Managing pain

178361875The World Health Organisation developed the analgesic ladder in 1986 to provide a framework for physicians to use when developing treatment plans for pain.

The analgesic ladder helps medical practitioners prescribe the right medication for their patient’s pain. Starting with simple medications and adding strong pain medications allows the pain medications to work together for maximum benefit with the least side effects.

Professor of Emergency Medicine Ian Rogers says it is a useful tool for deciding which pain medications to give patients when they come into the emergency department.

“There are four steps in all, and if you find yourself past the second step, you will need to consult a health practitioner,” says Professor Rogers.

“It’s best to take what you need to before the pain gets too bad.

“It’s much more difficult to treat pain when it’s already out of control.”

At the base of the ladder, sit physical therapies such as the application of splints or slings.

The next rung is over-the-counter medication such as ibuprofen and paracetamol. Both of these are effective and helpful in saving the use of stronger medications later on. Ibuprofen is slightly more effective, as it has an anti-inflammatory effect. Both are relatively safe when taken in prescribed doses, but can be harmful when taken over the long term or in excessive amounts without a doctor’s review. An overdose of paracetamol is toxic to the liver and ibuprofen can cause gastrointestinal upset and worsen kidney function.

The next step is an oral opioid such as Tramadol or Panadeine Forte. Oxycodone, Morphine and Buprenorphine are stronger opioids that are restricted to severe pain.

The last rung on the ladder is the injectable opiates such as morphine. If injectable morphine is required then patients might be prescribed a Patient Controlled Analgesic which enables them to administer levels of pain medication
that suits their needs. This system gives patients control over their dosage, but is designed so they are not able to overdose on the medications.

Anaesthetist and Pain Specialist Dr Roger Tan says good post-operative pain relief, which may include opioids, is the main determinant in reducing the risk of chronic pain.

“Morphine-type medications are strong and useful for short periods of time for management of pain, for example, to continue with rehabilitation after orthopaedic surgery or acute back pain,” says Dr Tan.

“It allows the patient to mobilise, improves range of motion and maintains their normal function.”

However, a real concern with using opiate or morphine-type medication is the side effects such as excessive drowsiness, impact level of breathing, nausea, vomiting and constipation.

“Morphine medications should also be kept to short term use to reduce the risk of addiction and dependence,” says Dr Tan.

“Opioid medications should be restricted to less than one month after surgery at the very most.”

“If opioid medication is still being required after three months, then careful management will be required by your doctor.”

Recent advances in pain medication include drugs designed to specifically target nerve pain. Medication like Pregabalin (Lyrica) has been useful in treatment of nerve pain but also severe acute pain.

How about the natural alternatives?
“Complementary therapies such as acupuncture, massage and aromatherapy are not well supported medically but if they make people feel better, then they are a valid form of pain relief,” says Professor Rogers.

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