyl or sufentanil.

40
Typical dosing schedules include the following:

 A loading dose may be prescribed e.g. 1-2 mg (0.05-0.2 mg/kg) morphine

 Incremental (bolus) dose: morphine 1 mg, pethidine 10 mg, fentanyl 20 µg

 Lock-out period 5-8 minutes

 Background infusions: may be prescribed - though close monitoring is

required

 1 hour infusion limit: 30 mg of morphine (or equivalent) in 4 hours

Epidurals

Continuous epidural infusions of local anesthetic drug (bupivacaine) and opioid

(typically morphine) have been used to effectively relieve postoperative pain.
Epidurals have been shown to provide superior analgesia and in addition it results in
a significant reduction in the stress response to surgery and in a reduction in surgical
morbidity. There is a reduced incidence of postoperative pulmonary complications,
cardiac complications and of paralytic ileus.

Potential adverse effects include:

 Hypotension (can be treated with adrenaline or ephedrine)

 Respiratory depression

 Very low incidence of neurological damage and infection

Intermittent or Continuous Local Neural Blockade

Local anesthetic blocks can be used to supplement postoperative analgesia.

Typical nerve blocks could include the following:

 Wound infiltration with 10-20 mLs of 0.25-0.5% bupivacaine

 Iliohypogastric or ilioinguinal nerve infiltration after hernia repair, using 10-

20 mLs of 0.25- 0.5% bupivacaine

41
  Intercostal nerve infiltration with 5-10 mLs of 0.25% bupivacaine
Intrapleural catheters after intrathoracic surgery, continuous infusion of 10
mLs/hr of 0.1% bupivacaine

12. Pain Management during Pregnancy and Labor

Although there is a general rule not to use any drug during pregnancy unless
absolutely necessary there are circumstances that dictate the use of analgesics
during pregnancy. In such cases a careful evaluation of the health status of the
pregnant woman and the fetus must be done by a qualified health worker. The health
care practitioner should explain the risks and benefits of taking the drugs 19. The
common problems associated with the use of drugs are summarized in Table 10.

The first stage of labor produces moderate to severe pain transmitted from spinal
segments T10-L1 to the brain. The second stage of labor produces more localized
pain transmitted by spinal segments S2-4 to the brain. Each woman's labor is unique
and the severity of the pain experienced during labor is dependent on many factors,
including:

 Size and position of the baby

 Dimension of the woman’s pelvis
 Strength of the contraction
 A woman’s previous experience and expectations

19
www.hon.ch/Dossier/MotherChild/preg_drugs/nsaid.html accessed on April 20,2007

42
12.1. Pain Relief Methods during Labor 20

Non-pharmacologic Methods of Pain Relief

Non-medical techniques21 that can help with pain during labor include:
 Breathing/relaxation techniques
 Warm showers
 Massage
 Position changes (standing, sitting, walking, rocking)
 Using a labor ball to name a few

Pharmacologic Methods of Labor Pain Management

 Intravenous medications: Opioids are the most effective medications for the
relief of pain during labor. The few commonly used for childbirth are
meperidine, morphine, fentanyl, butorphanol and nalbuphine. They provide
incomplete analgesia but can make labor more tolerable

 Patient controlled analgesia (PCA): Women can control the delivered

amount of pain medication up to a determined safety point. The nurse will
monitor the intravenous medications being administered. A major
disadvantage of IV medications is that these medications make laboring
women drowsy and sleepy. There may be other side effects including nausea,
vomiting, decreased respiratory rate, itching, constipation and urinary
retention. Initial efforts to breast feed, may be difficult

20
Bhavani Shankar Kodali and Karl Frindrich, Pain Relief during childbirth: A Comprehensive Review.
WWW.bringhamandwomens.org/painfreebirthing/painofchildbirth.asp.
Accessed on Feb 26 2007
21

43
Regional Anesthesia

There are two types of regional analgesia for labor and vaginal delivery:

 Epidural: Medication delivered through a small flexible catheter placed in the

epidural space at the L3-4 interspaces. Medications are delivered at a
constant rate by a pump or in bolus dose as needed

 Combined spinal epidural (CSE): Often given in multiparous women or

mothers late in labor to provide more immediate pain relief. This technique
combines the advantages of each technique. The distinct advantages of CSE
over the epidural are: Rapid onset, profound suppression of pain, minimal
loss of ability to move legs, negligible amount of medications going to other
systems of the body, including the baby , and high satisfaction rate from the
expectant mother

Inhalation of Analgesic Gases

 Entonox: - Mixture of 50% Nitrous oxide (N2o) and 50% Oxygen
 Trichloroethylene

Effect on the Baby

The baby has the ability to metabolize the medications, but it does so more slowly
than the mother. After delivery the baby may be slightly sleepy. Again, it is unlikely
that the baby will be affected adversely as a result of small amounts of pain
medications, but it is important to realize that the medication is getting to the baby.
The probability of seeing an effect of mother's medication in the baby may be
dependent on the dosing of medication in relation to the time of birth. If the baby has
adequate time to break down the medication, only with a minimal effect.

44
Table 10. Commonly Used Analgesic Drugs during Pregnancy and Associated
Problems22

Type Examples Problem

Nonsteroidal anti- Aspirin When the drugs are taken in large doses, a delay in
inflammatory Other salicylates the start of labor, premature closing of the connection
drugs (NSAIDs) between the aorta and artery to the lungs (ductus
arteriosus), jaundice, and (occasionally) brain
damage in the fetus and bleeding problems in the
woman during and after delivery and in the newborn
when the drugs are taken late in pregnancy, a
reduction in the amount of fluid around the
developing fetus
Acetaminophen Paracetamol Used widely during pregnancy due to its efficacy and
minimal side effects. No evidence of increased risk of
birth defects due to acetaminophen. Acetaminophen
crosses the placenta; the fetus is theoretically at risk
from maternal overdose. The antidote, N-
acetylcystein
Opioids Codeine Not known to be teratogenic. Rapid placental
Tramadol transfer, maternal addiction with subsequent signs of
Meperidine neonatal withdrawal are expected in chronic users.
Morphine Respiratory depression and decreased oxygen
consumption in the neonate born to mothers who
received opioids during labor
Antianxiety drug Diazepam When the drug is taken late in pregnancy,
depression, irritability, shaking, and exaggerated
reflexes in the newborn
Anticonvulsants Carbamazepine Some risk of birth defects. Bleeding problems in the
Phenobarbital newborn, which can be prevented if pregnant women
Phenytoin take vitamin K by mouth every day for a month
before delivery or if the newborn is given an injection
of vitamin K soon after birth, some risk of birth
defects
  Trimethadione Increased risk of miscarriage in the woman,
Valproate Increased risk of birth defects in the fetus, including a
cleft palate and abnormalities of the heart, face, skull,
hands, or abdominal organs (the risk is 70% with
trimethadione and 1% with valproate)

Chemotherapy Busulfan Birth defects such as less-than-expected growth

drugs Chlorambucil before birth, underdevelopment of the lower jaw, cleft
Cyclophosphamide palate, abnormal development of the skull bones,
Methotrexate spinal defects, ear defects, and clubfoot

Mood-stabilizing Lithium Birth defects (mainly of the heart), lethargy, reduced

drug muscle tone, poor feeding, under activity of the
thyroid gland, and nephrogenic diabetes insipidus in
the newborn

Source: http://www.merck.com/mmhe/sec22/ch259/ch259a.htmlAccessed on April 21,2007

22
http://www.merck.com/mmhe/sec22/ch259/ch259a.htmlAccessed on April 21,2007

45
 23
13. Management of Pain in Children (Pediatric Patients)

Pain in children is a topic that has received only minimal attention. Clinicians felt that
it was unnecessary to prevent or treat pain in children because of the prevailing
wrong opinion that peripheral nerves of neonates and infants were poorly myelinated
and they don't have the cortical maturation to experience pain. But clearly that is not
true and children suffer from pain although they may not be able to express pain in
the way adults do. Pain assessment however is very difficult in small children.

