---

You are called to the ward to see a patient in pain.

1. Look at the patient
2. What are they admitted for?
   1. PMHx, medications.
   2. Timing is important!
3. Brief medical assessment/examination – can you find the cause of the pain?
4. WHAT COULD I BE MISSING?
5. Is the patient safe? Unsafe? Likely to deteriorate?
   1. Consider blood tests/imaging as needed
   2. Plans in place to ensure follow up
6. How to treat pain:
   1. Non-pharmacological
   2. Surgical
   3. Pharmacological

• RICE
• Reassurance/education
• Pillows/tents/slings/bandages/bandaids
• Psychology

Surgical

• Drainage of collection/effusion/abscess
• Re-dressing of wound
• Decompression of whatever is inflated

Pharmacological

Basic principles:

• Don’t forget basic drugs! They work for lots of things….
• Start with gentle, then move to the big guns
• Always give an oral AND an injectable option
• If in doubt, use short-acting analgesics first
• ALWAYS ASK FOR ALLERGIES
• Only an idiot prescribes a drug without at least a basic understanding of the major side effects. Just ask the coroner!
• Reassess and follow up
• If in doubt, ASK SOMEONE! We are not alone…

If you want the drugs:

Panadol

• Safe for most patients, even hepatic encephalopaths
• Cheap
• Can be given IV, but costs more
• Few side effects
• Good for baseline analgesia (1g QID PO)

Aspirin

• Often forgotten, but good for back pain, inflammation
• Always ask about GI bleeds, asthma, previous serious bleeds

NSAIDS

• Useful for inflammatory pains.
• Ibuprofen 200-400mg tds/prn po. PR options available.
• Always ask about GI bleeds, asthma
• Can be given with a bit of pantoprazole if you’re keen

Oxycodone

• Dose for adults 18-60 years of age: 5-20 mg Q4H/PRN. Older adults: 2.5 or 5 – 10mg Q4H/PRN.
• Please warn patient about constipation, and consider coloxyl and senna (2 tabs bd). Interns are usually the disempactors, so do yourself a favour!
• Use for breakthrough pain relief

Morphine

• IV (only in ICU/ED), SC, IM. Dose according to age.
• Patients on morphine type drugs will have tolerance, so may need higher doses.
• Side effects to know: respiratory depression, hypotension, bradycardia, nausea and vomiting, constipation
• Always prescribe maxolon/antiemetic with morphine
• Consider naloxone if the patient stops breathing.

Fentanyl

• IV (ED/ICU), SC, IM
• 100 mcg fentanyl = 10mg morphine
• Usual doses: elderly 25-50 mcg Q2H/PRN. Younger people: 50-200mcg Q2H/PRN.
• Side effects: as for morphine. Reversal: same as morphine
• Useful for patients allergic to morphine
• Short acting, so if you’re unsure of the effect of opiates on pt, consider fentanyl.

Note: both morphine and fentanyl can cause histamine release, so watch for this. It’s pretty quick to occur.

Left-field options:

Buscopan

• Good for tummy cramps. Safe for pretty much everyone. 20mg PO/IV, qid.

Panadeine forte

• Constipating as anything, but some patients like it.

Benzodiazepines

Non-pharmacological

• I like to use diazepam for muscle spasms, particularly back pain. Lets the muscle relax, and makes the patient calmer (decreases SNS). 10mg diazepam PR/PO.

Remember: pain is a multifactorial thing, so needs a multifactorial approach!

---

_{The pain is immense –
Mountains roll over my brain
My agony – severe}