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).