Essential

PAIN Pain Management

Workshop Manual 2016

Authors:
Dr Wayne Morriss
Dr Roger Goucke
ESSENTIAL PAIN MANAGEMENT

Workshop Manual

2nd Edition
2016

Wayne Morriss
Anaesthesiologist
Christchurch, New Zealand

Roger Goucke
Pain Medicine Physician
Perth, Western Australia

The Essential Pain Management Course has been developed with the support
of the Faculty of Pain Medicine, Australian and New Zealand College of
Anaesthetists
Essential Pain Management by Wayne Morriss and Roger Goucke is licensed under a
Creative Commons Attribution-NonCommercial 3.0 Unported License.

http://creativecommons.org/licenses/by-nc/3.0/

You are free to share (copy, distribute and transmit the work) and to remix (to adapt the
work). You must attribute the work (give the original authors credit). You may not use this
work for commercial purposes. For any reuse or distribution, you must make clear to others
the license terms of this work. Any of the above conditions can be waived if you get
permission from the copyright holder.

Title - Essential Pain Management

Subtitle: Workshop Manual
ISBN: 978-0-9873236-1-3
Format: Paperback
Publication Date: 08/2016

Acknowledgements

We wish to acknowledge the Australian and New Zealand College of Anaesthetists for
supporting the development of this course.

We are also grateful for the support of the Ronald Geoffrey Arnott Foundation, the
Australian Society of Anaesthetists, the World Federation of Societies of
Anaesthesiologists and the International Association for the Study of Pain.

We thank our colleagues for their advice and help with course materials, especially Linda
Huggins and Gwyn Lewis (New Zealand), Max Sarma and Haydn Perndt (Australia),
Gertrude Marun and Harry Aigeeleng (Papua New Guinea), Luke Nasedra (Fiji) and Kaeni
Agiomea (Solomon Islands). We also thank River Gibson for drawing the diagrams and
Diane Perndt for her help with formatting this book.

We are grateful to Timothy Pack for allowing us to use his rat illustration.

Many thanks to Michael O’Connor (United Kingdom), Maurice Hennessy (Australia),

Ramesh Menon (New Zealand), Muralidhar Joshi and Palanisamy Vijayanand (India), and
Carolina Hayock Loor (Honduras) for their help with preparation of the second edition.

Disclaimer

We have done our best to provide accurate information regarding medication doses and
other treatments, however this book may contain mistakes. In addition, treatment
options vary from country to country. It is important that health workers double-check
medication doses and use their clinical judgement when treating patients.

2

CONTENTS

4 Introduction

5 What is Pain?

6 Why Should We Treat Pain?

8 Assessment of Severity

10 Classification of Pain

12 Physiology and Pathology

20 Pain Treatment Overview

26 Using Pain Medications

30 Pain Management Barriers

32 Using the RAT System

36 RAT Examples

42 Case Discussions

50 Overcoming Barriers

APPENDICES

52 Appendix 1: Medicine Formulary for Adults

56 Appendix 2: Paediatric Medicine Doses

58 Appendix 3: WHO Analgesic Ladder

59 Appendix 4: Using Morphine for Cancer Pain

60 Appendix 5: WHO Essential Medicines List

3

INTRODUCTION

Pain affects all of us – young and old, rich and poor. Pain has many
causes – cancer, injury, infection, surgery – and people experience pain in
many different ways.

Pain is often a ‘hidden’ problem and is poorly treated. We do not always

recognize that a person is in pain. There are also many barriers to the
treatment of pain – e.g. people’s attitudes, lack of health workers and lack
of medicines.

Pain can often be improved with very simple treatments.

In some ways, pain is like a rat – something that causes a lot of suffering
but is hidden from view.

The letters R.A.T. can also be used to help us manage pain:

R = Recognize
A = Assess
T = Treat

Essential Pain Management (EPM) is a system for managing pain and

teaching others about pain management.

The basic aims of this workshop are:

• To improve recognition, assessment and treatment of
pain
• To address pain management barriers

4

WHAT IS PAIN?

Think of a patient who has or had pain. How did he or she

describe the pain?

The International Association for the Study of Pain (IASP) defines pain in
the following way:

Pain is “an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or
described in terms of such damage”.

This definition is quite complicated but some important points can

be made:

• Pain is unpleasant.
• Emotions (psychological aspects) are important.

• Pain is not always associated with visible tissue damage. In

other words, a patient may be experiencing pain even if we
cannot see an obvious cause for it.

A patient may not appear to be in pain. The only way to find out whether
he or she has pain is to ask.

Another simpler definition of pain is:

“Pain is what the person says hurts.”

5

WHY SHOULD WE TREAT PAIN?

CASE 1
Mrs T is a 33-year-old woman with uterine cervical cancer. The cancer
has spread to her spine and she has disabling pain. The surgeons do
not have any other options to treat her cancer. She is married with two
children, aged 11 and 8.
Why should we treat her pain?

CASE 2
Mr G is a 54-year-old man who has just had a laparotomy for bowel
obstruction secondary to bowel cancer. You see him on the surgical
ward soon after the operation. He complains of severe pain.
Why should we treat his pain?

6

Acute pain is a symptom of tissue injury. Untreated pain causes
inflammatory changes in the body which may have harmful physical and
psychological effects. In addition, poorly treated acute pain may progress
to chronic pain.

There are benefits of effective pain management for the patient, the
patient’s family, and society (hospital and wider community).