Pain Assessment in Children

Pain is determined by many factors, including:

 The medical condition

 Developmental level
 Emotional and cognitive state
 Personal concerns
 Meaning of pain
 Family issues and attitudes
 Culture
 Environment

Obtaining a pain history and involving the parents in the child's care can optimize this
process. The pain history obtained prior to or at admission, focuses on the language
the child uses to describe pain (e.g., hurt, owe, boo-boo), previous pain experiences
and coping strategies, how and to whom the child communicates pain, and the
child's and the family's preferences to assess and treat pain.

As with adults, a self-report tool provides the most reliable and valid estimates of
pain intensity, quality, and location (Refer to the assessment of pain section). Self-
reports can be used for developmentally normal children. Self- report tools for

23
Acute Pain Management: Operative or Medical Procedures and Trauma
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.8991,Clinical Practice Guideline No. 1. ,AHCPR
Publication No. 92-0032:February 1992, Accessed on Feb 3 , 2007

46
children over the age of 4 include the faces scale. Children over the age of 7 or 8
who understand the concept of order and number can use a numerical rating scale,
or a visual analog scale.

Pain Management in Children

Effective interaction of the child, his or her parent(s), nurses, physicians, and other
health care providers are the key to effective pain management in children. Some
useful methods to comfort children include:

 Holding someone's hand

 A stuffed toy
 Favorite blanket
 Asking questions
 Using distraction
 Sleeping and resting
 Relaxing or using imagery
 Changing positions
 Engaging in humor

Seemingly simple interventions such as holding someone's hand can have powerful
effects. Facilitation of the child's usual strategies for decreasing pain is important.

Pharmacologic Strategies
As described in the general pain management section, it is useful to follow the step-
ladder approach in managing pain in children. Frequent assessment and adjustment
of treatment is useful. It is also important to identify the underlying cause of pain in
order to be more effective. Agents that have a broad range of applicability include:
 Local anesthetics: These agents may be administered by local infiltration or
topically. For topical use, a eutectic mixture of local anesthetics (EMLA) is
used.
 Opioids: These drugs can be given via the intravenous, oral, or transmucosal
route. The intravenous route has the advantage of rapid effect and ease of
titration. Intravenous opioids can be given in increments (e.g., morphine at

47
 0.03-0.05 mg/kg every 5 minutes) and titrated to analgesic effect. Oral opioids
can be used when close and rapid titration to effect is not required.
 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): They have several
advantages over opioid analgesics including a lack of respiratory depression
and sedation. They do not cause nausea or vomiting. NSAIDs have been
found to be very effective analgesics in older children. However use of these
agents is not recommended below one year of age due to the possibility of
immature renal function and hepatic metabolism. Diclofenac, ibuprofen and
ketorolac are the most commonly used agents. Administration before surgery
as a premedicant provides optimal analgesia due to their anti-inflammatory
activity. Paracetamol (acetominophen) is a very safe and effective analgesic
in children including infants and neonates.

Analgesic Medications24

Acetaminophen:
 Dose: 10-20 mg/kg/dose orally Q4-6h, 15-20mg/kg/dose PR < 5doses in
24hours
 Loading dose: 20 mg/kg
 Maintenance dose: 15 mg/kg
 Maximum dose: 90 mg/kg/day (Older children), 60 mg/kg/day (Neonates)
 Repeat every 12 hours as needed for infant’s postconceptual age < 32 weeks
 Repeat every 8 hours as needed for infant’s postconceptual age 32-36 weeks
 Repeat every 6 hours as needed for infants postconceptual age > 36 weeks

Doses of NSAIDs in Pediatric Patients:

 Ibuprofen 4-10 mg/kg/dose po Q6-8h (>6months)
 Diclofenac Suppositories or i.m injection
o Children: 5 – 10 years: Diclofenac 25mg supp. or 25mg i.m
o Children: 10 – 14 years: Diclofenac 50mg supp. or 50mg i.m
 Diclofenac should not be used in children below 5 years old and is not for IV
injection
24
Guideline for Pain Assessment and Management in Neonates,
www.metrohealth.org/documents/patient%20services/neonatology/PainGuidelineFinal%2003.pdf

48
Pethidine:
Dose: 0.5mg/kg i.v and/ or IM

Morphine:
 Dose: 0.2-0.5mg/kg/dose po Q4-6hrs, 0.05-0.2 mg/kg/dose IV push over 5
minutes, repeat every 4 hours as needed , 0.1MG/KG/DOSE ivq2h
or continuous infusion 0.01-0.02 mg/kg/hr, titrate to response
 Disadvantages: Histamine release may induce hypotension

Codeine:
\0.5-1mg/kg/dose po

Topical Anesthesia. (EMLA/Ela-max):

EMLA cream is a mixture of prilocaine and lignocaine and is very effective at
providing dermal anesthesia. To obtain effective analgesia, cream should be applied
to the skin with an occlusive dressing about 45 to 60 minutes prior to surgery.
Duration of analgesia is about one hour. EMLA should be used with caution in
infants less than 3 months of age or in patients who are taking sulphonamides or
other methaemoglobin inducing medications because of potential of methaemo-
globinaemia.

 Dose: EMLA 1gm applied for 1 hour prior to procedure

 Disadvantages: EMLA may cause methemoglobinemia

Flumazenil (for benzodiazepines):

Dose: 0.01 mg/kg/dose IV push over 15 seconds, repeat every minute as needed up
to a total of five doses

Naloxone (for opioids):

Dose: 0.1-0.2 mg/kg/dose rapid IV push, repeat in 3-5 minutes if needed

NSAID Dose Maximum dose mg/kg mg/kg/day

49
Ibuprofen 10 40
Diclofenac 1 3
Ketorolac 0.5 2
Naproxen 7.5 15
Indomethacin 1 3

50
 SECTION IV:
OPIOIDS USE IN PAIN MANAGEMENT

51
14. Opioids Use in Pain Management

An opioid is a chemical substance that has a morphine-like action in the body. The
main use is for pain relief. These agents work by binding to opioid receptors, which
are found principally in the central nervous system and the gastrointestinal tract. The
receptors in these two organ systems mediate both the beneficial effects, and the
undesirable side effects. There are four broad classes of narcotics:

1. Endogenous opioid peptides: opioids produced naturally in the body

2. Opiates: such as the two alkaloids - morphine and codeine, and heroin
(processed morphine)

3. Semi-synthetic opioids: such as hydromorphone and oxycodone

4. Fully synthetic opioids: such as fentanyl, pethidine and methadone.

Note: Although the term opiate is often used as a synonym for opioid, it is more
properly limited to the natural opium alkaloids and the semi-synthetics derived from
them.

Dosing

Doses should be tittered upwards until adequate analgesia is achieved or

unacceptable side effects occur. If pain is constant or recurs frequently, opioids
should be administrated on a time-contingent basis. Doses should be increased as
needed, not absolutely in terms of milligrams, but as a percentage increase of 33%
to 55% (see Table 7 for side effects of opioids).

Old people are sensitive to opioids since clearance and respiratory function are
altered. Coexisting neurological diseases may make it more difficult to assess
sedation and pain control. Pharmacotherapy for coexisting disease may prove
difficult because of interactions. Combinations with NSAID, thought advocated as
effective against opioid induced pruritus and reducing the opioid requirements, have
to be carefully decided because of the potential danger of reduction in renal
perfusion and increased risk of bleeding. These risks are higher in the elderly since

52
renal clearance and perfusion is already diminished, gastrointestinal bleeding may
be masked and drug compliance may not be reliable.

In neonates the opioid clearance is reduced. There is greater respiratory depression

for an equivalent adult dose, as morphine crosses the immature blood-brain barrier
more easily. Morphine clearance reaches adult levels in the baby child born at term
at the age of 1 month. At 6 months of age children are no more susceptible to
respiratory depression than adults but in children the titration against the pain is even
more important.

The following strategies may minimize opioid side effects:

 Titrating drug doses slowly

 Changing the dosing regimen or route of administration to obtain relatively

constant blood levels if side effect occurs

 Adding or increasing nonopioid or adjuvant analgesic doses for an opioid-

sparing effect whenever possible

 Adding drugs that counteract the effects

Route of Administration

Opioid can be administrated by a wide variety of routes, including oral, sublingual,

intravenous, subcutaneous, rectal, parenteral, transdermal, transmucosal,
intrathecal, and epidural. One of the longstanding myths regarding opioid therapy is
the IV administration is more effective than oral administration. In practice, however,
the same analgesic effect can be achieved with any route and oral or transdermal
administrations are easy, effective, and relatively inexpensive.

