Adult Pain Management Guideline

Version / 2
Name of responsible (ratifying) committee / Acute Pain Service
Date ratified (Pain Services) / December 2015
Date Agreed / 18 January 2016
Date Agreed locally / May 2016
Anaesthetic Clinical Governance Committee
Date agreed by Formulary and Medicines Committee / 20 May 2016
Document Manager (s) / Dr Maya Kai, Consultant in Anaesthesia & Acute Pain
Sister Charlotte Bellis, Specialist Nurse Practitioner
Sister Claire Wyman, Specialist Nurse Practitioner
Date issued / 01 November 2016
Review date / 31 October2018
Electronic location / Trust Clinical Guidelines web page
Acute Pain Service web page
Anaesthetic Department web page
Related Procedural Documents / Paracetamol for acute pain in adult patients
NSAIDs for acute pain in adult patients
Management of PCA, epidurals, peripheral nerve catheters
Specialist guidelines for Chronic Pain, Palliative Care, Paediatric Pain Management
Key Words (to aid with searching) / Adult Acute Pain Management
Acute Pain Service

CONTENTS LISTPage

Quick Reference Adult Acute Pain Management Ladder3

1. Introduction4

2. Status4

3. Purpose4

4. Scope/audience4

5. Definitions5

6. Clinical Process6

7. 1. Clinical Practice Guideline7

2. Specialist Pain Teams8

3. Interventions9

1. Non-pharmacological

2. Pharmacological Adult analgesic ladder10

Common analgesics11-15

Paracetamol11

NSAIDs11-12

Opioids12-15

Specialist interventions15

4. Adjuvants16

8. Patients with Additional/Special Needs 17-20

1. Older patients17

2. Renal dysfunction18

3. Neuropathic pain18

4. Opioid tolerant patients/substance misuser disorder19

5. Palliative care19

6. Obstructive Sleep Apnoea20

7. Pregnancy20

8. (Paediatric/neonatal patients)20

9. Training21

10. Supporting Evidence22

APPENDICES

Appendix 1:Use of the Abbey Pain Scale23-24

Adult Pain Management Guideline

Version: 2

Issue Date: 01 November 2016

Review date: 31 October 2018 (unless requirements change)Page 1 of 26

Adult Pain Management Guideline

Version: 2

Issue Date: 01 November 2016

Review date: 31 October 2018 (unless requirements change)Page 1 of 26

  1. Introduction/Background

Most patients experience pain or discomfort.

The presence of pain causes distress and anxiety for patients.

PHT believes that it is the right of all patients to receive adequate and appropriate pain relief.

  1. Status

This is a Portsmouth Hospitals NHS Trust clinical guideline

  1. Purpose

The relief of pain and discomfort is a fundamental objective of any health service and health care provider. Accurate and regular assessment of a patient’s pain and appropriate intervention reduces the risk of pain limiting an individual’s daily function. Optimal pain management reduces post-op complications and facilitates early or timely discharge.

This guideline describes the standards of care to be provided to Portsmouth Hospitals NHS Trust patients experiencing pain or discomfort.

  1. Scope / Audience

This guideline applies to all patients under the care of Portsmouth Hospitals NHS Trust and is for all health care providers involved in the direct care of patients. The guideline provides guidance on therapeutic choices and dosing of medication for pain relief.

It is intended to be used in conjunction with specialised guidelines provided by The Acute, Chronic Pain and Palliative care services. This and specialised guidelines are intended for guidance only. Health care providers should appreciate that there are no didactic protocols and need to recognise the importance of managing each patient episode as appropriate on an individual basis.

Acute Pain, Chronic Pain and Palliative Care Services (and any consultant anaesthetist acting on behalf of the Acute or Chronic Pain Services) provide specialist services and may not adhere to the advice in this guideline.

It is outside the scope of this guideline to cover all information about all analgesics - please refer to the eBNF, Electronic Medicines Compendium (EMC) or other appropriate resources for further information before prescription or administration.

Heath care providers need to be aware that it is their responsibility to access educational resources regarding pain management as appropriate to their clinical responsibilities. Help and advice regarding educational resources should be sought from line managers, educational supervisors and/or the Acute Pain Service.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

  1. Definitions

Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” International Association for the Study of Pain (IASP)

Acute pain

Pain associated with acute injury or disease

Chronic Pain

Pain that has persisted for longer then 3 months or past the expected time of healing following injury/disease

Palliative Care

Palliative care is the active total care of patients and their families, usually when their disease is no longer responsive to potentially curative treatment, although it may be applicable earlier in the illness.