For the patient:

• Treating pain is the “humane” thing to do

— Less suffering
— Greater dignity (especially for patients dying with cancer
pain)
• Fewer physical problems
— Better sleep, improved appetite
— Earlier mobilization, faster recovery after injury or
surgery
— Fewer medical complications
(e.g. heart attack, pneumonia, deep vein thrombosis)
• Fewer psychological problems
— Less depression and anxiety

For the family:

• Able to function as part of the family

• Able to provide for the family

For society:

• Reduced health costs

— Patients are discharged earlier
— Patients are less likely to be readmitted
• Patients are able to work and contribute to the community

Are there any reasons for NOT treating pain?

There is NO evidence that withholding pain treatment is beneficial.

Occasionally, people make incorrect statements about pain management,
e.g. untreated pain makes a person stronger, pain treatment delays
surgical diagnosis. There is no evidence for these statements.

7

ASSESSMENT OF SEVERITY

Pain assessment is the “fifth vital sign” (along with temperature, pulse
rate, blood pressure and respiratory rate).

Assessment of severity is important because it:

• Guides choice of treatment

• Measures response to treatment

The severity of pain can be quickly and easily measured using a simple
scoring system:

• Verbal Rating Scale (e.g. mild / moderate / severe or 0 to 10)

• Visual Analogue Scale (VAS)
• Faces Pain Scale (FPS)

Visual Analogue Scale (VAS)

Faces Pain Scale

8

It is important to assess the pain score at rest and with movement (some
patients will appear to have mild pain at rest but be unable to move
because of severe pain).

How is the pain affecting the patient? Examples:

• Post-laparotomy patient
— Can the patient cough, get out of bed, walk?
• Chronic cancer patient
— Can the patient look after himself / herself at home?
Work?

The Functional Activity Score (FAS) can be used to measure limitation of

function compared to normal activity:

• A: No limitation
• B: Mild to moderate limitation
• C: Severe limitation

Using the post-laparotomy patient as an example, ask the patient to score

his pain at rest and then during an activity, e.g. getting out of bed. The
following scores may be obtained:

• Pain score at rest: 2/10

• Pain score while getting out of bed: 8/10
• FAS: C

9

CLASSIFICATION OF PAIN

Not all pain is the same.

It is important to classify the pain (make a pain diagnosis) because this

helps us to choose the best treatment.

Pain can be classified in many ways, but it is helpful to classify pain using
three main questions:

1. How long has the patient had pain?

2. What is the cause?
3. What is the pain mechanism?

1. Acute versus chronic pain (duration)

Pain can be acute (pain for less than 3 months) or chronic (pain for more
than 3 months or pain persisting after an injury heals). Sometimes, a
patient with chronic pain may experience additional acute pain (acute on
chronic pain).

There is evidence that poorly treated acute pain is more likely to become
chronic pain.

2. Cancer versus non-cancer pain (cause)

Cancer pain

• Examples include pelvic pain due to uterine cervical cancer,

bone pain due to cancer spread.
• Pain symptoms tend to get worse over time if untreated (i.e.
symptoms are progressive)
• Often cancer pain is chronic but the patient may get acute pain
as well (e.g. pain due to a new fracture from bone metastases)

Non-cancer pain

• There are many different causes, including:

— Surgery or injury
— Degenerative disease (e.g. arthritis)
— Childbirth
— Nerve compression or injury
(e.g. sciatica, “neuralgia”)

10

 Non-cancer pain (continued)

• Pain may be acute and last for a limited time or may become
chronic.
• The cause may or may not be obvious.

3. Nociceptive versus neuropathic pain (mechanism)

Pain can also be classified by mechanism (the physiological or pathological

way the pain is produced). There is currently much research in this area –
understanding the exact cause of pain at the nerve level will help guide
more specific treatments.

The pain can either be nociceptive, neuropathic or mixed (both nociceptive

and neuropathic). Nociceptive and neuropathic pain are also discussed in
the Physiology and Pathology section.

Nociceptive pain

• Commonest type of pain following tissue injury.

• Sometimes called physiological or inflammatory pain.
• Caused by stimulation of pain receptors in the tissues that have
been injured.
• Has a protective function.
• Patients describe pain as sharp, throbbing or aching, and it is
usually well localised (the patient is able to point to exactly
where the pain is).
• Examples: Pain due to a fracture, appendicitis, burn.

Neuropathic pain

• Caused by a lesion or disease of the sensory nervous system.

• Sometimes called pathological pain.
• Tissue injury may not be obvious.
• Does not have a protective function.
• Patients describe neuropathic pain as burning or shooting. They
may also complain of numbness or pins and needles. The pain
is often not well localised.
• Examples: Post-amputation pain, diabetic pain, sciatica.

11

PHYSIOLOGY AND PATHOLOGY

Understanding pain physiology and pathology helps us to understand how

to treat pain.

Normal pain physiology involves a number of steps between the site of

injury and the brain – this is called the nociceptive pathway (Fig 1). Pain
signals can be changed (modulated) at many points along the nociceptive
pathway and this affects the severity and nature of the pain we feel.

Pain pathology involves damage to or abnormality of the pain pathway.

This can cause neuropathic pain.

Different treatments (non-pharmacological and pharmacological) work on

different parts of the nociceptive pathway. Usually, more than one
treatment is needed.

Nociception and pain

Nociception is not the same as pain perception (how we “feel” pain).

