Analgesics

Simple non-opioid analgesics Paracetamol: 1g 4-6 hourly, oral as tablets or liquid;

suppositories available. No contraindication in liver disease; useful in mild to moderate pain. Anti-inflammatory drugs Ibuprofen 800mg or diclofenac 75-100mg bd as slow release formulations can be synergistic with other analgesics; combined formulations of diclofenac with misoprostol may reduce risks of gastric irritation bleeding; useful in combination with paracetamol or weak opioids Weak opioids Dextropropoxyphene 100mg usually combined with paracetamol 1g as coproxamol tablets; usual dosage is 2 tablets 6 hourly or codeine 30-60mg or dihy-drocodeine 30-60mg up to 4 hourly provide effective analgesia for moderate pain. Confusion, drowsiness may be associated with initial usage in some. Weak (and strong) opioids cause constipation; usually requires simple laxatives Strong opioids Morphine available as liquid or tablets commencing at 5-10mg and given 4 hourly is treatment of choice in severe pain. Once daily requirements are established patients can be 'converted' to 12 hourly slow release morphine preparations. Breakthrough pain can be treated with additional doses of 5-10mg morphine. Diamorphine preferred for parenteral usage. Highly soluble and suitable for use in a syringe driver for continuous administration or as a 4 hourly injection.

Alternatives to opioids Tramadol may be given orally. Fentanyl given as slow release transdermal patches may be a valuable alternative to slow release morphine for moderate to severe chronic pain.

For chronic pain give analgesia PO regularly, wherever possible.

• Pain control is very specific to the individual patient, there is no 'correct' formula other than the combination of measures which alleviate the pain.

• The clinician should work 'upwards' or 'downwards' through the levels of available analgesics to achieve control.

• Constipation due to analgesics should be managed with aperients.

• Nausea or vomiting may occur in up to 50% patients with strong opiates; cyclizine 50mg 8 hourly, metoclopramide 10mg 6 hourly or haloperidol 1.5mg 12 hourly are available options to limit nausea or vomiting.

• Additional general measures include

- Radiotherapy for localised cancer pain.

- Physical methods e.g. TENS or consideration of nerve root block.

- Surgery, especially in myeloma where stabilising fractures and pinning will relieve pain and allow mobility.

- Encouraging/allowing patients to utilise 'alternative' approaches. including relaxation techniques, aromatherapy, hypnosis, etc.

• Additional drug therapy

- Antidepressants e.g. amitriptyline may help in neuropathic pain.

- Anticonvulsants e.g. carbamazepine may be helpful in neuropathic pains especially in post-herpetic neuralgia.

- Corticosteroids, particularly dexamethasone, to relieve leukaemic bone pain in late stage disease.

Many hospitals also run specific pain clinics. The support and expertise available should be enlisted particularly for difficult problems with persistent localised pain e.g. post-herpetic neuralgia. For long term painful conditions it is essential to work with medical and nursing colleagues in Primary Care and in Palliative Care so that the patient receives appropriate support in the community setting.

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