1. Pain management in the community setting in 2010
Lynn Grigg MSc
Senior Nurse Specialist for Pain Management
In 1990 the Royal college of surgeons and anaesthetists published a report advising all general hospitals to create an acute pain service

2. Pain Assessment
How bad is the pain on movement, coughing, deep breathing?
Where is the pain?
Does the pain come and go?
How long have they had the pain?
What makes the pain worse/better?
What is the quality of the pain?
Is there a clear reason for the pain?
Use the 0-10 visual analogue scale or verbal rating scale (for children use the 0-3 and smiley faces scale – for neonates use the FLACC assessment tool)
Amount of pain should be related to past experiences of pain.
Use a body chart if there are multiple sites of pain.
ie hours, days, weeks, months, years.
is the pain of sudden onset or the pain changed lately?
Not all pain is responsive to opioids – give a test dose (caution in the opioid naïve).
Don’t forget about non-pharmacological treatments ie positioning.
ie shooting, stabbing, pins and needles, numbing, burning.
long term neuropathic pain usually needs a multi-modal approach – see analgesic ladder.

3. Treat the pain
Treat according to pain score not your perception of how bad the pain should be
Don’t be afraid to try strong opioids
Patients with long term, chronic pain may benefit from psychological intervention

4. Misconceptions
Potential side effects of opioids make them too dangerous to use for pain in the elderly
Alzheimer’s patients and others with cognitive impairment do not feel pain and their reports of pain are most likely invalid
Elderly patients report more pain as they age
Guidelines
Observation of nursing staff
Checking on Epidural patients 2 per day – this will be addressed later
PCA 1 a day
Good assessment means on movement on coughing-
site of pain
type of pain
duration of pain
density of pain (pain score)
possible cause of pain
Most importantly, asking the patient
Aiming for simplicity will be addressed later
Education is an enormous part of my job. Expand

5. Addressing the Myths Opioids cause respiratory depression (rare)
Opioids are addictive (rare)
Analgesia inhibits diagnosis (no it doesn’t)
Pain is character building (no it isn’t)
Pethidine: build up of matabolites and can cause toxcisity - IM
Good assessment should tell you appropriate analgesia
If you write mg of Pethidine patient will get 50
Avoid peaks and troughs
Paracetamol / Codeine see Oxford pain chart (Senna)
Codydramol – 10mg dihydrocodeine /paracetamol 500mg
NSAIDs - prohibits the synthesis of prostaglandins
not good in renal patients, asthmatics, on Warfarin, some bowel surgery patients, gastro
Good patient management can mean earlier discharge – chest infections, blood clots

6. Benefits of good pain management
Patient satisfaction
Reduced morbidity
Early mobilisation
Decrease DVT / chest infections etc
Staff satisfaction
Cost implications

7. Harmful effects of unrelieved pain
Endocrine - increase in release of some hormones
decrease in insulin, testosterone
Cardio - >heart rate, cardiac output,
hypertension
Respiratory - < flows and volumes, cough
Gastro <gastric and bowel motility
Future pain - chronic pain syndrome
Quality of life - sleeplessness, anxiety, fear,
thoughts of suicide

8. General points
Patients prefer comfort and freedom from side effects rather than a total absence of pain
A combination of drugs should always be considered
Pain management should be tailor made for each patient
Analgesics are commonly prescribed badly

9. The WHO analgesic ladder
Strong opioid
Paracetamol
+/- NSAID
+/- Adjuvants
Mild to moderate opioid Paracetamol /- NSAID /- Adjuvants
Paracetamol /- NSAID

10. Sensible prescribing in the community
3 key medications
Regular Paracetamol
Regular Opioid – some care in the elderly but prescribe to pain score not age
NSAID – care in the elderly and those with renal impairment

11. Golden rules Listen to and believe your patient Remember to: K Keep
I IT
S Simple
Be aware of what to look for as you will probably be the first port of call for the ward nurse
Epidural - traditionally nursed on HDU ITU now on wards
What we have is mixed bags Fentanyl 2mcg per ml with Bupivicaine 0.1%
Fentanyl is highly lipid soluble and has rapid onset and subsequently a short half life making it very safe to use in the Epidural space
Bupicicaine is a vasodilator and can cause hypotension - retension of urine
Look for other causes of hypotension - hypovolaemia
Ask for help

12. Summary Good pain assessment - act on pain score >3
Always believe the patient
Prescribe simple, regular analgesia alongside more complex regimes
Remember, don’t be afraid to admit gaps in your knowledge