Pain perception depends on many other factors, including:

• Beliefs / concerns about pain

• Psychological factors (e.g. anxiety, anger)
• Cultural issues, e.g. expectations
• Other illnesses
• Personality and coping strategies
• Social factors (e.g. family, work)

12

 Fig 1: The nociceptive pathway

13

The nociceptive pathway

1. Periphery (Fig 2 and 3)

• Pain receptors (nociceptors) are activated by intense thermal

(heat or cold), mechanical (pressure) or chemical stimuli.
• This results in activation of pain nerves called Aδ and C nerves.
• Tissue injury causes release of chemicals - the “inflammatory
soup” (e.g. hydrogen ions, prostaglandins, substance P). The
chemicals increase / amplify the pain signal and this process is
called peripheral sensitization.
• The pain signal travels along the Aδ and C nerves, through the
dorsal root to the dorsal horn of the spinal cord.

Fig 2: “Inflammatory soup” and stimulation of nociceptors

Fig 3: Transmission of pain signal from the periphery to the dorsal horn

14

2. Spinal cord (Fig 4)

• The dorsal horn of the spinal cord is the first relay station. This
is a vital area for two main reasons:
— The Aδ and C nerves connect (synapse) with second order
nerves.
— There is input from other peripheral and spinal cord nerves
than can modulate the pain signal.

• The second order nerves cross to the other side of the spinal
cord and travel up the spinothalamic tract to the thalamus at
the base of the brain.

Fig 4: Dorsal horn connections

15

3. Brain (Fig 5)

• The thalamus is the second relay station. There are many

connections with other parts of the brain, including:
— Cortex
— Limbic system
— Brainstem

• The cortex, limbic system and brainstorm all contribute to pain

perception.

• The cortex is important for localisation of pain (i.e. awareness

of the site of tissue injury).

• The limbic system is responsible for many of the emotions we

feel when we experience pain (e.g. anxiety, fear).

• The brainstem plays an important role in reflex responses to

pain and coordination of pain modulation.

Fig 5: Brain connections

16

4. Modulation (Fig 6)

• The pain signals can be changed (modulated) in the spinal cord

or the brain.

• In the dorsal horn of the spinal cord, peripheral pain nerves or

spinal cord nerves can either increase (excite) or reduce
(inhibit) pain.

• A major descending inhibitory pathway travels from the

brainstem down the spinal cord to the dorsal horn where it
inhibits pain signals from the periphery.

Fig 6: Descending pain modulation

17

What happens in neuropathic pain (pathological pain)?

The International Association for the Study of Pain (IASP) defines

neuropathic pain as:

“Pain caused by a lesion or disease of the somatosensory

nervous system.”

The lesion or disease results in abnormal pain signals travelling to the

brain and perception of pain.

Pain may occur spontaneously (no stimulus) or pain may result from
stimuli that are normally non-painful (e.g. light touch). Psychological
changes (e.g. increased anxiety) may also contribute to the pain.

Unlike nociceptive pain, neuropathic pain does not have a protective

function.

Mechanisms:

There may be anatomical or chemical changes in the peripheral or central

nervous system. Examples include:

• Abnormal nerve tissue, e.g. stump neuroma after amputation

• Abnormal firing of pain nerves
• Changes in chemical signaling at the dorsal horn
• Abnormal nerve connections in the dorsal horn
• Loss of normal inhibitory function

Examples:

• Nerve trauma, amputation

• Diabetic neuropathy
• Invasive cancer (e.g. uterine cancer invading the lumbosacral
plexus)
• Chronic pain following prolonged, poorly treated acute pain

18

NOTES

19

PAIN TREATMENT OVERVIEW

Because many factors contribute to the amount and type of pain we feel,
it is often necessary to use a combination of treatments to manage an
individual patient’s pain.

Both non-pharmacological and pharmacological treatments are important.

What non-pharmacological treatments are available where you

work?

20

 What pharmacological treatments are available where you
work? What preparations (e.g. injections, syrup,
suppositories) are available?

21

Non-pharmacological treatments

Both physical and psychological factors affect how we feel pain.

Treatments include:

• Physical
— RICE (rest, ice, compression, elevation) of injuries
— Surgery (e.g. for drainage of abscess, removal of inflamed
appendix)
— Acupuncture, massage, physiotherapy

• Psychological
— Explanation
— Reassurance
— Counselling

Pharmacological treatments

Medicines are often the mainstay of treatment. Different medicines work

on different parts of the nociceptive pathway and it is often important to
use a combination of medicines. In addition, combining medicines may
result in fewer side effects, e.g. prescribing regular paracetamol in
addition to morphine allows the dose of morphine to be reduced, resulting
in fewer morphine-related side effects.

What is a placebo treatment?

A placebo treatment involves giving a patient a medicine that has no

pharmacological effect (e.g. giving an injection of saline for pain). Because
psychological factors are very important, the patient’s pain may improve.

Non-pharmacological treatments can also have a placebo effect.

If the placebo treatment works, this does not mean that the patient did
not have pain in the first place or that the patient was lying! The placebo
effect is a very valuable component of many health treatments.

22

Classification of pain medications (analgesics)

Note: Refer to the appendices for individual medication information and

doses.

1. Simple analgesics

• Paracetamol / acetaminophen (Pamol, Panadol, Tylenol)

• Non-steroidal anti-inflammatory medicines (NSAIMs)
— Aspirin
— Ibuprofen (Brufen, Nurofen)
— Diclofenac (Voltaren)

2. Opioids

• Mild opioids
— Codeine
— Tramadol (also acts on descending inhibitory pathways)
• Strong opioids
— Morphine
— Pethidine (Demerol)
— Oxycodone

3. Other medications

• Tricyclic antidepressants
— Amitriptyline
— Nortriptyline
• Anticonvulsants
— Carbamazepine (Tegretol)
— Sodium valproate (Epilim)
— Gabapentin
— Pregabalin
• Local anaesthetics
— Lignocaine / lidocaine (Xylocaine)
— Bupivacaine (Marcaine)
• Others
— Ketamine
— Clonidine

23

Where do pain medications work?