53
Table 11: Common Opioids Side Effects and Management Approaches
Opioid Side Treatment
Effect
Constipation General approach
 Increase fluid intake and dietary fiber
 Encourage mobility and ambulation if appropriate
 Ensure comfort and convenience for defecation
 Rule out or treat impaction if present
Pharmacological Approach (see comments above)
 Contact laxative plus stool softener (e.g., senna plus
docusate)
 Osmotic laxative (e.g., Milk of Magnesia)
 Lavage agent (e.g., oral propylethylene glycol)
 Prokinetic agent (metoclopramide)
 Oral naloxone

Nausea General approach

 Hydrate as appropriate
 Progressive alimentation
 Good mouth care
 Correct contributory factors
 Adjust medication
Pharmacological Approach
 If associated with vertiginous feelings, antihistamine (e.g.,
scopolamine, meclizine)
 If associated with early satiety, prokinetic agent (e.g.,
metoclopramide)
 In other cases, dopamine antagonist drugs (e.g.,
prochlorperazine, chlorpromazine, haloperidol,
metoclopramide)
Somnolence General approach
or  Reassurance
Cognitive  Education
Impairment  Treatment of potential etiologies
Pharmacological Approach
 If analgesia is satisfactory, reduce opioid dose by 25% to
50%
 If analgesia is satisfactory and the toxicity is somnolence,
consider a trial of a psycho stimulant (e.g., methylphenidate)
SOURCE: American Society of Pain.

54
Drug Interaction

Opioids have the potential to interact with a variety of medications, primarily resulting
in additive effects (see Table 12).

Table 12. Opioids Drug Interaction

Opioid Interaction Drugs Effect
All Antihistamines Increased sedation
All Tricyclic antidepressants Increased sedation, potentiation of
opioid-induced respiratory
depression
Codeine Quinidine Inhibition of conversion to morphine,
decreased analgesia
Controlled Metoclopramide Early peak plasma concentration,
release opioid increased sedation
Meperidine, Cimetidine Inhibition of opioid metabolism
morphine
Methadone Carbamazepine, Increased opioid metabolism
erythromycin, phenytoin
Methadone, Desipramine Inhibition of desipramine
morphine
Propoxyphene Carbamazepine Increased carbamazepine action
Metoprolol, propranolol Increased plasma level of these
beta blockers

55
Fear of Opioid Addiction

It is known that many health workers are seriously concerned about opioid addiction
in managing pain. Addiction is a psychological disorder of drug craving and
compulsive drug use. This kind of addiction is known to be very rare in people who
take opioids for illness. Tolerance, the need for increasing doses of an Opioid to
maintain its effects, is however common. Physical dependence, body becomes used
to having an Opioid present, happens to everyone who uses opioids for more than a
few days. Thus, opioids should never be stopped suddenly; should be weaned over
a few days if they are going to be stopped. If they are stopped suddenly, you may
have withdrawal - a very uncomfortable flu-like syndrome including muscle aches,
nausea, diarrhea, and sometimes vomiting or even muscle spasms. If a person
suddenly cannot take opioids by mouth, the weaning needs to be done by rectal
suppository or intravenous infusion.   Inappropriate fear of addiction among health
workers is a common problem worldwide associated with legitimate efforts to prevent
drug abuse, preoccupation with only the risks of drug use, widespread confusion
about the meaning of "addiction," and health care workers' lack of knowledge about
opioid pharmacology25.

Three Steps to Confront Fear of Addiction:

1. Know the facts. Addiction is very rare when treating cancer pain with opioids;
Opioid analgesics such as morphine and its derivatives are safe and effective
when prescribed by a trained health care professional.
2. Ensure that you have a good working knowledge of the mechanisms of action
of opioids and their side-effects in case management.
3. Be prepared to tell everyone but especially patients and families the facts
about pain management in relation to addiction.

25
http://www.whocancerpain.wisc.edu/eng/11_3/fear.html

56
Signs of Addiction

The development of addiction is signaled by the presence of certain drug-taking

behaviors such as loss of control over drug use, compulsive use of drugs for their
mood-altering effects and continued use despite harm. Table 13 presents behaviors
which are more predictive and less predictive of addiction.
 
Table 13. Behaviors Predictive of Addiction in Patients Receiving Opioids for
Pain26
More Predictive Less Predictive
Selling prescription drugs Requesting more or stronger analgesics
Hoarding drugs when symptoms are
Forging prescriptions
less
Stealing drugs Requesting specific drugs
Acquiring analgesics from more than
Injecting oral formulations
one source
Buying prescription drugs from illicit Unapproved dose escalation once or
sources twice
Unapproved use of drug to treat other
Abusing illicit drugs
symptoms
Multiple dose escalations despite Reporting psychic effect not intended
warnings by physician
Multiple episodes of prescription loss
 

26
Portenoy, RK. Opioid therapy for chronic nonmalignant pain: Clinicians' perspective. J Law Med
Ethics 1996; 24: 301.

57
 SECTION V:
APENDICIES: ADDITIONAL
REFERNCE MATERIALS

58
Appendix 1: Estimated Relative Potencies and Dosages of
Opioids*

Drug Potency Ratio Analgesic Dose Anesthetic Dose

Morphine 1 10 mg 1-5 mg.kg-1
Meperidine 0.1 100 mg -
Fentanyl 100 100 µg 50-150 µg.kg-1
Sufentanil 500-1000 10-20 µg 5-20 µg.kg-1
Alfentanil 10-20 500-1000 µg 100-200 µg.kg-1
Pentazocine 0.3-0.5 30-50 mg -
Butorphanol 5 203 mg -
Nalbuphine 1 10 mg -
Buprenorphine 30 0.3 mg -
Dezocine 1 10 mg -
Potency ratios and doses are estimates relative to morphine and are
intended only as guidelines.

59
Appendix 2: Barriers to Effective Pain Management

Barriers to effective pain management are imposed by the health care system,
physicians, and by patients themselves. The major barriers under each jurisdiction
are described below:

 Reluctance to report pain to physicians

 Reluctance to take pain medication
 Lack of education regarding available pain therapies
Patient Barriers
 Compromised cognitive function secondary to certain
pain medications
 Fear of addiction
 Other side drug effects

 Inadequate training and knowledge concerning pain

management
 Improper assessment of pain
Health Care  Concern about scrutiny from regulatory agencies
Provider Barriers  Fear of patient addiction
 Concern regarding analgesic side effects
 Concern regarding the development of tolerance to
analgesics
 Misbelieve that patients are not in pain

60
Appendix 3: Steps in the Management of Chronic Pain

61
Appendix 4: Management of Ongoing Chronic Pain

62
Appendix 5: Tips for Using Opioids for Pain Relief

Dosing schedule and titration:

 Prevent pain with proper dosing
 Titrate to pain relief – doses are individualized. The right dose is
whatever it takes to relieve the pain with the least amount of side
effects/toxicity
 Long-acting opiates should be used for long-term pain

Conversion/equianalgesic dosing:
 Morphine 10 mg sc/im = 20 mg oral solution
 Hydromorphone 4 mg sc/im = 8 mg oral
 When switching from one opiate to another, reduce the dose by 1/3 due
to incomplete crossover tolerance and titrate from that dose

Delivery formulations:
 Morphine: concentrated oral immediate release solutions, suppository,
short and long-acting oral pills, IV and im/sc
 Oxycodone: with or without aspirin and acetaminophen, long and short-
acting formulations (Q12h and Q4h)
 Hydromorphone: suppository, short-acting pill, IV, im/sc
 Fentanyl: short-acting lollipop and long-acting patch (q48-72h)
 Meperidine: not recommended when doses of >300 mg/day are needed
as can lead to tremors, restlessness and seizures; oral form is equivalent
to acetaminophen and should be avoided

Tips with long-acting oral opiates:

 Do not crush or break
 Hydration is important
 Supplement with short-acting opiates for break-through pain
 Dolophine (methadone) should be given q6h and titrated very slowly to
avoid accumulation due to long half-life

