Pain is the most common symptom of disease. It is an unpleasant sensation localized to a part of the body. It is often described in terms of a penetrating or tissue-destructive process (e.g., stabbing, burning, twisting, tearing, squeezing) and/or of a bodily or emotional reaction (e.g., terrifying, nauseating, sickening).
Any pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling.
Diagnosis
Self-report is the key to pain assessment. In non- or pre verbal children, facial expression is the most valid indicator of pain; therefore use faces pain scale to assess severity. Pain should be assessed by:
- Duration
- Severity, e.g. does the patient wake up because of the pain
- Site
- Character, e.g. stabbing, throbbing, crushing, cramp like
- Persistent or intermittent
- Relieving or aggravating factors
- Accompanying symptoms
- Distribution of pain
- In children pain can be assessed by childs’ crying voice, posture, movement and colour.
Treatment for Acute and Mild pain
Aspirin, Paracetamol, and Non -steroidal Anti-Inflammatory Agents (NSAIDs); these drugs are considered together because they are used for similar problems and may have a similar mechanism of action.
Adult
- A: Acetylsalicylic acid 600mg every 4 hours until pain subsides, OR,
- A: Paracetamol 500- 100mg every 6-8 hours until pain subsides.
Children
- A: Paracetamol 15 mg/kg/dose 4–6 hourly when required to a maximum of 4 doses per 24 hours;
Treatment for Severe Pain
Opioids are the most potent pain-relieving drugs currently available.They have the broadest range of efficacy, providing the most reliable and effective method for rapid pain relief.
Adults
- C: Tramadol tablets or injection 50-100mg every 6 hours or until pain is controlled, OR,
- C: Morphine 10mg IV every 6 hours on a “when necessary” basis;
Children
- 0.2mg/kg body weight IV every 6 hours.
For sugery and obstetric conditions
- C: Pethidine 100mg IM/ IV every 6 hours when necessary.
Do not administer morphine in:
- advanced liver disease
- severe head injury
- acute asthma
- advanced chronic obstructive bronchitis, emphysema or other
- respiratory disease with imminent respiratory failure
- untreated hypothyroidism
Use morphine with extreme care if there is:
- Recent or concurrent alcohol intake or other CNS depressants
- Hypovolaemia or shock
- In the elderly
Referral
Refer to Regional and Tertiary care for:
- All children with moderate and acute severe pain
- No response to oral pain control and unable to initiate opioids therapy
- Uncertain diagnosis
- Management of serious underlying conditions
Treatment for Chronic Non Cancer Pain
Chronic pain is a pain that persist for more than 4 weeks chronic pain can arise from:
- Tissue damage (nociceptive pain), e.g. arthritis, fibromyalgia’s, lower back pain, pleurisy, cancer pain etc
- Injury to nerves (neuropathic pain) e.g. post herpetic neuralgia (pain following shingles), trigeminal neuralgia, diabetic neuropathy, HIV related peripheral neuropathy, drug induced peripheral neuropathy or phantom limb
- Abnormal nerve activity following disease
Psychological evaluation and behaviorally based treatment paradigms are frequently helpful, particularly in the setting of a multidisciplinary pain-management center.
Drug Treatment
Mild Pain
- Adult: A: Paracetamol 1000 mg (O) 6 hourly until pain subsides
Moderate pain (Including neuropathy)
- Adults: If still no relief to simple analgesics as above, add
- C: Tramadol 50 mg (O) 4–6 hourly as a starting dose (May be increased to a maximum of 400 mg daily)
Adjuvant therapy
- Adults: In addition to analgesia as above add antidepressants;
- C: Amitriptyline 25 mg (O) at night; Maximum dose: 75mg.
Anticonvulsants and Antiarrhythmics may also be helpful in neuropathic pain. Give Phenytoin or carbamazepine.
Referral
- Pain requiring strong opioids
- Pain requiring definitive treatment for the underlying disease
- All children
Chronic Cancer Pain
The long-term use of opioids is accepted for patients with pain due to malignant disease. Some degree of tolerance and physical dependence are likely with long-term use.
Therefore, before embarking on opioid therapy, other options should be explored, and the limitations and risks of opioids should be explained to the patient.