Fig 7: Sites of actions of pain medications

24

How do pain medications work?

Simple analgesics

Paracetamol Change prostaglandin levels in the brain

NSAIMs Mainly work by changing prostaglandin levels in the

periphery, thereby reducing inflammation

Opioids

Codeine Acts on opioid receptors in the brain and

spinal cord

Tramadol Acts weakly on opioid receptors, also increases descending

inhibitory signals in the spinal cord

Morphine, pethidine, Act on opioid receptors in the brain and

oxycodone spinal cord

Other analgesics

Tricyclic antidepressants Increase descending inhibitory signals in the spinal cord

Anticonvulsants “Membrane stabilisers”, probably work by reducing abnormal

firing of pain nerves

Local anaesthetics Temporarily block signalling in pain nerves in periphery (e.g.

infiltration or nerve block) or spinal cord (e.g. spinal block)

Ketamine Blocks NMDA receptors in the brain and spinal cord

(especially in the dorsal horn)

Clonidine Increases descending inhibitory signals in the spinal cord

25

USING PAIN MEDICATIONS

Medication effectiveness

The effectiveness of an individual analgesic medication depends on the

type of pain. Table 1 shows the usefulness of some analgesic medications
for treating different types of pain.

It is important to note that combinations of medications are usually

required, e.g. paracetamol plus morphine for severe acute nociceptive
pain.

Acute Acute Acute Chronic non- Chronic

nociceptive nociceptive neuropathic cancer cancer
mild severe

Paracetamol +++ ++ + + +

NSAIMs ++ ++ + +/- +/-

Codeine ++ + - - +/-

Tramadol ++ ++ ++ + +

Morphine - +++ ++ -- +++

TCAs - - ++ ++ ++

Anticonvulsants - - ++ + +

Table 1: Analgesic usefulness

-- Not useful, may be harmful

- Not usually useful or not indicated
± Occasionally useful
+ Useful, mildly effective
++ Useful, moderately effective
+++ Useful, highly effective

TCAs = Tricyclic antidepressants

26

Cancer pain

Use the WHO Ladder (Fig 8 and Appendix 3). This was developed for pain
that is getting worse over time as the cancer progresses. The steps on
the ladder are:

1. Mild pain
Use simple analgesics.

2. Moderate pain
Continue simple analgesics. Add codeine or tramadol.

3. Severe pain
Continue simple analgesics. Add a strong opioid, usually
morphine.

The WHO Ladder emphasizes regular, oral administration of medications.

Additional medications may be required, for example:

• Strong opioids and NSAIMs for acute on chronic bone pain

• Tricyclic antidepressants or anticonvulsants for acute or chronic
neuropathic pain

Fig 8: WHO Ladder (modified)

27

Nociceptive pain

For acute, severe, nociceptive pain, use the Reverse WHO Ladder (Fig 9).
Start at the top of the ladder and step down (reduce the strength of
analgesics) as the pain improves:

1. Severe pain
Use a strong opioid plus simple analgesics.

2. Moderate pain
Continue simple analgesics. Change from strong opioid to
codeine or tramadol.

3. Mild pain
Stop opioids but continue simple analgesics.

Fig 9: Reverse WHO Ladder

Neuropathic pain

Tricyclic antidepressants and anticonvulsants are likely to play an

important role. Simple analgesics may also be helpful.

Tramadol may be useful because of its action on descending inhibitory

pathways.

Occasionally, strong opioids are helpful in acute, severe, neuropathic pain,

but they may not be particularly effective and their use should be
frequently reassessed.

28

Chronic non-cancer pain

Pharmacological treatment for this group may be complicated because

there are nociceptive and neuropathic features. Tricyclic antidepressants
and anticonvulsants may be helpful. It is important to consider the
potential side effects of long term administration of medications, e.g.
NSAIMs.

In general, strong opioids should be avoided in chronic non-cancer pain.

Non-pharmacological treatments are usually very important.

29

PAIN MANAGEMENT BARRIERS

Pain is often poorly managed. What are some of the reasons for this?

What are the barriers where you work?

30

Possible barriers:

• Patient factors

— Patients may not seek help

— Patients may expect to have pain
— Patients may see complaining about pain as a weakness
— Patients may be afraid of addiction or side effects
— It may be difficult to communicate with the patient (e.g.
babies, intellectual impairment, language difficulties)

• Medications

— Supply of medications may be unreliable

— Appropriate medications may be missing from the hospital
formulary
— Appropriate preparations may be unavailable (e.g. fast
release oral morphine)

• Health workers

— There may be a shortage of health workers

— Workers may be too busy
— Workers may not recognize pain
— Workers may have inadequate knowledge about pain and
its treatment
— Workers may be unable to prescribe or give appropriate
medications

• System issues

— Pain management may be seen as a low priority

— There may be no culture of pain assessment and
management
— Pain management protocols may not be available
— There may be no forms for recording pain (e.g. on post-op
observation charts or routine vital signs charts)

31

USING THE RAT SYSTEM

R = Recognize
A = Assess
T = Treat

+ Reassess (Repeat RAT)

1. RECOGNIZE

We sometimes forget to ask whether the patient has pain and sometimes
patients don’t or can’t tell us. If you don’t look or ask, you don’t find!

Does the patient have pain?

• Ask
• Look (frowning, moving easily or not, sweating?)

Do other people know the patient has pain?

• Other health workers

• Patient’s family

32

2. ASSESS

To treat pain better, we need to think about the cause and type of pain. We
may be able to better treat the injury that is causing the pain. We may
also be able to choose better medications to treat the pain itself.

a) HOW SEVERE IS THE PAIN?