Topical fentanyl:
 Used cautiously if patient is febrile
 Do not apply topical fentanyl to broken skin

Opioid rotation for chronic pain and long-term therapy:

 When a patient is on opiates for several months, tolerance often
develops and improved pain control can be achieved by rotating to an
alternate opiate – for example, going from long-acting oxycodone to long-
acting morphine and then to the fentanyl patch

63
Appendix 6: Use of Combination of Drugs in Pain Management

64

(Morphine)
Appendix 7: Drug Management for Special Pain Problem

65
Appendix 8: Detailed Evaluation of Pain
History
 Pain history: Chronology of the
presenting complaint. Mechanism of
onset and Characterization of pain
 Location of pain; referral/radiation
 Quality of pain (stabbing, burning,
aching, etc.). A pain diagram can be very
useful here
 Intensity of pain: a numeric pain rating
scale (0 = no pain; 10 = worst pain
imaginable) provides a frame of
reference
 Duration of pain
 Aggravating and relieving factors
 Additional symptoms: motor, sensory
and autonomic changes
 Impact of pain on sleep, mood, work,
activities of daily living, social function
 Special needs of elderly patients and
those with dementia
 History of treatment: previous surgical,
pharmacological, physical, psychological,
and other treatments and their
effectiveness
 Psychological history: screen for anxiety
and depression, addiction, somatoform
disorder, personality disorder, other prior
psychiatric diagnoses, coping style, and
personality traits
 Vocational and medical legal issues and
related
 General medical history
 Patient’s ideas about the cause of pain
 Patient’s goals for evaluation and
treatment
Examination
 Musculoskeletal examination: posture and gait
 Joint examination: symmetry, range of motion, size,
ligamentous stability, provocative maneuvers
 Spinal examination: symmetry, range of motion,
focal tenderness, provocative maneuvers
 Muscular examination: symmetry, tenderness,
tender points (for fibromyalgia), trigger points (taut
bands or “knots” palpable in muscle), and strength
 Neurological examination:
o Mental status and cranial nerves
o Sensation: touch, pressure, pinprick, heat,
cold, vibration. In neuropathic pain, there
may be findings of decreased sensation or
of increased response to painful stimuli
(hyperalgesia). Pain from normally
nonpainful stimuli is called allodynia
o Reflexes: deep tendon, pathological
 Psychological examination:
o Basic screening for depression, anxiety,
and substance abuse can be conducted
during the history interview
o For patients with complex pain problems
and/or significant prior psychiatric histories,
a detailed psychological evaluation,
conducted by a psychiatrist or psychologist,
is recommended
o For pain patients with a history of alcohol or
other drug addiction, an evaluation by a
certified addiction counselor or an addiction
medicine physician is recommended prior to
the initiation of chronic opioid analgesic
therapy
o Assessment of function: abilities and
deficits
66
Appendix 9: List of Additional Pain Assessment Tools
Assessment Tool
The Oucher Scale (AKA
Faces Rating Scale or
Smiley Analogue Scale)
The Poker Chip Scale
Analogue Chromatic
Continuous Scale (ACCS)
Assessment
Tools for Body Outlines
Children
The Children's Hospital of
Eastern Ontario Pain Scale
(CHEOPS)
The Breakthrough Pain
Questionnaire (Portenoy et
al, 1999)
Brief Pain Inventory
(Cleeland 1994)
City of Hope Mayday Pain
Resource Center Patient
Pain Questionnaire
Integrated Pain Score
(Ventafridda 1983)
McGill Pain Questionnaire
(Melzack 1975), Short-
Form McGill Pain
Questionnaire (Melzack
1987)
Memorial Pain Assessment
Assessment Card (Fishman 1987)
Tools for Adults
Pain as assessed in the
Medical Outcomes Study
(Hays 1990)
Pain Disability Index (Tait
et al. 1987)
Pain Management Index
(Cleeland et al. 1994)
Description
Depicts a range of numbered faces that the
child can relate to. This scale can be used in
all verbal children. As young as ages 3–5
Quantitates the child's pain by the number of
chips (0–4) he/she/ selects, "pieces of hurt"
This system potentially is useful for children
as young as 3 years old. Children tend to
associate red & black with increased pain
sensation. (The back is ruled for easy
scoring)
A useful tool that allows children to color the
area that hurts. Coloring is a favorite pastime
for children. They tend to associate blue with
cold and red with hot. What color is pain?
Is based on observation of child behavior by
physicians or nurse. The scale assigns a
point score to 6 categories of behavior and
the total score is supposed to correlate with
pain. It’s not too reliable. Note: crying can be
caused by pain, hunger, frustration, restraints
or anxiety
An instrument with explicit questions
identifying patients with breakthrough pain
Quantitates the child's pain by the number of
chips (0–4) he/she/ selects, "pieces of hurt"
A 16 item ordinal scale that measures a
patient’s knowledge and experience in
managing chronic cancer pain
An instrument designed to take into account
both pain intensity and pain duration
Questionnaires incorporating a series of
adjectives to describe the characteristics and
intensity of pain
A two-sided card that measures pain intensity
and the patient’s mood on one side, and has
a modified version of the Tursky Pain
Description Scale on the other
Pain is measured in terms of its severity,
duration, frequency, and impact on behavior
and mental well being
An instrument designed to measure the
impact of chronic pain on various daily
activities. The instrument has been employed
in a study which examined physical and
psychological morbidity after node dissection
for breast cancer
Compares the most potent analgesic with
reported level of pain. The PMI has been
employed in a study examining treatment for
chronic cancer pain (de Wits et al. 1999)
67
Appendix 10: Common Pain Problems in Cognitively Impaired
Persons

Common Pain Behaviors in Cognitively Impaired Elderly Person

Facial Expression
Verbalization and
Vocalization
Body Movements
Changes in Interpersonal
Interaction
Change in the Activity
Pattern or Routines
Mental Status Change
Note: Some patients demonstrate little or no specific behavior associated with
severe pain. Source AGS Panel on Persistent Pain in Older person .The
management of persistent pain in older person. J Am Geriatr Soc 2002;50 S205-
S224
 Slight frown, sad, frightened face
 Grimacing
 Wrinkled forehead
 Closed or tightened eyes
 Any distorted expression
 Rapid blinking
 Sighing, moaning, groaning
 Grunting
 Chanting
 Calling out
 Noisy breathing
 Asking for help
 Verbally abusive
 Rigid, tense body posture
 Guarding
 Fidgeting
 Increased pacing, rocking
 Restricted movement
 Gait or mobility change
 Aggressive, combative, resisting care
 Decreased social interaction
 Socially inappropriate, disruptive
 Withdrawn
 Refusing food, appetite change
 Increased rest period
 Sleep, rest pattern change
 Sudden cessation of common routines
 Increased wandering
 Crying or tears
 Increased confusion
 Irritability or distress

68
Appendix 11: Drug Formulary for Analgesics
Pain can be classified as acute or chronic.
 Acute pain: It is usually of short duration and the cause often identifiable
(disease, trauma)
 Chronic pain: It persists after healing is expected to be complete, or is
caused by a chronic disease
Pain may be modified by psychological factors and attention to these is essential in
pain management. Drug treatment aims to modify the peripheral and central
mechanisms involved in the development of pain. Neurogenic pain generally
responds poorly to conventional analgesics; treatment can be difficult and includes
the use of carbamazepine for trigeminal neuralgia and amitriptyline for diabetic
neuropathy and postherpetic neuralgia.

Non-opioid analgesics are particularly suitable for pain in musculoskeletal conditions

whereas the opioid analgesics are more suitable for moderate to severe visceral
pain. Those non-opioid analgesics which also have anti-inflammatory actions include
salicylates and NSAIDs (nonsteroidal anti-inflammatory drugs); they can reduce both
pain and inflammation of chronic inflammatory disorders such as rheumatoid
arthritis, but they do not alter or modify the disease process itself.

