1. Pain Management for AKU patients Dr Tom Kennedy FRCP Consultant Physician in Acute Medicine and Rheumatology Senior Lecturer and Director of Education Liverpool Health Partners

2. What is Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (International Association for the Study of Pain) Give me 3 examples where there is damage but no pain Give me 3 examples of pain with no injury

3. 2 approaches to managing pain Non Drug management Pain tool kit (www.paintoolkit.org)www.paintoolkit.org Planning your day Distraction Exercise and support for joints Drug therapy Simple analgesia NSAID’s (non steroidal anti-inflammatory drugs) Powerful analgesics Neuropathic pain control

4. Non Drug management Planning your day Very important not to use your better days to do too much Bite size chunks of activity Enjoy the better days Distraction Concentrate on something else TV, books, radio, talking etc. Exercise Important to keep fit. Very clear research for knee pain, thigh muscle strength very important Also supporting joints with braces can be of help Keep weight controlled

5. Drug management Simple analgesia NSAID’s (non steroidal anti-inflammatory drugs) Powerful analgesics Neuropathic pain control

6. How do people take their pain tablets? Paracetamol or Cocodamol As on the packet –2 tablets 4 x daily When your pain is very bad Before activity

7. Pain Graph X 10/10 No pain Time Pain Controlled pain Out of control

8. In summary Take simple pain tablets before activity You may take 2 more tablets, 2 hours after first set of tablets Maximum 2 tablets 4 x daily (if contain paracetamol)

9. Pain Graph X 10/10 No pain Time Pain Controlled pain Out of control 10.00 12.00

10. Other examples Examples of taking medicines to prevent symptoms

11. NSAID’s – non steroidal anti-inflammatory tablet Ibuprofen – diclofenac- naproxen Drug regulators talk about lowest dose for shortest period of time Why are we so worried about them Stomach and Bowel ulcers Kidney damage Asthma Heart attacks and strokes with long term use Think of these as if they were antibiotics for a chest infection i.e. take for 5-10 day courses Creams much safer and can work for hands especially

12. Powerful analgesics – morphine based Tramadol, Dihydrocodiene, MST, Oromorph Can be very helpful but be sure they really do help Patches of Butrans / Fentanyl MST x 2 daily Often used to give background pain control – much more likely to be addictive Constipation – Targinact may be used

13. Neuropathic pain 2 main groups Antidepressants e.g. amitriptyline, duloxetine nortriptyline Anticonvulsants e.g. gabapentin, Pregabalin Typically helpful after shingles or if nerve irritation Often helps sleep Titrate from very small doses to maximum tolerated Take at maximum tolerable dose for 6 weeks, then assess benefit Do not withdraw suddenly

14. Summary Keep as fit as you can – see a physio to develop your programme Keep weight under control Pace your selves – see OT to learn about this Be very careful lifting – please!! Use simple analgesics before activity NSAIDs for courses Try to avoid powerful analgesia unless very clear benefit Neuropathic pain is often missed and responds well to medicines

15. Thank you Any questions