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Pain Management

By Michelle English, MPSI, Abbey Healthcare Ltd.

Pain is a subjective sensation that must be accepted by others as being whatever the sufferer says it is. One individual's severe pain might be felt as mild and easily tolerated by another. Pain is more common in the elderly as older people are more likely to suffer from arthritis, bone and joint disorders, back pain and other chronic diseases.

Types of Pain

Pain can be categorised according to origin as somatic, visceral or neuropathic.

Somatic Pain arises from the peripheral pain receptors in the skin and musculoskeletal systems. Examples include myalgia, osteoarthritis and tension headache.

Visceral Pain originates in the organs of the thorax and abdomen. Examples include angina, colic and pleuritic pain.

Neuropathic Pain results from injury to the peripheral or central nervous system such as trigeminal neuralgia, post heretic neuralgia and phantom limb pain.

Pain can be either acute or chronic. Acute pain is functional in some circumstances. It prevents further injury by provoking people to move quickly away from harmful stimuli. This fast pain has a quality that is sometimes described as burning, tingling, pulsing, beating or throbbing.

Chronic pain is often described as an ill-defined ache, where the pain is more poorly localised and constantly nagging. This is due to the pain being transmitted by slowly conducting nerves. It is often musculosketol in origin and can lead to the development of a range of co morbidities. If inadequately treated chronic pain will cause depression, sleep disturbance, reduced movement, less socialisation and a poorer quality of life.

Research suggests that for many people, old age and pain are synonymous. Indeed it has been reported that between two thirds and three quarters of nursing home residents experience chronic pain. In older people, pain is the most common symptom of disease and the most common presenting problem in general practitioners surgeries. Some older people are often reluctant to vocalise or report pain, assuming that is part of old age, that it is associated with death and that there is little to be done to alleviate it.

Pain Assessment

Thorough assessment of pain is essential for correct treatment and is based on both the patients' own reports and the clinical signs. With chronic pain, a body chart can be used to indicate the site of the pain while a pain diary and visual analogue scale can be used to record its severity. Using this approach and continuing it during follow-up assessments will allow the determination of efficacy or adverse effects from treatments. It will also help establish whether continuing pain is related to disease progression or not.

1. Mild Pain

Analgesics such as aspirin, paracetemol or NSAIDs are used to treat mild pain. They are even effective in patients already receiving strong opioids who develop mild pains such as tension headaches.

Paracetamol is the analgesic if choice for use in elderly patients. It has antipyretic and analgesic effect, but little or no antiplatelet or anti-inflammatory effects. The mode of action of paracetemol is not fully understood. It is thought that paracetemol exerts its effects by inhibiting prostaglandins in the central nervous system. It causes little or no side effects, but should not be used in patients with liver impairment or in overdose as it is dangerously hepatotoxic. It has to be taken when required or as a regular medication at a dose of two tablets four times daily to keep pain away and patients should be reassured that it is not an addictive drug. Solid dose, liquid and suppository formulations are available. It is also the analgesic of choice for patients receiving warfarin, although chronic use can occasionally enhance warfarins anticoagulant effect.

Non steroidal anti-inflammatory drugs, including aspirin, have pharmacological properties that include analgesic antiplatelet, antipuretic and at higher doses, anti-inflammatory effects. They act primarily by inhibiting the synthesis of prostaglandins from arachidonic acid by peripheral inhibition of the enzyme cyclooxygenase (COX).

Aspirin is indicated for headache, transient musculoskeletal pain and pyrea. In inflammatory conditions most physicians prefer anti-inflammatory treatment with another NSAID which is better tolerated and more convenient for the patient. Aspirin is used increasingly for its antiplatelet properties. Gastric irritation may be a problem but it is minimised by taking the dose after food. Enteric-coated preparations are available but have slow onset of action and are therefore unsuitable for single-dose analgesic use (though prolonged action may useful for night pain). Aspirin interacts significantly with a number of other drugs and its interaction with warafin is a special hazard.

Non-steroidal anti-inflammatory analgesics are particularly useful for the treatment of patients with chronic disease that is accompanied by pain and inflammation. In single doses non-steroidal anti-inflammatory drugs have analgesic activity comparable to that of paracetemol, but paracetemol is preferred particularly in the elderly. In regular full dosage NSAIDs have both a lasting analgesic and an anti-inflammatory effect which is useful for conditions associated with the inflammation for example rheumatoid arthritis. NSAIDs should be used with caution in elderly patients as bleeding associated with aspirin and other NSAIDs is more common in the elderly who are more likely to have a fatal or serious outcome. NSAIDs are also a special hazard in patients with cardiac disease or renal impairment which may again place older patients at particular risk.

Owing to the increased susceptibility of the elderly to the side effects of NSAIDs the following recommendations are made:

  • For osteoarthritis, soft tissue lesions and back pain, weight reduction, warmth and exercise should be tried. Paracetemol should provide adequate pain relief.
  • Alternatively, a low dose NSAID for example, ibuprofen up to 1.2g daily may be given.
  • For pain relief when either drug is inadequate, paracetemol in a full dose plus a low dose NSAID may be given.
  • If necessary, the NSAID dose may be increased or an opioid analgesic given with paracetemol.
  • Do not give two NSAIDs at the same time. The addition of the stomach protectants (proton pump inhibitors) is only partly successful in reducing the risk of gastro intestinal bleeding and does nothing to minimise the risk of renal impairment. Newer COX-2 inhibitors are as effective as non-selective NSAIDs (e.g. diclofenac); however the risk of serious upper gastro intestinal events is lower. COX-2 inhibitors are not free of the risk of renal impairment.