Pain Management

Pain management is a multidisciplinary approach to the assessment and treatment of patients with pain(Pain Management Services: The Royal College of Anaesthetists and the Pain Society)

Health Care Professionals

Registered Practitioners

Non-registered Practitioners

Practitioners in bands 2 - 4

Wessex Pain Score

0 = no pain at rest or on movement

1 = no pain at rest, mild pain on movement

2 = moderate pain at rest or on movement

3 = severe pain at rest

Rescue dose

An as-neededdose of medicationforsporadicworsening of pain not controlled by regular pain medication (also called breakthrough dose)

  1. Clinical Process

The provision of pain management for patients in PHT is underpinned by the following principles:

  • Pain management is the responsibility of all members of the multidisciplinary team
  • Pain will be anticipated wherever possible and appropriate prophylactic interventions instigated e.g. prior to painful procedures
  • Patients should receive an initial and then regular pain assessment(s) subsequently as part of their care
  • All patients with pain should have evidence of pain management and a management plan recorded in their notes
  • Pain assessment should be formally documented on patient observation charts or relevant devices such as vitalpak
  • Pain intensity should be measured using the Wessex Pain Score (verbal rating Score) and recorded on Vital Pac or the patients observation chart/record of care. (Some departments may use the verbal rating 1-10 score).

This pain scale may not be appropriate for all adult patients, such as those with learning disabilities and/or dementia. In these cases the Abbey Pain Scale may be found to be more appropriate (see appendix1)

As pain intensity is subjective, it is impossible to mandate when pain relief should be administered. However any painful episode should be assessed and managed as appropriate to that individual.

  • Pain will be reassessed and documented as part of each set of vital signs
  • Within an appropriate time after pain relief intervention (i.e. when pain relief action is anticipated)
  • After any procedure or activity anticipated as being painful
  • At intervals determined by ongoing chronic pain issues
  • With each new report of pain
  • Pain assessment, intervention and effectiveness will be documented. Ineffective pain relief or an ineffective management plan should be documented and appropriate senior help sought prior to specialist help.
  • All health care providers should be appropriately trained in the effective management of pain according to their clinical responsibilities (see training section 8)
  • All aspects of pain management will be regularly audited or audits managed by the Acute Pain Team

7.1 Clinical Practice Guideline

All health care professionals are responsible for

  • Assessment
  • Planning
  • Implementation of action plans
  • Evaluation
  • Clear documentation
  • Liaison with all members of the multi-professional team

All non-registered Practitioners

  • Assess the patient using the Wessex or other appropriate pain score
  • Report and document
  • Liaise with all members of the multi-professional team

Doctors, Dentists and Non-Medical Prescribers are responsible for:

  • The prescribing of appropriate medication and regular daily review
  • Completion of clear unambiguous prescription sheets (refer to Medicines Management Policy for completing prescription sheet)

All Health Care Professionals have a role in the

  • Initial and ongoing assessment of pain
  • Provision of non-pharmacological pain relief intervention (see 7.3.1)
  • Administration of prescribed medication in a timely and non-judgemental fashion
  • Monitoring effect of medication
  • Ensuring non registered practitioner given delegated tasks are competent to undertake said task
  • Provisions of therapies and aids to support pain relief

Pharmacists are responsible for monitoring prescribing practice and that medicines prescribed within The District Formulary are available.

7.2 Specialist Pain Teams

For specialised areas of pain management, Portsmouth Hospitals NHS Trust provides an Acute Pain Service, a Chronic Pain Service and a Palliative Care Service.

Please note that these are specialist teams (including any consultant anaesthetist who may act on behalf of the Acute or Chronic Pain Services) whose advice and practice in certain circumstances may not be reflected by this guideline.

1. Acute Pain Service

Please note, the Acute Pain Team is not a Trust-wide service.

We currently provide an inpatient service to the following areas:

Surgical Unit (including Head and Neck)

Orthopaedic Unit

Renal/Urology Unit

Gynaecology Unit

Maternity Unit

Paediatrics

The Acute Pain Team consists of 4 Consultant Anaesthetists and 5 Specialist Nurse Practitioners.