1. Non-opioid Analgesics

Non-opioid analgesics with anti-inflammatory activity include salicylates such as

acetylsalicylic acid and other nonsteroidal anti-inflammatory drugs such as ibuprofen.
Non-opioid analgesics with little or no anti-inflammatory activity include paracetamol.
1.1. Acetylsalicylic acid

The principal effects of acetylsalicylic acid are anti-inflammatory, analgesic,

antipyretic and antiplatelet. Oral doses are absorbed rapidly from the gastrointestinal
tract; rectal absorption is less reliable but suppositories are useful in patients unable
to take oral dosage forms. Acetylsalicylic acid is used for the management of mild to
moderate pain such as headache, acute migraine attacks, transient musculoskeletal
pain and dysmenorrhoea, and for reducing fever. Although it may be used in higher
doses in the management of pain and inflammation of rheumatoid arthritis, other
NSAIDs are preferred because they are likely to be better tolerated.
Adverse effects with analgesic doses are generally mild but include a high incidence
of gastrointestinal irritation with slight blood loss, bronchospasm and skin reactions
in hypersensitive patients, and increased bleeding time. Anti-inflammatory doses are
associated with a much higher incidence of adverse reactions, and they also cause
mild chronic salicylism which is characterized by tinnitus and deafness.
Acetylsalicylic acid is contraindicated for children under 12 years, unless specifically
indicated for juvenile arthritis, because of an association with Reye syndrome
(encephalopathy and liver damage).

69
 Acetylsalicylic acid
Tablets, acetylsalicylic acid 300 mg
Dispersible tablets, acetylsalicylic acid 300 mg
Suppositories, acetylsalicylic acid 150 mg, 300 mg
Uses: Mild to moderate pain including dysmenorrhoea, headache; pain and
inflammation in rheumatic disease and other musculoskeletal disorders
(including juvenile arthritis); pyrexia; also acute migraine attack; antiplatelet
Contraindications: Hypersensitivity (including asthma, angioedema, urticaria
or rhinitis) to acetylsalicylic acid or any other
NSAID; children under 12 years (Reye syndrome) unless for juvenile arthritis
(Still disease); gastrointestinal ulceration; haemophilia and other bleeding
disorders; gout
Precautions: Asthma, allergic disease; impaired renal or hepatic function;
pregnancy; breastfeeding; elderly; to avoid risk of haemorrhage do not
administer within 7 days of surgery; G6PDdeficiency; dehydration.
Dosage: Mild to moderate pain, pyrexia, by mouth with or after food, ADULT
300–900 mg every 4–6 hours if necessary; maximum 4 g daily; CHILD
contraindicated under 12 years Mild to moderate pain, pyrexia, by rectum,
ADULT 600–900 mg inserted every 4 hours if necessary; maximum 3.6 g
daily;
CHILD contraindicated under 12 years
Inflammatory arthritis, by mouth with or after food, ADULT 4–8 g daily in
divided doses in acute conditions; up to 5.4 g daily may be sufficient in
chronic conditions Juvenile arthritis, by mouth with or after food, CHILD up to
130 mg/kg body weight daily in 5–6 divided doses in acute conditions; 80–100
mg/kg body weight daily in divided doses for maintenance
Adverse effects: Generally mild and infrequent for lower doses, but common
with anti-inflammatory doses; gastrointestinal discomfort or nausea, ulceration
with occult bleeding (occasionally major haemorrhage); also other
haemorrhage (including subconjunctival); hearing disturbances such as
tinnitus (rarely deafness), vertigo, confusion, hypersensitivity reactions
(angioedema, bronchospasm and rash); increased bleeding time; rarely
edema, myocarditis, blood disorders (particularly thrombocytopenia)

1.2. Paracetamol

Paracetamol is similar in analgesic and antipyretic efficacy to acetylsalicylic acid. It is

used for mild to moderate pain including headache and acute migraine attacks
(section 7.1) and for reducing fever, including post-immunization pyrexia.
Paracetamol is particularly useful in patients in whom salicylates or other NSAIDs
are contraindicated, such as asthmatics and those with a history of peptic ulcer, or

70
for children under the age of 12 years in whom salicylates are contraindicated
because of the risk of Reye syndrome. It is generally preferred to acetylsalicylic acid,
particularly in the elderly, because it is less irritant to the stomach. Unlike
acetylsalicylic acid and other NSAIDs, paracetamol has little anti-inflammatory
activity which limits its usefulness for long term treatment of pain associated with
inflammation; however it is useful in the management of osteoarthritis, a condition
with only a small inflammatory component. In normal doses adverse effects are rare,
but over dosage with a single dose of 10–15 g is particularly dangerous because it
may cause hepatocellular necrosis and, less frequently, renal tubular necrosis.

Paracetamol
Tablets, paracetamol 500 mg
Dispersible tablets, paracetamol 120 mg, 500 mg
Oral solution, paracetamol 120 mg/5 ml, 250 mg/5 ml Suppositories,
paracetamol 60 mg, 100 mg, 125 mg, 250 mg, 500 mg
Uses: mild to moderate pain including dysmenorrhoea, headache; pain relief
in osteoarthritis and soft tissue lesions; pyrexia including post-immunization
pyrexia; also acute migraine attack (section 7.1)
Precautions: hepatic impairment (Appendix 5); renal impairment; alcohol
dependence; pregnancy and breastfeeding
Dosage: Post-immunization pyrexia, by mouth, INFANT 2–3 months, 60 mg
followed by a second dose, if necessary, 4–6 hours later; warn parents to
seek medical advice if pyrexia persists after second dose Mild to moderate
pain, pyrexia, by mouth, ADULT 0.5–1 g every 4–6 hours, maximum 4 g daily;
CHILD 3 months–1 year 60–120 mg, 1–5 years 120–250 mg, 6–12 years
250–500 mg, these doses may be repeated every 4–6 hours if necessary
(maximum 4 doses in 24 hours)
Mild to moderate pain, pyrexia, by rectum, ADULT 0.5–1g; CHILD 1–5 years
125–250 mg, 6–12 years 250–500 mg; doses inserted every 4–6 hours if
necessary, maximum 4 doses in 24 hours
NOTE. Infants under the age of 3 months should not be given paracetamol
unless advised by a doctor; a dose of 10 mg/kg (5 mg/kg if jaundiced) is
suitable.
Adverse effects: rare, but rashes, blood disorders; acute pancreatitis
reported after prolonged use; important: liver damage (and less frequently
renal damage) following over dosage
1.3. Other NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

NSAIDs, including ibuprofen, have analgesic, anti-inflammatory and antipyretic

properties. In single doses NSAIDs have analgesic activity comparable to that of
paracetamol. In regular full dosage, they have a lasting analgesic and anti-
inflammatory effect, which makes them useful for continuous or regular pain due to
inflammation. Differences in anti-inflammatory activity between different NSAIDs are
small but there is considerable variation in individual patient response and in the
incidence and type of adverse effects. Ibuprofen has fewer adverse effects than
other NSAIDs but its anti-inflammatory properties are weaker. Ibuprofen is used in

71
the treatment of mild to moderate pain and in the management of pain and
inflammation in rheumatoid arthritis and juvenile arthritis. It may also be of value in
the less well-defined conditions of back pain and soft-tissue disorders. Ibuprofen is
also used to reduce pain and fever in children. With all NSAIDs caution should be
exercised in the treatment of the elderly, in allergic disorders, during pregnancy and
breastfeeding. In patients with renal, cardiac or hepatic impairment, the dose should
be kept as low as possible and renal function should be monitored. NSAIDs should
not be given to patients with active peptic ulceration and used with caution in those
with a history of the disease. The commonest adverse effects are generally
gastrointestinal including nausea, vomiting, diarrhoea, dyspepsia; hypersensitivity
reactions including anaphylaxis, bronchospasm, rash; also fluid retention.

