Pain Relief

Consider simple measures as well as taking pain killers. Elevate the affected limb to the level of the heart or just above. Rest the affected limb.

The following advice is generic advice for patients on no regular medication with drug allergies, and no medical problems.  You should discuss pain relief with the medical professional who is treating you. If pain not responding to simple pain killers in acute injury seek further medical attention.

See post operative advice

There are four main goups of pain killers:

1. Paracetamol

2. Non Steroidal anti-inflammatory drugs  – NSAID’s (ibuprofen, diclofenac, naproxen)

3. Opiates or opioids (morphine/ codeine compounds)

4. Other

All the groups of pain killers above work in different ways and act on different places hence one kind to pain killer from each group can be used in isolation or in combination with pain killers from other groups.  It is possible to mix all the above medication as long as they are in their pure form and you use only one pain killer from each group.

Please ensure you read the information on the box or on the paper inside to find out what is contained within the tablet.  For example the “co “tablets ( Co dydramol, co codomol, co proxomal) are combination drugs usually containing paracetamol mixed with a drug from the opioid group. Therefore it is not safe to take these plus a further paracetamol tablet.

Some over the counter preparations of ibuprofen may contain paracetamol and or codeine.

1. Paracetamol

Paracetamol offers good pain relief with minimal side effects.  This should be your first line pain relief, and then consider a further drug from group 2 if you still have pain.

The standard dose for an adult is 1 Gram of paracetamol every six hours ie 2 x 500mg tablets 4 times a day (Max 8 x 500mg tablets per day).

2. NSAID’s – (Non Steroidal Anti Inflammatories) e.g Ibuprofen

NSAID’s are very good for muscle, bone and joint pain.

The main side effects and complications of NSAID’s in the short term is on the stomach (indigestion, heartburn and ulcers), long term use is associated with kidney damage. It is therefore important to take them with food, and discontinue use and consider seeking medical advice if you get stomach pain.

Asthma can be made worse by NSAID’s, patients with severe brittle asthma are probably better off avoiding NSAID’s.
Some NSAID’s may be associated with increased risk of heart problems.

There are several different kinds of NSAID, no one NSAID is perfect for everyone. NSAID’s softer on the stomach are available and it is possible to take medication to soften the effects of NSAID’s on the stomach.

Although they are very good for reducing pain from broken bones (fractures). NSAID’s have been shown to slow down bone healing following fractures. For most fractures this is only a small effect, however if you have a fracture that is being slow to heal (unite) or a fracture of a bone that is known to be slow to heal, then they are best avoided or only used if the pain cannot be controlled with the other kinds of pain killers.

No perfect NSAID exists for everyone and it is best to find the one that suits you.

BEWARE NSAIDS thin the blood a little and increase the effect of warfarin and other blood thinning drugs (aspirin, clopidogrel, plavix)
BEWARE if you have stomach ulcers, asthma, kidney problems angina or heart failure – consult your doctor.

• Ibuprofen, brufen, nurofen – Over the counter NSAID, very good, safe and low side effect profile

  Standard dose 400mg 8 hourly best taken after meals./p>

• Voltarol, Diclofenac – Slightly stronger than Ibuprofen, still well tolerated. Long acting versions available and combination compounds to help protect the stomach

  Standard doses 50mg 8hourly or longer acting 75mg 12 hourly.

• Naproxen, Naprosyn – Very good perhaps better choice for long term use (months/ years)

  Standard doses 250-500mg 12 hourly

• Aspirin is about the same strength as paracetamol and is a weak NSAID. It is used more frequently in low doses (75mg) now to “thin the blood a little” more so than for its NSAID and pain killing action. Low dose aspirin can be taken with another NSAID, avoid taking high dose aspirin and another NSAID as the stomach and kidney side effects are magnified.

3. Opiates / opioids (e.g. Codine, Dihydrocodine, