1. Pharmacological Management of Pain
Gerry Hughes
Senior Antimicrobial Pharmacist
St. James’s Hospital Dublin
NAHPT Conference April 2016

2. Learning Objectives
Pain classifications and definition Brief pathophysiology Pharmacological management Evidence based practice and case studies Review and Summary Discussion

3. “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” 1 “always subjective” and “learned through experiences related to injury in early life”
 Recognition and acceptance of the subjectivity of pain are among the most challenging aspects of patient care; concepts that have evolved since 1968 when Margo McCaffery first defined pain as "whatever the person experiencing says it is, existing whenever he says it does.

5. 3

6. Nicholson BD. Journal of the American Academy of Nurse Practitioners, 15(12), S3-S9.

9. World Health Organisation Pain Ladder 4
Three step approach
Maintain patient free from cancer pain
Mild < Moderate < Strong analgesia
Principle also used for other sources of pain
Non-opioids, weak opioids, strong opioids, adjuvants
Non-pharmacological therapy

11. Paracetamol
Exercise
TENS OR +
NSAIDS
Ibuprofen
Naproxen

12. Codeine (Solpadeine®/Solpadol®)
Tramadol
Morphine sulphate
Paracetamol
Diclofenac
Amitriptyline
Duloxetine
Carbamazepine

13. Oxycodone
Fentanyl (Durogesic®/Effentora®)
Buprenorphine (Butrans®)
Alfentanyl
Hydromorphone
Methadone
Gabapentin
Pregabalin
Hyoscine
Baclofen
Paracetamol
Diclofenac

14. Opioid Conversions 5

15. Opioid Conversions 5

16. Opioid Conversions 5

17. Some case studies… Putting knowledge to practice

18. Mr JR Regular customer, very chatty, mobile
Noticed not called in for about six weeks
Now in a wheelchair; above knee amputation
Presents to pharmacy counter with regular rx
Talking about new life challenges
Difficulty with pain

19. Mr JR’s Prescription Paracetamol 500mg: Two TDS
Eplerenone (Inspra®) 25mg: One daily
Ramipril (Ramitace®) 5mg: One daily
Atorvastatin (Lipitor®) 80mg: One nocte
Bisoprolol (Bisop®) 5mg: One daily
Furosemide 40mg: One daily
Gliclazide (Diaglyc®) MR 30mg: Three mane
Metformin 500mg: Two BD
Diclofenac 75mg: One BD
Pregabalin (Lyrica®) 25mg: One TDS

20. Mr JR’s Prescription Paracetamol 500mg: Two TDS
Eplerenone (Inspra®) 25mg: One daily
Ramipril (Ramitace®) 5mg: One daily
Atorvastatin (Lipitor®) 80mg: One nocte
Bisoprolol (Bisop®) 5mg: One daily
Furosemide 40mg: One daily
Gliclazide (Diaglyc®) MR 30mg: Three mane
Metformin 500mg: Two BD
Diclofenac 75mg: One BD 
Pregabalin (Lyrica®) 25mg: One TDS 

21. Mr JR’s Prescription Diclofenac 75mg: One BD 
Contraindicated in established congestive heart failure (NYHA II- IV), ischemic heart disease, peripheral arterial disease and/or cerebrovascular disease. 6
NSAIDS = fluid accumulation

22. Mr JR’s Prescription Pregabalin (Lyrica®) 25mg: One TDS 
Neuropathic pain: “phantom limb pain”
“Burning, shooting up my leg”
…reports of congestive heart failure in some patients receiving pregabalin. These reactions are mostly seen in elderly cardiovascular compromised patients during pregabalin treatment for a neuropathic indication. Pregabalin should be used with caution in these patients 7

23. Mr JR’s Prescription: Pharmaceutical Care Action
Discuss with patient
Flag to pharmacist
Consider cautions vs contraindications
Alternative analgesia
May require contact with GP or hospital consultant
Documentation

24. Ms GR Just transferred out of ICU
Post-op, ileostomy and stoma formation
Not very talkative, drowsy
Using patient controlled analgesia (PCA)
Morphine sulphate
10mg bolus
5mg doses with 7 minute lockout

25. Ms GR’s Kardex
Paracetamol 1g QDS IV
Tramadol mg PO QDS prn
Ideos PO BD
Atorvastatin 20mg PO Nocte
Centyl K ® Mane
Oxycodone 5-10mg PO QDS prn

26. Ms GR’s Kardex Paracetamol 1g QDS IV (?)
Tramadol mg PO QDS prn 
Ideos PO BD
Atorvastatin 20mg PO Nocte
Centyl K ® Mane
Oxycodone 5-10mg PO QDS prn 

27. Ms GR’s Kardex: Pharmaceutical Care Action
Paracetamol 1g QDS IV (?)
Tramadol mg PO QDS prn 
STOP
Ideos PO BD
Atorvastatin 20mg PO Nocte
Centyl K ® Mane
Oxycodone 5-10mg PO QDS prn 

28. Team change to oxycontin 20mg BD 10-15mg oxynorm prn QDS
Ms GR’s Kardex
After 24 hours
38mg morphine used in PCA
Team change to oxycontin 20mg BD
10-15mg oxynorm prn QDS

29. Ms GR’s Kardex: Pharmaceutical Care Action
After 24 hours
38mg morphine used in PCA [~40mg IV morphine = 80mg PO morphine]
Team change to oxycontin 20mg BD
40mg in 24 hrs = 80mg morphine in 24 hours
10-15mg oxynorm prn QDS for breakthrough pain
prn doses should be 1/10 – 1/6 total daily dose q2 – 4hrly 8

30. MS TM New customer, mid 30’s
Presents with prescription for tramadol (back pain)
50mg QDS prn
Counselling points
Monitor for confusion/dizziness
Driving
Constipation
*Any other medications*

31. Ms TM’s Prescription Regular rx for sertraline 150mg daily
Drug-Drug Interaction
Serotonin Syndrome 9
Tachycardia, hypertension
Nausea, vomiting, diarrhoea
Agitation, restlessness, hallucinations
Medical emergency

32. Ms TM’s Prescription: Pharmaceutical Care Action
Explore other analgesia options
Paracetamol/codeine
NSAIDS *caution* anti-platelet effect 10
Local analgesia
Non-pharmacological therapy

33. Summary Pain is subjective, multifactorial, multimodal
Nociceptive vs neuropathic
Acute vs chronic
WHO Pain Ladder
Opioids, non-opioids, adjuvants
Drug-disease, drug-drug interactions; side effects
Communication with patients, pharmacists
NB exploring analgesia options

34. Discussion & Questions

35. References
International Association for the Study of Pain. Taxonomy. Accessed online at
Wall Street Journal (Online). Doctors' Challenge: How Real Is That Pain? July Accessed online at
Nicholson BD. Journal of the American Academy of Nurse Practitioners. 2003; 15 (12), S3-S9.
World Health Organisation (WHO). Cancer Pain for Adults. Accessed online at
Our Lady’s Hospice & Care Services. Pain Management: Opioid Conversion Chart Accessed online at
Difene ® 75mg Dual Release Capsule Summary of Product Characteristics. Updated October Accessed at
Lyrica ® 25mg Hard Capsules Summary of Product Characteristics. Updated January Accessed online at _Product_Information/human/000546/WC pdf
British National Formulary (BNF) March Ed. Prescribing in Palliative Care. Accessed online at
US National Library of Medicine. Serotonin Syndrome. Updated July Accessed online at
Lustral ® 100mg Tablets Summary of Product Characteristics. Updated November Accessed online at