Referrals may be made by phone on extension 5890 or via bleep 1645/1643 or 1838.

Out-of-hours – advice may be sought from the second on-call anaesthetist on Bleep 1622 (please note the anaesthetist may not be able to attend as they have other clinical duties)

2. Chronic Pain Service

The Department of Pain Medicine serves patients with chronic pain on an outpatient basis only. Patients needing this service should be referred by their GP. In exceptional circumstances, the Acute Pain Service only may request an in-patient review from the Chronic Pain Team.

3. Palliative Care Team

The Hospital Palliative Care Team is a specialist service working within the hospital which also liaises closely with community services. They work with patients who have a life limiting illness and are experiencing difficulties (such as pain management) at any stage. Guidance can also be obtained from the green ‘Palliative Care Handbook’ (available in all clinical areas).

Contact details

Mon – Fri 0800-2300 Ext6132

Outside these hours, a senior doctor may seek advice from the Rowan’s Hospice

02392 250001

7.3 Interventions

Pain can be managed by a variety of methods comprising pharmacological and non-pharmacological.

7.3.1 Non-Pharmacological Interventions

It is outside the scope of this guideline to include intricate details of non-pharmacological interventions. However, health care providers need to be aware of their importance in the management of all types of pain.

Non-pharmacological interventions may be classified as cognitive behavioural approaches (education, relaxation, distraction) and physical agents (heat/cold, positioning, transcutaneous electrical nerve stimulation – TENS).

Non-pharmacological methods are considered an important element of pain relief and management. These include simple repositioning or ambulating when possible, application of hot or cold packs, distraction or relaxation techniques including deep breathing. Consideration should be given to referring for physiotherapy.

7.3.2 Pharmacological Intervention

Pharmacological methods range from simple oral medication to systemic analgesia including patient controlled analgesia and to specialised interventions such as epidural infusions and specific nerve blocks.

The WHO analgesic ladder

  • Is a long-established systematic approach to the management of pain.
  • Is a statement of principles that should be used and interpreted depending upon individual circumstances and need, rather than a rigid framework.
  • Regular analgesia should be given in timed intervals and on demand (PRN) analgesia should be given promptly when requested.
  • Paediatrics: same principles, but drug doses depend on weight. (Refer to specific paediatric guidelines found on the hospital intranet)

The Portsmouth Hospitals NHS Trust Acute Pain Service suggests a modified analgesic ladder for adults for acute or an acute exacerbation of chronic pain.

Please note it is not intended as a didactic protocol.

It is important that all health care providers recognise the importance of managing each patient episode as appropriate on an individual basis. This includes regular review of any medication and its effect and recognition that analgesic requirements can increase or decrease.

Multimodal analgesia consists of using analgesics with different mechanisms of action simultaneously to produce a synergistic analgesic effect, thus improving the efficacy of analgesia whilst reducing unwanted side effects

Adult Pain Management Guideline

Version: 2

Issue Date: 01 November 2016

Review date: 31 October 2018 (unless requirements change)Page 1 of 26

Adult Pain Management Guideline

Version: 2

Issue Date: 01 November 2016

Review date: 31 October 2018 (unless requirements change)Page 1 of 26

COMMON ANALGESICS

It is outside the scope of this guideline to cover all information about all analgesics.

Please refer to the BNF, the EMC ( or other appropriate resources for further information before prescription or administration.

Paracetamol

  • Effective analgesic and anti-pyretic
  • Regular administration has an opioid-sparing action

( opioid requirements by 20-30%)

  • Integral component of multimodal analgesia
  • Maximum of 4 grams per day (8  500 mg tablets)
  • If patient weighs less than 50kg, the maximum dose is 60mg/kg/day
  • Good oral bioavailability (rectal administration commonly results in sub-therapeutic blood concentrations)
  • Intravenous paracetamol is available only for those patients unable to tolerate oral medication
  • Please ensure patient isn’t also prescribed/receiving any other paracetamol-containing analgesiaeg co-codamol, co-dydramol

NSAIDs - Non Steroidal Anti-Inflammatory Drugs

  • Mechanism of action by inhibition of prostaglandin synthesis (inhibition of cyclooxygenase – COX)
  • Effective analgesia
  • Integral component of multimodal analgesia

opioid requirements (by up to 55%)

inflammation

nausea and vomiting

sedation

  • The lowest effective dose should be used for the shortest duration of time
  • Consider concomitant proton pump inhibitor (PP

Ibuprofen 400mg tds (initial dose) – qds. May increase to 600mg tds/qds if necessary

Ibuprofen is the Trust first-line NSAID of choice.