• What is the pain score?

— At rest
— With movement

• How is the pain affecting the patient?

— Can the patient move, cough?
— Can the patient work?

b) WHAT TYPE OF PAIN IS IT?

Is the pain acute or chronic?

The cause of acute nociceptive pain may be very obvious but chronic
pain may be more complicated. In chronic pain, psychological factors
may be more important and the pain may have both nociceptive and
neuropathic features.

The pain may be acute on chronic (e.g. fracture in a patient with

chronic cancer pain).

Is the pain cancer pain or non-cancer pain?

Does the patient’s disease explain the pain?

There may be an obvious cause of the pain that requires specific

treatment. For example:
— Fracture needing splinting or surgery
— Infection needing cleaning and antibiotics

33

 Is the pain nociceptive, neuropathic or mixed?

Neuropathic pain is more likely in some situations:

— Diabetes
— Nerve injury (including amputation)
— Chronic pain

Ask about specific symptoms:

— Burning or shooting pain
— Pins and needles, numbness
— Phantom limb pain

c) WHAT OTHER FACTORS ARE CONTRIBUTING TO THE PAIN?

• Physical factors
— Underlying illness
— Other illnesses

• Psychological and social factors

— Anger, anxiety, depression
— Lack of social supports

3. TREAT

Treatment can be divided into non-pharmacological and pharmacological

treatments. Both types of treatment are important.

Many factors may be contributing to an individual patient’s pain, so there

is no set list of treatments. The exact treatments will depend on the
individual patient, the type of injury or disease, the type of pain and other
factors contributing to the pain.

34

a) NON-PHARMACOLOGICAL TREATMENTS
(for both nociceptive and neuropathic pain)

• Physical
— Rest, ice, compression and elevation of injuries (RICE)
— Surgery may be required
— Nursing care
— Acupuncture, massage, physiotherapy

• Psychological
— Explanation and reassurance
— Input from social worker or pastor, if appropriate

b) PHARMACOLOGICAL TREATMENTS

• Nociceptive pain

— Consider paracetamol, NSAIMs, tramadol, codeine,

morphine
— Use combinations, e.g. paracetamol + NSAIM + opioid
— Use the Reverse WHO Ladder for acute, severe pain. Start
at the top – consider small doses of morphine IV to control
pain early. Step down the ladder as pain improves.
— Use the WHO Ladder for progressive cancer pain. Start at
the bottom and step up!

• Neuropathic pain

— The WHO Ladder and Reverse WHO Ladder may not work
very well
— Consider using a tricyclic antidepressant (amitriptyline) or
anticonvulsant (carbamazepine or gabapentin) early.
Tramadol may also be helpful.
— Don’t forget non-pharmacological treatments

4. REASSESS

It is essential to reassess the patient to assess whether your treatment is

working. Repeat RAT.

Remember to record your assessment of severity. Pain is the 5th vital

sign!

35

RAT EXAMPLES

EXAMPLE 1
A 32-year-old man caught his right hand in machinery at work. He
presents with a compound fracture of his hand.
How would you manage his pain using RAT?

1. RECOGNIZE

• Pain easily recognized

• Obvious cause, patient likely to be distressed

2. ASSESS

• Severity
— Pain may be moderate to severe
• Type
— Acute pain, musculoskeletal (non-cancer) cause
— Nociceptive mechanism, pain described as sharp, aching
— Possibility of neuropathic pain is nerve injury
• Other factors
— Other factors may be contributing to the pain (e.g. anxiety,
infection if old injury)

3. TREAT

• Non-pharmacological treatments
— Reduce inflammation (immobilisation, sling)
— Surgery will probably be necessary
— Prevention or treatment of infection
— Explanation and reassurance

36

 • Pharmacological treatments
— Pain will be improved by simple medications (e.g.
paracetamol) but may need to add other medications
— Regular paracetamol (1G four times daily)
— Consider adding codeine (30-60mg four-hourly)
— NSAIMs will reduce inflammation but may affect bone
healing
— Morphine is effective and may be necessary if
severe pain

4. REASSESS

• Repeat RAT
• Record pain scores

Summary

Moderate to severe, acute pain due to injury, nociceptive

mechanism

• Treat the injury

• Regular simple analgesics
• Morphine if severe pain

37

 EXAMPLE 2
A 55-year-old woman presents with a large breast tumour with spread
to her spine. She has severe pain.
How would you manage her pain using RAT?

1. RECOGNIZE

• Patient may have pain in both her breast and back.

• New severe back pain may not be recognized.
• Ask the patient about her pain symptoms!

2. ASSESS

• Assessment may be difficult because of two types of pain.

• Severity
— Both breast pain and back pain may be severe.
• Type
— Chronic cancer pain getting worse over time, acute
musculoskeletal pain caused by spinal metastases (e.g.
collapse of vertebra with nerve compression)
— The pain may have both nociceptive and neuropathic
features. Neuropathic symptoms may be present especially
if nerve compression – burning, pins and needles
• Other factors
— Multiple factors may be contributing to the pain – physical,
psychological and social.
— Try and explore these with the patient and her family.

3. TREAT

• Non-pharmacological treatments
— Treatment of breast tumour – nursing care, possibly
surgery, treatment of infection
— Psychological or social support
— Other treatments?

38

 • Pharmacological treatments
— Regular simple analgesics + opioid
— If possible, control acute, severe pain with IV morphine
— Convert to oral morphine when pain controlled
— Consider amitriptyline if features of neuropathic pain
(especially if poor sleep)

4. REASSESS

• Repeat RAT
• Record pain scores

Summary

Severe, acute on chronic pain. Mixed cause – chronic cancer pain

and acute musculoskeletal pain. Nociceptive and neuropathic
mechanisms.