1.3.1. Ibuprofen
Ibuprofen is a representative nonsteroidal anti-inflammatory drug (NSAID).
Various drugs can serve as alternatives
Tablets, ibuprofen 200 mg, 400 mg, 600 mg, 800 mg
Oral suspension, ibuprofen 100 mg/5 ml
Uses: pain and inflammation in rheumatic disease and other musculoskeletal
disorders including juvenile arthritis; mild to moderate pain including
dysmenorrhoea, headache; fever and pain in children; also acute migraine
attack
Contraindications: hypersensitivity (including asthma, angioedema, urticaria
or rhinitis) to acetylsalicylic acid or any other NSAID; active peptic ulceration
Precautions: renal and hepatic impairment; history of peptic ulceration;
cardiac disease; elderly; pregnancy and breastfeeding; coagulation defects;
allergic disorders.
Dosage: Mild to moderate pain, pyrexia, inflammatory musculoskeletal
disorders, by mouth with or after food, ADULT 1.2–1.8 g daily in 3–4 divided
doses, increased if necessary to maximum 2.4 g daily; maintenance dose of
0.6–1.2 g daily may be sufficient Juvenile arthritis, by mouth with or after food,
CHILD over 7 kg, 30–40 mg/kg body weight daily in 3–4 divided doses
Fever and pain in children (not recommended for child under 7 kg body
weight), by mouth with or after food, 20–30 mg/kg body weight daily in divided
doses or 1–2 years 50 mg 3–4 times daily, 3–7 years 100 mg 3–4 times daily,
8–12 years 200 mg 3–4 times daily
Adverse effects: gastrointestinal disturbances including nausea, diarrhoea,
dyspepsia, gastrointestinal haemorrhage; hypersensitivity reactions including
rash, angioedema, bronchospasm; headache, dizziness, vertigo, tinnitus,
photosensitivity, haematuria; fluid retention, renal failure; rarely hepatic
damage, alveolitis, pulmonary eosinophilia, pancreatitis, visual disturbances,
erythema multiforme (Stevens-Johnson syndrome), toxic dermal necrolysis
(Lyell syndrome), colitis, aseptic meningitis

72
 1.3.2. Diclofenac 27

Indications: Relief of pain and inflammation in rheumatic disease, and in a

wide variety of other conditions including gout.
Pharmacokinetics: Oral absorption is rapid and complete, the rate, but not
the extent, decreased by food. T½ = 1-2 hours; protein binding, 99%.
Metabolized in the liver, almost half being eliminated via first-pass
metabolism. 40-65% is excreted renally and 35% via bile, little or none as
unchanged drug.
Precautions:
Contraindications: Absolute - hypersensitivity to aspirin or other NSAIDs;
active peptic ulceration. Suppositories are contraindicated in patients with
proctitis or haemorrhoids. Relative - history of dyspepsia or peptic ulceration;
in the elderly, and in patients with renal or hepatic impairment,
atherosclerosis, compromised cardiac function, angina, hypertension,
bleeding disorders, asthma, atopy, nasal polyps or urticaria.
Drug interactions: Apply to all the NSAIDs:
Oral anticoagulants: Enhanced risk of bleeding. If the combination is
needed, ibuprofen or naproxen may be preferable but caution should
nevertheless be exercised.
Other anti-inflammatory agents: Potential for ulcerogenicity and other
adverse effects may be additive.
Glucocorticosteroids: May enhance the potential toxicity of both
medications.
Lithium: Possibly all NSAIDs, but indometacin in particular, may decrease
renal clearance and increase lithium serum levels.
Digoxin: Monitor for an altered response to digoxin.
Antihypertensive, antiangina, anti-cardiac failure or diuretic therapy:
Efficacy may be markedly attenuated.
Sulphonylureas, sulphonamides, hydantoins, verapamil and nifedipine:
Being highly plasma protein bound, the NSAIDs may displace such agents
from protein-binding sites, and clinicians should consider the potential for
increased effects.
Probenecid: May inhibit the renal excretion of the NSAIDs.
Agents causing hypoprothrombinaemia and/or inhibition of platelet
aggregation, e.g. the penicillin’s, cefamandole, dipyridamole and valproic acid:
May enhance the risk of bleeding problems with a NSAID.
Pregnancy: Crosses the placenta; the use of NSAIDs is not recommended.
Administration, particularly during the third trimester, has been associated
with a prolonged gestation period and prolonged labor, increased risk of
antepartum and postpartum bleeding, and premature closure of the ductus
arteriosus.

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73
Lactation: Amounts excreted in breast milk with usual doses are considered
too small to be harmful to the nursing infant.
Porphyria: May prove unsafe: use with extreme caution.
Geriatrics: Increased risk of GI disturbances, renal or hepatotoxicity; reduced
dosage and monitoring of patients over 70 yrs of age recommended.
Pediatrics: Not recommended for general analgesic purposes. It has been
used with good effect for juvenile chronic arthritis in a limited number of
cases.
Adverse effects: Frequently - gastric effects ranging from mild irritation to
erosion, peptic ulceration (mainly gastric ulcers) and bleeding; fluid and
sodium retention.
Hypersensitivity reactions are usually manifested by bronchospasm, skin
rashes, pruritus, urticaria and angioedema, and may be precipitated in
patients who are sensitive to aspirin or other NSAIDs.
CNS effects include headache, dizziness, drowsiness and depression.
Nephrotoxicity and renal insufficiency may occur, particularly in the elderly
and in patients with pre- existing renal disease or SLE.
Hepatic dysfunction (mild increases in liver enzymes) occurs occasionally;
irreversible hepatic damage is rare.
Platelet aggregation may be inhibited. Haematological disorders such as
aplastic or haemolytic anaemia, agranulocytosis and thrombocytopenia have
rarely been reported.
Other adverse effects include, toxic amblyopia, blurred vision and tinnitus.
Local irritation may follow insertion of rectal suppositories.

Special Prescriber's Points

 Symptoms of infection may be masked by the use of NSAIDs
 GI irritation may be diminished by administration with food or milk
 Concomitant use of alcohol may aggravate GI irritation
 A doctor should be consulted if persistent dyspeptic symptoms, black
stools, visual disturbances, skin rashes and other signs of adverse
effects occur
 Drowsiness or dizziness may impair ability to drive a car or perform
other tasks requiring alertness; patients should be warned to exercise
caution
 Use during demanding physical exertion may interfere with skeletal
muscle perfusion, and in the presence of dehydration renal toxicity
potential may be enhanced
Adult dose: Oral, 25-50 mg 3 times daily; the lower dosage range (75-100
mg/day) is indicated for long- term therapy, but patients with arthritic disorders
may require up to 150 mg/day. IM, in acute exacerbations of arthritic
conditions or in acute pain, 75 mg 1-2 times daily. Rectal, 100 mg usually at
night.

74
 * The maximum total dose (combined oral and rectal dose) should not exceed
150 mg.
* Doses should be reduced in the elderly and in patients with hepatic or renal
impairment.
Pediatric dose: Oral, 1-3 mg/kg/day, in 3 divided doses, has been used in
children > 2 years; not recommended for general analgesic purposes.
Preparations include: Diclofenac tablets, 25 mg, 50 mg, 75 mg, 100 mg
(sodium) inject, 75 mg/3 mL suppositories, 12.5 mg, 25 mg, 100 mg
drops, 15 mg/mL

1.3.3. Indometacin28

Indications: Relief of pain and inflammation in rheumatological disorders;

closure of patent ductus arteriosus in premature infants.
Pharmacokinetics: Oral absorption is rapid and almost completes the rate
but not the extent decreased by food and antacids. The bioavailability of
rectal suppositories is comparable to oral bioavailability. 99% is bound to
plasma proteins, mainly albumin. T½ is variable (2-11 hours) due to variation
in enterohepatic recycling. Undergoes conjugation in the liver; 60% is
excreted in urine (10-20% unchanged) and 33% in bile.