Ibuprofen negates the cardioprotective effects of low dose aspirin (75mg) in those at high risk of cardiovascular disease. Ibuprofen should be taken at least 30mins after aspirin ingestion or at least 8hrs before aspirin ingestion.

There is limited evidence about the effect of ibuprofen on enteric-coated aspirin

Naproxen e/c500mg bd

Thought to cause least increase in cardiovascular risk but is not particularly effective for acute pain management

Diclofenac 25-50mg tds (max daily dose 150mg/24hrs)

May be used orally or rectally

Use if other NSAIDs ineffective and after careful consideration of individual risks and benefit

Diclofenac (150 mg/day) likely to be more effective than ibuprofen (2400 mg/day) or

naproxen (1000 mg/day)

Cautions

Cardiovascular disease (CVS disease)

Both non-selective NSAIDs (eg ibuprofen, naproxen, diclofenac, meloxicam) and COX2 selective NSAIDs (eg celecoxib) have been shown to cause a small increase in the risk of adverse cardiovascular events in those with cardiovascular disease. The risk is greatest in those with a prior history of cardiovascular disease or in those already at high risk of cardiovascular disease. The risk depends upon clinical context, NSAID and dose.

The risk is low over a short course of therapy and therefore, the lowest effective dose should be used for the shortest duration of time.

Renal Dysfunction

Risk of adverse renal effects increased with pre-existing renal dysfunction, hypovolaemia, hypotension, other nephrotoxins, ACE inhibitors. Risk lower with appropriate patient selection and monitoring

Elderly

At risk of cardiovascular disease and renal dysfunction

Peptic Ulcer Disease (PUD)

Increased risk of PUD in those aged over 64, prior history of peptic ulcer disease and low-dose aspirin therapy.

Co-administration of proton pump inhibitor (PPI) or high dose H2 receptor antagonist decreases risk of endoscopic evidence of PUD.

Impaired Clotting

Exacerbation of platelet dysfunction by inhibiting platelet function

Potentiates effects of anticoagulant therapyeg warfarin, LMWH, NOACs

Asthma

May cause bronchospasm in those with a previous history of sensitivity.

Affects <10% of asthma sufferers

Pregnancy

Contraindicated in pregnancy unless specialist advice.

OPIOIDS

Opioids are the systemic analgesia of choice for moderate to severe pain.

Determination of appropriate dose may be difficult due inter-individual variabilities and pharmacogenetic differences. Suggested doses should be used as a guide only and individual management plans implemented.

Although there is little evidence that any opioid is better than any other, some opioids may be better for some patients.

Determinants of opioid dose

  • Large interpatient variation
  • Patient age - Age rather than weight (2-4 x decrease in opioid requirements with increasing age)
  • Genetics - Response to opioids is affected by genetic variability
  • Psychological factors

Adverse effects

All are dose-related and may be decreased by using multimodal analgesia and opiate-sparing techniques eg concomitant use of NSAIDs, peripheral or central nerve blocks.

Active metabolites may accumulate in renal dysfunction, thus potentiating their action and increasing the risk of adverse events and toxicity.

Morphine and morphine-containing analgesia should not be prescribed for those with an eGFR less than 30mls/min/1.73m2 – please seek specialist advice.

(see 8.2 for dose adjustments in renal impairment)

Respiratory depression & sedation

  • Can be avoided by careful attention to titration of dose against effect and appropriate monitoring
  • Respiratory rate is a poor indicator of respiratory depression
  • Best early clinical indicator is increasing sedation

(NB Concomitant sedative medications)

  • Administration of opiates to achieve desirable pain scores increases the risk of respiratory depression

Nausea & vomiting

  • Common and dose-related
  • Decreased by concomitant anti-emetic therapy (combinations of anti-emetics are more effective)

Confusion and decreased cognitive function