• Assessment may be difficult

• Non-pharmacological treatments are important
• Regular simple analgesics
• Control acute severe pain with IV morphine, then change
to regular oral morphine
• Amitriptyline may be helpful

39

 EXAMPLE 3
A 51-year-old man has a 2-year history of lower back pain which
sometimes radiates down his right leg. He fell recently and is now
having problems walking.
How would you manage his pain using RAT?

1. RECOGNIZE

• Patient may not show outward signs of pain

• Other people may think that the patient is avoiding work.
• Ask the patient about his symptoms!

2. ASSESS

• Severity
— Pain may be moderate to severe
— Measure his pain score, e.g. by using Verbal Rating Scale
and Functional Activity Score (FAS)
• Type
— Chronic pain, musculoskeletal (non-cancer) cause
— There may have been a recent injury causing acute-on-
chronic pain.
— The pain may be difficult to localise and have both
nociceptive and neuropathic features (e.g. burning, pins
and needles)
• Other factors
— Multiple factors may be contributing to the pain – physical,
psychological and social.

3. TREAT

• Non-pharmacological treatments
— Rest is often not helpful in chronic back pain
— Occasionally, there may be an acute on chronic problem
that needs surgical treatment (e.g. prolapsed disc)
— Acupuncture, massage and physiotherapy may be helpful
— Psychological or social support
§ Work issues
§ Family issues

40

 • Pharmacological treatments
— Regular paracetamol and NSAIM may be helpful, especially
if acute on chronic pain.
— In general, morphine is not helpful for chronic back pain.
Occasionally, morphine may be needed for acute severe
nociceptive pain.
— Consider amitriptyline if features of neuropathic pain
(especially if poor sleep).

4. REASSESS

• Repeat RAT
• Record pain scores

Summary

Moderate to severe, acute on chronic non-cancer pain, mixed

neuropathic and nociceptive mechanisms

• Assessment may be difficult

• Non-pharmacological treatments are important
• Regular simple analgesics
• Morphine usually not helpful (unless severe
nociceptive pain)
• Amitriptyline may be helpful

41

CASE DISCUSSIONS

CASE 1
A 22-year-old man fell off a truck and has a fractured right femur.
There are no other obvious injuries. He says the pain in his thigh is
very bad.
How would you manage his pain using RAT?

42

 CASE 2
A 44-year-old woman with known cervical cancer is admitted to
hospital because she can’t look after herself at home.
How would you manage her pain using RAT?

43

 CASE 3
A 60-year-old man has just had a laparotomy for bowel obstruction.
He is now lying very still and appears to be in severe pain.
How would you manage his pain using RAT?

44

 CASE 4
A 5-year-old girl has advanced bone cancer that has spread from her
leg to her spine. She cries most of the time and is frightened of
injections.
How would you manage her pain using RAT?

45

 CASE 5
A 49-year-old man with longstanding diabetes has to have a below
knee amputation for gangrene. You see him four weeks after the
amputation and he complains of leg pain.
How would you manage his pain using RAT?

46

 CASE 6
A 9-year-old boy with probably appendicitis is waiting for an operation.
How would you manage his pain using RAT?

47

 CASE 7
A 24-year-old woman presents to a clinic with a two-year history of
severe headache. Doctors told her 6 months ago that there is
“nothing wrong inside her head”.
How would you manage her pain using RAT?

48

 CASE 8
A 12-year-old girl was admitted three days ago with burns to her chest
and abdomen. She needs dressing changes every 2-3 days.
How would you manage her pain using RAT?

49

OVERCOMING BARRIERS

What are the most important pain management barriers where you work?
Are there any barriers that will be easy to change?

What are some of the changes that can be made to improve

pain management where you work?

50

NOTES

51

APPENDICES

Appendix 1: Medicine Formulary for Adults

Note: Exact formulations (e.g. tablet strength) may vary.

Exact morphine doses will depend on the individual patient.

Abbreviations:
• IM = intramuscular, IV = intravenous, PO = oral, PR = rectal,
SC = subcutaneous
• OD = once daily, BD = twice daily, TDS = three times daily,
QDS = four times daily

1. Simple Analgesics

Medication Uses Problems Adult dose

Paracetamol / Generally very safe. Not all patients are Usually given PO but
acetaminophen able to take oral can be given PR.
Good for mild pain
(Pamol, Panadol, liquids or tablets.
but can be useful for PO or PR: 1G (two
Tylenol)
most nociceptive Can cause liver 500 mg tablets) QDS
pain. damage in overdose.
Maximum dose: 4G
Usually need to add per 24 hours
other medications for
moderate to severe
pain.
Also used to lower
body temperature in
fever.

Aspirin Can be used with Not all patients are PO: 600 mg
paracetamol. able to take oral (two 300 mg tablets)
tablets. 4-6 hourly
Good for nociceptive
pain. Side effects: Maximum dose: 3.6
G per 24 hours
Gastro-intestinal
problems, e.g.
gastritis
Kidney damage
Fluid retention
Increased risk of
bleeding

52

 Diclofenac As above for aspirin. As above for aspirin, PO: 25-50 mg TDS
(Voltaren, but can be given IM
PR: 100 mg OD
Voltarol) or PR.
IM: 75 mg BD
Maximum dose:
150 mg per 24 hours

Ibuprofen As above for aspirin. As above for aspirin. PO: 400 mg QDS
(Brufen,
Nurofen)

Naproxen As above for aspirin. As above for aspirin. PO: 500 mg BD

(Naprosyn)

2. Opioids

Medication Uses Problems Adult dose

Codeine Generally very safe. Not all patients are Usually given PO
able to take oral but sometimes given
Often added to
liquids or tablets. IM.
paracetamol and/or
NSAIM for moderate Similar side effects to PO or IM: 30-60 mg
pain. other opioids: 4-hourly
Constipation
Respiratory
depression in high
dose
Misunderstandings
about addiction.
Different patients
require different
doses (variable dose
requirement).