2. Moderate Pain

Weak opioids alone or in conjunction with mild analgesics are the treatment of choice for moderate pain. Dextropoxyphene with paracetemol, dilydrocodeine with paracetemol, codeine with paracetemol and codeine with aspirin are usually used first time. Compound analgesic preparations that contain a simple analgesic such as paracetemol or aspirin with a low dose of opioid (e.g. 8mg codeine phosphate) are commonly used but the advantages have not been substantiated. The low dose of opioid may be enough to cause opioid side effects (in particular, constipation). This can complicate treatment in over dosage and yet may not provide significant additional relief from pain.

Combination products that certain paracetemol and a higher dose of weak opioid (e.g. paracetamol and 30mg codeine) may be less suitable towards the top end of the moderate pain scale because there is a risk of exceeding the maximum dose of non opioid (4g paracetemol). In such circumstances it is better to use codeine, dihydrocodeine or tramadol as single ingredient formulations, adding in paracetemol, aspirin or and NSAID separately if required. Weak opioids particularly codeine, can cause severe constipation. Laxatives may be used prophylatically rather than being withheld until constipation develops. Clinical experience with tramadol suggests it is less constipating. Tramadol produces analgesia by two mechanisms on opioid effect and an enhancement of serotonergic and adrenergic pathways. It has fewer of the typical opioid side effects - less respiratory depression, less constipation and less addiction potential.

3. Severe Pain

Strong opioids such as morphine, oxycodeine, fentanyl, buprenorphine and methadone may be required for most forms of severe continuous pain, such as cancer pain, but may not be as effective in neuropathic pain. Strong opioids may also be used in severe musculosketol pain, but long term use should be avoided.

Morphine is the most commonly used of the strong opioids and is particularly suitable for severe continuous pain of visceral or soft tissue origin. When initiating therapy a dose of 5mg-10mg is enough to replace a weaker analgesic (such as paracetemol or co-proxomoll) but 10mg-20mg or more is required to replace a strong one (comparable to morphine itself). If the first dose of morphine is no more effective than the previous analgesic, the next dose should be increased by 50% to 100% every four hours until the pain is controlled. Once control is established the formulation can be suited to sustained release with a dose interval of 12 hours (MST continues) or of 24 hours (Morcap SR, MXL capsules). It is imperative that doses are given 'around the clock'. Do not wait until the patient experiences pain. If there is a break through pain, immediate release formulation should be given at 1/6 of the total daily dose.

Contrary to popular misconception there is no maximum dose for morphine in such circumstances. When used to control true continuous pain, there is no danger of addiction, tolerance or respiratory depression. As long as with each incremental dose that an incremental degree of analgesic is obtained, it is safe to continue to titrate upwards to optimum pain control. There is no ceiling effect. Constipation with morphine is severe, so laxitaves must be administered, a faecal softener with a peristaltic stimulant (e.g. co-danthramer) or lactulose solution with a senna preparation should be used. Nausea and vomiting may occur with opioid therapy, particularly in the initial stages but can be prevented by giving an anti-emetic such as haloperidol or metoclopromide. Liquid formulations of morphine are available if swallowing is difficult.

Transdermal buprenorphine of fentanyl are alternatives to morphine in the relief of chronic intractable malignant or non-malignant pain. Each patch provides 12 hours continuous pain relief equivalent to that of morphine. The strength of the patch chosen depends on the patients opioid history. Assessment of analgesic efficacy should be made after 72 hours. Immediate release oral morphine or sublingual buprenorphine must be available as required for breakthrough pain or symptoms of withdrawal.

If the patient becomes unable to swallow, the equivalent intramuscular dose of morphine is half the oral solution dose. Diamorphine is preferred for injection because being more soluble, it can be given in a smaller volume. The equivalent intramuscular or subcantenous is approximately a third of the oral dose of morphine. Subcantenous infusion of diamorphine via syringe driver can be useful as it provides good control of symptoms with little discomfort or inconvenience to the patient. Many drugs are compatible with diamorphine in the syringe driver; examples include cyclizine, haloperidol, hyoscine and metoclopromide. Subcutaneous infusion solutions should always be monitored to check for precipitation and discolouration.

Adjunctive Therapy

Some types of pain, for example bone pain, incident-related pain, nerve and cerebral compression pain and neuropathic pain are only partially responsive and may require adjunctive therapy. Adjunct drugs can be used at all stages of the analgesic ladder to enhance the analgesic effect. Corticosteroids can be considered for patients with neurpathic pain from nerve compression or infiltration, bone pain and raised intracranial pressure. Dexamethascone and bethamnethascone are the drugs of choice due to their high glucocorticoid activity relative to mineralocorticoid activity. They have an anti inflammatory effect and reduce compressed pain by reducing oedema.

Gabapentin and pregabalin are licensed for neuropathic pain of all causes including diabethic peripheral neuropathy and postherpetic neuralgia.

Anti-depressants and anticonvulsants - although not all licensed, low doses of antidepressants (e.g. amitriphyline) and anticonvulsants (e.g. carbonazepine) have been shown to be of value in neuropathic pain. Diazepan can be used to relieve associated muscular spas, in musculosketol pain, but should only be used for acute episodes.

If pain control cannot be achieved by drugs, non-pharmacological procedures may be tried. These include acupuncture, transcutaneous electrical nerve stimulation, physiotherapy and surgery.

Pain control is a very important aspect in care of the elderly. Pain can affect people's appetite, ability to sleep, energy levels, motivation, mood, and relationships with others. Absence from pain can improve patients' quality of life greatly. It is important to monitor your patients' pain and also the pain relief that they are receiving in order to ensure efficacy. All patients taking analgesics should also be monitored for side effects of drugs and be reassessed if necessary. If chronic pain continues despite treatment the patient should be referred to a pain specialist or palliative care expert. It is important to recognise the full extent of pain in the elderly population and to manage it appropriately.