PAIN
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.
1.1 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.
CAUTION‼ Opioids may cause respiratory depression; therefore use opioids carefully. In case
of toxicity, reverse with the narcotic antagonist naloxone.
C: Naloxone 0.1-0.2mg IV intermittently. Max. dose 10mg
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
Pain Associated with Trauma or Inflammation
See under Trauma and Injuries section
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
Pain Associated with Trauma or Inflammation
See under Trauma and Injuries section
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 (For detailed information, refer to Malignant Disease
chapter).