Tramadol Can be used with Not widely available. PO or IV: 50-100 mg

(Tramal) paracetamol and/or QDS
Nausea and vomiting
opioids for
nociceptive pain. Confusion
Sometimes helpful
for neuropathic pain.
Less respiratory
depression and
constipation than
morphine.

53

 Morphine Very safe if used Similar problems to Can be given PO, IV,
appropriately. other opioids: IM or SC.
Often added to Constipation Different patients
paracetamol and/or require different
Respiratory
NSAIM for moderate doses.
depression in high
to severe pain.
dose Oral dose is 2-3
Oral morphine very times the injected
Nausea and
useful for cancer dose.
vomiting
pain.
PO (fast): 10-30 mg
Myths about
In general, should be 4-hourly (e.g. for
addiction
avoided in chronic controlling cancer
non-cancer pain. Oral dose is not the pain)
same as the injected
Available as either PO (slow): BD dosing
dose.
fast release tablets or (may need high
syrup, or slow doses for cancer
release tablets. pain)
IV: 2.5-10 mg (e.g.
during or after
surgery)
IM or SC: 5-10 mg 4-
hourly

Pethidine As above for As above for PO: 50-100 mg

morphine. morphine. 4-hourly
(Demerol)
Often added to Seizures caused by IV or IM dose about
paracetamol and/or metabolite 10 times morphine
NSAIM for moderate (norpethidine) if high dose.
to severe pain. dose given for more
IV: 25-50 mg (e.g.
than 48 hours.
during or after
surgery.)
IM or SC: 50-100 mg
4-hourly

Oxycodone As above for As above for PO (fast): 5-10 mg

(Oxynorm, morphine morphine. 4-hourly
Oxycontin)
Can be used for Not widely available. PO (slow): 10 mg
cancer pain. BD, increased as
needed.
Available as fast
release (Oxynorm) or
slow release
(Oxycontin).

54

3. Other Analgesics (in alphabetical order)

Medication Uses Problems Adult dose

Amitriptyline Useful in Sedation PO: Usually 25 mg at

neuropathic pain. Postural hypotension night
Also used to treat (low blood pressure) “Start low, go slow”,
depression and Cholinergic side especially in elderly
improve sleep. effects: patients (e.g. start at
10 mg, increase
Dry mouth
every 2-3 days as
Urinary retention tolerated)
Constipation

Carbamazepine Anticonvulsant Sedation PO: 100-200 mg BD,

(Tegretol) (“membrane Unsteadiness increased to 200-400
stabiliser”) mg QDS as tolerated
Confusion in high dose
Useful in “Start low, go slow”,
neuropathic pain. especially in elderly
patients

Clonidine May be useful if Not widely available. IV: 15-30 mcg 15-
pain is difficult to Sedation minutely up to 1-2
treat. mcg/kg
Hypotension
PO: 2 mcg/kg

Gabapentin Anticonvulsant Sedation PO: 100 mg TDS,

(“membrane increased to 300 mg
stabiliser”) TDS as tolerated
Useful in
neuropathic pain.

Ketamine May be useful in Sedation (only need IV: 5-10 mg for

severe pain small dose for pain severe acute pain
(nociceptive or relief) SC infusion: 100 mg
neuropathic). Dreams, delirium, over 24 hours for 3
Also used as a hallucinations days, can be
general anaesthetic increased to 300 mg,
then 500 mg per 24
hours

Sodium valproate Anticonvulsant Gastro-intestinal side PO: 200 mg 8-12-

(Epilim) (“membrane effects, sedation hourly
stabiliser”)
Useful in
neuropathic pain.

55

Appendix 2: Paediatric Medicine Doses

Note: Exact formulations (e.g. tablet strength) may vary.

Exact morphine doses will depend on the individual patient.

Abbreviations:
• IM = intramuscular, IV = intravenous, PO = oral, PR = rectal,
SC = subcutaneous
• OD = once daily, BD = twice daily, TDS = three times daily,
QDS = four times daily

1. Simple Analgesics

Paracetamol / PO or PR: 15 mg/kg 4-hourly

acetaminophen Maximum dose: 90 mg/kg per 24 hours

Aspirin PO: 15 mg/kg 4-6 hourly

Not for children under 10 years old

Diclofenac PO or PR: 1 mg/kg BD or TDS

Ibuprofen PO: 5 mg/kg QDS

Indomethacin PO: 0.5-1 mg/kg TDS

Naproxen PO: 5-10 mg/kg BD or TDS

Not for children under 2 years old

56

2. Opioids

Codeine (see below) PO: 0.5-1 mg/kg 4-hourly

Tramadol PO or IV: 1-2 mg/kg QDS

Morphine – fast IV: 0.02 mg/kg 10-minutely (e.g. after surgery)

IM or SC: 0.1-0.2 mg/kg 3-4-hourly
PO (fast release): 0.2-0.4 mg/kg 3-4-hourly (e.g. for
controlling cancer pain)

Morphine – slow PO (slow release): Start with 0.6 mg/kg BD, increase every
48 hours as required

Pethidine / meperidine IV: 0.5 mg/kg 10-minutely (e.g. after surgery)

IM: 1mg/kg 3-4-hourly

Oxycodone IV, SC or PO (fast): 0.1 mg/kg 4-hourly

PO (slow): 0.2-0.5 mg/kg BD

3. Other Analgesics

Amitriptyline PO: 0.5 mg/kg at night

Carbamazepine PO: 2 mg/kg BD to TDS

Clonidine PO: 2.5 mcg/kg as a pre-med for painful procedures

Sodium valproate PO: 5 mg/kg BD to TDS

Can be increased to 10 mg/kg/dose

Note:
In the United Kingdom and many other countries, codeine is not recommended
for children aged less than or equal to 12 years.