Precautions:
Contraindications: As for diclofenac; also, use with caution in patients with
epilepsy, parkinsonism or psychiatric disorders.
Drug interactions: As for diclofenac.
Pregnancy: Crosses the placenta; not recommended, especially during the
third trimester. See also diclofenac.
Lactation: Not recommended.
Porphyria: Use with caution.
Geriatrics: Increased risk of renal insufficiency, nephrotoxicity and adverse
CNS effects; reduced dose recommended.
Pediatrics: Safety in children under 14 years has not been established. If
used in juvenile chronic arthritis, liver function should be monitored
periodically as hepatotoxicity (sometimes fatal) has occurred.
Adverse effects: As for diclofenac. Indometacin is more inclined to cause GI
disturbances (in 3-9% of patients), CNS effects such as dizziness,
drowsiness, mental depression, headache (in > 10% of patients) and
confusion.
Corneal deposits and retinal disturbances may be complications of prolonged
exposure.
Special Prescriber's Points:
 See also diclofenac.
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75
  Ophthalmic examinations and blood counts are advisable with
prolonged treatment.
 The rectal route may be better tolerated by some patients than oral
administration. However, local irritation of the rectum may occur and
the potential for upper gastrointestinal irritation remains.
Adult dose: Arthritic disorders: Oral, 25 mg 2-3 times daily, increased if
needed to 150 mg/day in divided doses. To relieve night pain or morning
stiffness, 100 mg of the total dose can be taken at bedtime. The low dosage
range may be adequate for maintenance. Sustained-release capsules may
be administered once or twice daily. Rectal, 100 mg at bedtime, and again in
the morning if necessary. Acute gout: Initially 50-100 mg, then 50 mg 3 or 4
times daily. Antipyretic: Oral, 25-50 mg 3 times daily.
* The total daily dose (oral plus rectal dose) should not exceed 200 mg.
* Doses should be reduced in the elderly, and in patients with cardiac, hepatic
or renal impairment.
Antirheumatic, if benefits outweigh risks: Oral, 1.5-2.5 mg/kg/day in 3-4
divided doses; maximum 4 mg/kg/day up to 150-200 mg/day.
Patent ductus arteriosus, if adequate renal, haematological and liver functions
are demonstrated: Course of 3 doses at 12-24 hour intervals. First dose, IV,
0.2 mg/kg regardless of age. Second and third doses depend on age at time
of first dose: < 48 hours, 0.1 mg/kg; 2-7 days, 0.2 mg/kg; > 7 days, 0.25
mg/kg.
Preparations include: Indometacin capsules, 25 mg
sustained-release capsules, 75 mg, suppositories, 100 mg
gel, 1%

2. Opioid Analgesics
Morphine and pethidine are opioid analgesics which are effective in relieving
moderate to severe pain, particularly of visceral origin; there is a large variation in
patient response. Weaker opioids such as codeine are suitable for mild to moderate
pain.
Morphine remains the most valuable analgesic for severe pain. In addition to pain
relief it confers a state of euphoria and mental detachment; repeated administration
may cause dependence and tolerance, but this should not be a deterrent in the
control of pain in terminal illness .In normal doses common adverse effects include
nausea, vomiting, constipation and drowsiness; larger doses produce respiratory
depression and hypotension.
Pethidine produces prompt but short-acting analgesia; it is less constipating than
morphine, but even in high doses it is less effective. A neurotoxic metabolite,
norpethidine, accumulates during repeated administration and can cause central
nervous system excitation, including myoclonus and seizures. These adverse effects
together with the short duration of analgesic action make pethidine unsuitable for
severe, continuing pain. It is used for analgesia in labour; however other opioid
analgesics such as morphine are often preferred.

76
Codeine is an opioid analgesic much less potent than morphine and much less
liable, in normal doses, to produce adverse effects including dependency. It is
effective for mild to moderate pain but is too constipating for long-term use.

2.1. Morphine
Tablets, morphine sulfate 10 mg
Oral solution, morphine hydrochloride or sulfate 10 mg/5 ml Injection, morphine
sulfate 10 mg/ml, 1-ml ampoule
Uses: severe pain (acute and chronic); myocardial infarction, acute pulmonary
oedema; also adjunct during major surgery and postoperative analgesia (section
1.5)
Contraindications: acute respiratory depression, acute alcoholism, where riskof
paralytic ileus; acute abdomen; raised intracranial pressure or head injury
(interferes with respiration, also affects pupillary responses vital for neurological
assessment); avoid injection in phaeochromocytoma
Precautions: renal and hepatic impairment; reduce dose or avoid in elderly and
debilitated; dependence (severe withdrawal symptoms if withdrawn abruptly);
hypothyroidism; convulsive disorders; decreased respiratory reserve and acute
asthma; hypotension; prostatic hypertrophy; pregnancy and breastfeeding;
Dosage: Acute pain, by subcutaneous injection (not suitable for oedematous
patients) or by intramuscular injection ADULT 10 mg every 4 hours if necessary
(15 mg for heavier well muscled patients); INFANT up to 1 month 150
micrograms/kg body weight, 1–12 months 200 micrograms/kg body weight;
CHILD 1–5 years 2.5–5 mg, 6–12 years 5–10 mg
Chronic pain, by mouth or by subcutaneous injection (not suitable for
oedematous patients) or by intramuscular injection 5–20 mg regularly every 4
hours; dose may be increased according to need; oral dose should be
approximately double corresponding intramuscular dose Myocardial infarction, by
slow intravenous injection (2 mg/ minute), 10 mg followed by a further 5–10 mg if
necessary; elderly or debilitated patients, reduce dose by half Acute pulmonary
oedema, by slow intravenous injection (2 mg/minute), 5–10 mg
NOTE. The doses stated above refer equally to morphine sulfate and
hydrochloride
Adverse effects: nausea, vomiting (particularly in initial stages) constipation;
drowsiness; also dry mouth, anorexia, spasm of urinary and biliary tract;
bradycardia, tachycardia, palpitations, euphoria, decreased libido, rash, urticaria,
pruritus, sweating, headache, facial flushing, vertigo, postural hypotension,
hypothermia, hallucinations, confusion, dependence, miosis; larger doses
produce respiratory depression and hypotension

2.2. Pethidine Hydrochloride

Tablets, pethidine hydrochloride 50 mg, 100 mg
Injection, pethidine hydrochloride 50 mg/ml, 1-ml ampoule

77
 Uses: moderate to severe pain; also adjunct during major surgery and
postoperative analgesia, obstetric analgesia.
Contraindications: severe renal impairment; acute respiratory depression, acute
alcoholism, where risk of paralytic ileus; acute abdomen; raised intracranial
pressure or head injury (interferes with respiration, also affects pupillary
responses vital for neurological assessment); avoid injection in
phaeochromocytoma (risk of pressor response to histamine release)
Precautions: not suitable for severe continuing pain; hepatic impairment,
moderate renal impairment; reduce dose or avoid in elderly and debilitated;
dependence (severe withdrawal symptoms if withdrawn abruptly);
hypothyroidism; convulsive disorders; asthma and decreased respiratory reserve;
hypotension; prostatic hypertrophy; pregnancy; and breastfeeding.
Dosage: Acute pain, by mouth, ADULT 50–150 mg every 4 hours; CHILD 0.5–2
mg/kg body weight By subcutaneous or intramuscular injection ADULT 25–100
mg, repeated after 4 hours; CHILD by intramuscular injection, 0.5–2 mg/kg body
weight. By slow intravenous injection, 25–50 mg, repeated after 4 hours
Adverse effects: nausea, vomiting (particularly in initial stages), constipation;
drowsiness; also dry mouth, anorexia, spasm of urinary and biliary tract;
bradycardia, tachycardia, palpitations, euphoria, decreased libido, rash, urticaria,
pruritus, sweating, headache, facial flushing, vertigo, postural hypotension,
hypothermia, hallucinations, confusion, dependence, miosis; larger doses
produce respiratory depression and hypotension;
Important: convulsions reported in overdosage.

2.3 Codeine Phosphate

Tablets, codeine phosphate, 30 mg
Uses: mild to moderate pain; also diarrhea
Contraindications: respiratory depression, obstructive airways disease, acute
asthma attack; where risk of paralytic ileus
Precautions: renal and hepatic impairment; dependence; pregnancy;
breastfeeding
Dosage: Mild to moderate pain, by mouth, ADULT 30–60 mg every 4 hours when
necessary to a maximum of 240 mg daily; CHILD 1–12 years, 3 mg/kg daily in
divided doses
Adverse effects: constipation particularly troublesome in long term use;
dizziness, nausea, vomiting; difficulty with micturition; ureteric or biliary spasm;
dry mouth, headaches, sweating, facial flushing; in therapeutic doses, codeine is
much less liable than morphine to produce tolerance, dependence, euphoria,
sedation or other adverse effects.

