1. Foundation Teaching Wendy Caddye Senior CNS Acute Pain

2. Pain Assessment Always assess pain on movement Ask the question and record it accurately in the notes

3. Pain Treatment Principles Multiple Drugs in combinations Pain pathways

4. Acute Pain Management Regular prescription of paracetamol by appropriate route (PO or IV) Regular prescription of Ibuprofen/Naproxen if appropriate + PPI Oral opioids prn (oramorph); IV only where patients can be observed carefully

5. IV Morphine – if used on a general ward always ensure patient monitored after giving an IV dose – dilute 10mg morphine in 10ml N/Saline and give in small bolus doses

7. Drug Names Prescribe oramorph as mg and not ml Use the generic name when prescribing (cf. OXYCODONE)

8. PCA Use Prescribed only by an anaesthetist or acute pain team (see Trust PCA Policy) Plus regular paracetamol and an NSAID (if appropriate) If patient takes stuff at home they need to be on that too – tolerance and dependence (inc. patches)

9. PCA opioids Opioids may make patients feel nauseous or vomit but they are not the only reason for these symptoms Ask the ward staff to treat PONV first before removing a PCA machine because of nausea – otherwise they are in pain and feel sick

10. Anti emesis Use a multimodal approach to anti- emetics Cyclizine plus Ondansetron plus Metoclopramide Refer to Trust PONV guidelines

11. Management of opioid-induced constipation Bulk forming laxatives – Fybogel; Normacol Stimulant laxatives – Senna; Docusate Osmotic laxatives – Lactulose, Macrogol 3350

12. Patients with patches How long do they take to work or to stop working if you remove them? Partial agonist effect of buprenorphine patches affect opioid requirements but – leave them on but expect them to need more prn opioids

13. Oramorph Consider the 1 st pass effect and prescribe effective doses (individual patient response varies) BUT be wary of patient with renal impairment (metabolite accumulation) Consider opioid switch

14. Oxycodone (not to be used as a first line opioid) Useful as an alternative to morphine when side effects are poorly tolerated Beware – twice as strong as morphine when taken orally

15. Oxycodone – avoiding errors OxyCONTIN = oxycodone slow release bd OxyNORM = oxycodone immediate release prn Make sure it is clear which preparation is intended when prescribing

16. Tramadol Only on formulary for patients who are admitted on it or on the advice of the acute pain team Not well tolerated in the elderly Evaluate effectiveness and side effects with a stat dose before a reg. Rx

17. Tramadol and serotonin syndrome Tramadol increases serotonin levels - prescribe with caution with other drugs that influence serotonin E.G. SSRI and tricyclic antidepressants. Serotonin syndrome monitor for: neurotoxic symptoms - myoclonus, seizures, rigidity, tremor psychiatric symptoms - agitation, restlessness, confusion, hypomania autonomic dysfunction - sweating, tachycardia, hypertension

18. Acute Neuropathic pain Gabapentin - first line approach to acute neuropathic pain in secondary care – works fast Reduce doses for patients with renal impairment: stat dose as can make pts feel awful (Seek advice from the Acute Pain Team or Drug Information: 8153)

19. Epidurals Always exclude other reasons for hypotension before stopping epidurals – anaesthetists put a lot of effort into placing them! Treat low Hb and hypovolaemia Refer to Trust epidural policy

20. Entonox - consider for short procedures (e.g. drain removal) Acute & short acting analgesia Rapid onset Rapid recovery Minimal side effects (can cause nausea & vomiting) Long Term use? Why not? Are there alternatives for procedural pain?

21. Opioid dependent Pts - Pre-operatively Maintain ‘normal’ regime for as long as possible Establish trust and maintain confidentiality Use – long acting preparations; oral route whenever possible and prophylactic laxatives Avoid – short acting preparations; as required doses if possible; parenteral route (if not available consider subcutaneous)

22. DO NOT Use pethidine OR Use a combination of opioids

23. In opioid dependent patients Post-operative period Use tablet rather than liquid form Agree a reducing regime with patient and communicate this in writing to GP, and substance misuse if necessary

24. PLEASE DISCUSS ANALGESIA WITH YOUR PATIENT - YOU WILL GET BETTER COMPLIANCE IF YOU PRESCRIBE WHAT THEY SAY WORKS OR WHAT THEY USUALLY TAKE

25. GET HELP! Use the prescribing guidelines on the intranet Avoiding opioid confusion poster Follow this link on intranet for more information: http://nww.bsuh.nhs.uk/clinical/teams- and-departments/division-of- medicine/acute-pain

26. If you call the pain team You need to tell us name, age, consultant, diagnosis then - eGFR Current drug regime We often will not come without a diagnosis ALWAYS CHECK WHETHER THE NURSES HAVE TRIED ALL THEIR PRESCRIBED MEDS FIRST!