57

Appendix 3: WHO Analgesic Ladder

This “ladder” was developed by the WHO to mainly guide treatment of

cancer pain. It may not work well for some other types of pain, e.g.
neuropathic pain.

In cancer pain, the correct dose of morphine for an individual is the dose
that relieves that patient’s pain.

Medicines should be given:

1. By mouth – so that medicines can be taken at home.

2. By the clock – medicines are given regularly so that pain does not
come back before the next dose.
3. By the ladder – gradually giving bigger doses and stronger
medicines until the patient is pain-free.
4. For the individual – there is no standard dose of morphine. The
correct dose is the dose that relieves the patient’s pain.
5. With attention to detail – includes working out the best times to give
medicines and treating side effects (e.g. giving a laxative to treat
constipation).

58

Appendix 4: Using Morphine for Cancer Pain

The most important medication for managing cancer pain is morphine.

Acute severe pain may need to be controlled with morphine injections but
this should be changed to oral morphine as soon as the pain is under
control.

The oral morphine dose is 2-3 times the injected dose.

Steps for controlling pain with morphine:

1. Control severe pain quickly with injections or fast release oral

morphine. Give 4-hourly as needed.

2. Work out morphine requirement per 24 hours.

e.g.: Patient needing 10 mg IM/SC morphine every 4 hours
IM/SC morphine requirement per day = 6 x 10 mg = 60 mg
Equivalent oral morphine dose is 2-3 times (120-180 mg)

3. Halve the total daily oral dose and give as slow release morphine
twice daily.
e.g.: Total daily oral dose = 120-180 mg
Start with slow release morphine 60 mg PO BD
Increase to 90 mg PO BD as needed

4. Continue to give extra fast release morphine 4-hourly if needed for

“breakthrough pain”. If frequent extra doses are needed, work out
total daily dose and increase slow morphine dose.

59

Appendix 5: WHO Essential Medicines List

The following table is based on the WHO Model List, 16th edition
(updated). Medicines useful for managing pain can be found in a variety of
sections of the list (e.g. anticonvulsants, medicines used in mood
disorders).

For the full list, see:

http://www.who.int/medicines/publications/essentialmedicines/en/

Analgesics, Antipyretics, Non-Steroidal Anti-Inflammatory Medicines

(NSAIMs)
(section 2)

Non-opioids and NSAIMs (section 2.1)

Acetylsalicylic acid (aspirin) Suppository: 50 mg to 150 mg

Tablet: 100 mg to 500 mg

Ibuprofen Tablet: 200 mg; 400 mg

(>3 months)

Paracetamol Oral liquid: 125 mg per 5ml

Suppository: 100 mg
Tablet: 100 mg to 500 mg

Opioid Analgesics (section 2.2)

Codeine Tablet: 15 mg (phosphate); 30 mg

(phosphate)

Morphine Injection: 10 mg (morphine hydrochloride or

morphine sulfate) in 1 ml ampoule
Oral liquid: 10 mg (morphine hydrochloride or
morphine sulfate) per 5 ml
Tablet: 10 mg (morphine sulfate)
Tablet (prolonged release): 10 mg; 30 mg;
60 mg (morphine sulfate)

Anticonvulsants, Antiepileptics (section 5)

Carbamazepine Oral liquid: 100 mg per 5 ml

Tablet (chewable): 100 mg; 200 mg
Tablet (scored): 100 mg; 200 mg

60

 Valproic acid (sodium valproate) Oral liquid: 200 mg/5 ml
Tablet (crushable): 100 mg
Tablet (enteric-coated): 200 mg; 500 mg

Medicines Used in Mood Disorders (section 24)

Amitriptyline Tablet: 25 mg (hydrochloride)

Other Medicines

General Anaesthetics (section 1.1)

Ketamine Injection: 50 mg (as hydrochloride) per ml in

10 ml vial

Nitrous oxide Inhalation

Local Anaesthetics (section 1.2)

Bupivacaine Injection: 0.25%; 0.5% (hydrochloride) in vial

Lidocaine (lignocaine) Injection: 1%; 2% (hydrochloride) in vial

Lidocaine + epinephrine (lignocaine Injection: 1%; 2% (hydrochloride)

+ adrenaline) + epinephrine 1:200 000 in vial

Antiemetic Medicines (section 17.2)

Dexamethasone Injection: 4 mg/ml in 1-ml ampoule

Oral liquid: 0.5 mg/5 ml; 2 mg per ml
Solid oral dosage form: 0.5 mg; 0.75 mg;
1.5 mg; 4 mg

Metoclopramide Injection: 5 mg (hydrochloride)/ml in 2-ml

(not in neonates) ampoule
Tablet: 10 mg (hydrochloride)

Ondansetron Injection: 2 mg base/ml in 2-ml ampoule (as

(>1 month) hydrochloride)
Oral liquid: 4 mg base/5 ml
Solid oral dosage form: Eq 4 mg base;
Eq 8 mg base; Eq 24 mg base.

61

NOTES

62