3. Other Drugs

3.1. Carbamazepine

78
 Tablets, carbamazepine 100 mg, 200 mg
Uses: generalized tonic-clonic and partial seizures; trigeminal neuralgia; bipolar
disorder
Contraindications: atrioventricular conduction abnormalities; history of bone-
marrow depression; porphyria
Precautions: hepatic impairment; renal impairment; cardiac disease (see also
Contraindications); skin reactions (see Adverse effects); history of blood
disorders (blood counts before and during treatment); glaucoma; pregnancy;
breastfeeding; avoid sudden withdrawal
Interactions: Blood, Hepatic or Skin Disorders. Patients or their care givers
should be told how to recognize signs of blood, liver or skin disorders, and
advised to seek immediate medical attention if symptoms such as fever, sore
throat, rash, mouth ulcers, bruising or bleeding develop. Leukopenia which is
severe, progressive and associated with clinical symptoms requires withdrawal (if
necessary under cover of suitable alternative) SKILLED TASKS. May impair
ability to perform skilled tasks, for example operating machinery and driving.
Dosage: Generalized tonic-clonic seizures, partial seizures, by mouth, ADULT
initially 100 mg twice daily, increased gradually according to response to usual
maintenance dose of 0.8–1.2 g daily in divided doses; ELDERLY reduce initial
dose; CHILD 10–20 mg/kg daily in divided doses
Trigeminal neuralgia, by mouth, ADULT initially 100 mg 1–2 times daily increased
gradually according to response; usual dose 200 mg 3–4 times daily with up to
1.6 g daily in some patients
NOTE. Plasma concentration for optimum response 4–12 mg/litre (17–50
micromol/litre)
Adverse effects: dizziness, drowsiness, headache, ataxia, blurred vision,
diplopia (may be associated with high plasma levels); gastrointestinal intolerance
including nausea and vomiting, anorexia, abdominal pain, dry mouth, diarrhoea
or constipation; commonly, mild transient generalized erythematous rash
(withdraw if worsens or is accompanied by other symptoms); leukopenia and
other blood disorders (including thrombocytopenia, agranulocytosis and aplastic
anaemia); cholestatic jaundice, hepatitis, acute renal failure, Stevens-Johnson
syndrome (erythema multiforme), toxic epidermal necrolysis, alopecia,
thromboembolism, arthralgia, fever, proteinuria, lymph node enlargement,
arrhythmias, heart block and heart failure, dyskinesias, paraesthesia, depression,
impotence, male infertility, gynaecomastia, galactorrhoea, aggression, activation
of psychosis, photosensitivity, pulmonary hypersensitivity, hyponatraemia,
oedema, disturbances of bone metabolism with osteomalacia also reported;
confusion and agitation in elderly.

3.2. Amitriptyline Hydrochloride

Amitriptyline hydrochloride is a representative tricyclic antidepressant.

Tablets, amitriptyline hydrochloride 25 mg

Uses: moderate to severe depression

79
 Contraindications: recent myocardial infarction, arrhythmias (especially heart
block); manic phase in bipolar disorders; severe liver disease; children; porphyria
Precautions: cardiac disease (see Contraindications above), history of epilepsy;
pregnancy; breastfeeding; elderly; hepatic impairment; thyroid disease;
phaeochromocytoma; history of mania, psychoses (may aggravate psychotic
symptoms); angleclosure glaucoma, history of urinary retention; concurrent
electroconvulsive therapy; avoid abrupt withdrawal; anaesthesia (increased risk
of arrhythmias and hypotension)
Interactions: SKILLED TASKS. May impair ability to perform skilled tasks, for
example operating machinery, driving

Dosage: Depression, by mouth, ADULT initially 75 mg (elderly and adolescents 30–

75 mg) daily in divided doses or as a single dose at bedtime increased gradually as
necessary to 150 mg daily; CHILD under 16 years not recommended for depression
376 24.2.1: Drugs used in depressive disorders WHO Model Formulary 2002
Adverse effects: sedation, dry mouth, blurred vision (disturbance of
accommodation, increased intra-ocular pressure), constipation, nausea, difficulty in
micturition; cardiovascular adverse effects particularly with high dosage including
ECG changes, arrhythmias, postural hypotension, tachycardia,syncope; sweating,
tremor, rash and hypersensitivity reactions (urticaria, photosensitivity); behavioral
disturbances; hypomania or mania, confusion (particularly in elderly), interference
with sexual function, blood sugar changes; increased appetite and weight gain
(occasional weight loss); endocrine adverse effects such as testicular enlargement,
gynaecomastia and galactorrhoea; convulsions, movement disorders and
dyskinesias, fever, agranulocytosis, leukopenia, eosinophilia, purpura,
thrombocytopenia, hyponatraemia (may be due to inappropriate antidiuretic hormone
secretion); abnormal liver function test. In overdose, excitement, restlessness,
marked anticholinergic effects; severe symptoms including unconsciousness,
convulsions, myoclonus, hyperreflexia, hypotension, acidosis, respiratory and
cardiac depression with arrhythmias

80
Appendix 12. Kersa Hospital action plan to implement PFHI

No Intervention Activities/ Steps Person Time Frame

Responsible
1 Notifying the Presenting the plan to
Management Team implement the PFHI, for
the mgt. 12-8-19
Encouraging the mgt. to till
be invested in the plan. 26-8- 19
2 Forming official Pain The mgt. team will select
committee the committee 12-8-19
Official appointment till
letters will be handed 26-8- 19
3 Performing Baseline Reviewing Medical
Hospital Study Records 12-8-19
Distributing till
Questionnaires 31-8- 19
Interviewing Pts
4 Preparing Appropriate Incorporating pain in the
Documentation vital sign sheet. 12-8-19
Preparing visual aid tools till
and making them 12-9- 19
accessible
Preparing Hospital Pain
Protocol
5 Staff Training Informal Training on a
departmental basis 12-8-19
Providing one day formal till
training to all 12-9- 19
professionals
6 Availing Important pain Having Morphine in the 12-8-19
medication essential Drugs list Till
Monitoring the 30-9-19
availability of Drugs
Frequently
7 Auditing Performing Quarterly
Hospital Based study on 12-8-19
the Till
performance of the 30-9-19
program

81
Appendix 13. Vital sign sheet for kersa hospital Template

Name_____________________________________ age____________sex____________

D Ti Wei Heig BP T P RR Pain O2 Inp Outp Oth Sign

at me ght ht R Score Sa ut ut er
e t

Appendix 14 Pain Assessment in Advanced dementia Scale (PAINAD)

82
83
Glossary29
Abstinence: The voluntary self-denial of food, drink, or sex. Today, abstinence is commonly
taken to mean no sexual activity.

Substance abuse: The excessive use of a substance, especially alcohol or a drug. (There is
no universally accepted definition of substance abuse.)

Addiction: A chronic relapsing condition characterized by compulsive drug-seeking and

abuse and by long-lasting chemical changes in the brain.

Allodynia: Pain from stimuli which are not normally painful. The pain may occur other than
in the area stimulated. Allodynia means other pain

Analgesia: The inability to feel pain while still conscious. From the Greek an-, without +
algesis, sense of pain.

Chemotherapy: In the original sense, it is a chemical that binds to and specifically kills
microbes or tumor cells. The term chemotherapy was coined in this regard by Paul Ehrlich
(1854-1915).
In oncology, it is drug therapy for cancer and often called "chemo" for short.

Cognitive: Pertaining to cognition, the process of knowing and, more precisely, the process
of being aware, knowing, thinking, learning and judging. The study of cognition touches on
the fields of psychology, linguistics, computer science, neuroscience, mathematics, ethology
and philosophy.

Causalgia: Intense burning pain and sensitivity to the slightest vibration or touch, usually in
the hand or foot, at a site some distance removed from a wound that has healed. This
phenomenon was first described in 1872 by the American neurologist Silas Weir Mitchell
(1829-1914).

Dependence: the quality or state of being dependent upon or unduly subject to the influence

Nociceptor-Peripheral receptors for pain.

Neuralgia: Pain along the course of a nerve.

Neuropathy: Any and all disease or malfunction of the nerves

Tolerance:-1. The ability to endure unusually large doses of a drug or toxin.

2. Acquired drug tolerance, a decreasing response to repeated constant doses of a drug or
the need for increasing doses to maintain a constant response.

29
http://www.medterms.com/script/main/alphaidx.asp?p=a_dict

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