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CDHB

Acute Persistent Pain and Chronic Pain in the Non-Cancer/Non-Palliative Setting

Acute Pain

• Good management of acute pain reduces the chance of developing persistent pain.
• Frequent pain assessment is essential to good pain management and to quality of life.
• Measure pain, "the fifth vital sign". Pain needs to be measured alongside temperature, blood pressure, heart rate, and respiratory rate.

Risk Factors for Acute Persistent Pain

Identify patients with high risk factors for developing persisting post surgical pain (see Summary - Recommendations in the Prevention and Management of Acute Persistent and Chronic Pain), and follow up after discharge.

Chronic Pain

• Chronic pain is pain that persists and lasts beyond the usual healing period. One in six (16.9%) New Zealanders report chronic pain. Chronic pain remains a major public health problem.
• The biopsychosocial model is helpful here. Patients' understanding and interpretation of symptoms (beliefs and cognition) can modulate their pain experience. Patients with psychological risk factors (fear avoidance, catastrophizing, pain behaviour, depression), can be identified and early preventative measures instituted.
  • Assessing patients with chronic pain includes a full medical history and detailed examination according to a biopsychosocial approach and applying 'universal precautions' to make a misuse risk assessment.
  • A management plan should consider a range of non-opioid modalities, with a focus on active rather than passive strategies. Integrated multidisciplinary pain services have been shown to improve pain and function outcomes for patients with complex chronic pain issues, but access is often limited.
  • Time-limited opioid use is recommended with initial and regular monitoring, including pain and function scores, urine toxicology, compliance with regulatory surveillance systems and assessment for adverse reactions and drug-related aberrant behaviours.
  • When ceasing prescribing, opioids should be weaned slowly, except in response to violence or criminal activity. Seek advice.
• Refer the patient to the Pain Management Centre, Burwood Hospital.

Reference: Holliday S, Hayes C, Dunlop A. Opioid use in chronic non-cancer pain--part 2: prescribing issues and alternatives. Australian Family Physician 2013;42(3):104-111.

Pharmacological Treatment of Acute Persistent Pain and Chronic Pain in the Non-Cancer/Non-Palliative Setting

• Note allergies, drug intolerances, contra-indications, and adverse effects.
• Analgesics should be individually tailored and monitored.
• Start low and go slow (except in cancer/HIV pain).
• Provide multimodal analgesia with a baseline of regular paracetamol.

Primary Analgesics

• Paracetamol: oral dose is 1000 mg four times daily in the adult patient (TDS may be sufficient in smaller or frailer patients).
• Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen (200 mg eight hourly), diclofenac (50 mg eight hourly), and naproxen (250 mg twelve hourly).
• Tramadol: start oral tramadol; immediate release 50 mg six hourly or tramadol slow release 50 mg twelve hourly. (The long-acting tramadol preparation of 50 mg is not funded in the community; higher long-acting tramadol doses are funded.)
• Strong opioids:
  • These are generally not used in chronic non-malignant pain.
  • Cancer pain of moderate to severe intensity should be managed with the systemic administration of strong opioids.
  • Full opioid agonists include morphine, oxycodone, methadone and fentanyl (usually used transdermally in cancer pain).
  • Consult the Senior Registrar/Consultant if strong opioids are required.

    Note: Pethidine is no longer considered a first-line analgesic and should not be used.

Secondary Analgesics (or Co-Analgesics)

• Antidepressants: start with nortriptyline 5 mg to 10 mg nocte.
• Anti-epileptics (anti-convulsants): start with gabapentin. Starting dose is 100 mg eight to twelve hourly (a tricyclic must have been trialled prior to gabapentin for Special Authority to be granted).

Peripheral Neural Blockade

• Local anaesthetic blocks (0.2% ropivacaine, 0.25% bupivacaine) can be used for diagnostic purposes or act as an aid to physical therapy with corticosteroids (triamcinolone acetate 40 mg, methyl prednisolone acetate 40 mg). Consult the Senior Registrar/Consultant.

Summary - Recommendations in the Prevention and Management of Acute Persistent and Chronic Pain

Topic Code: 9437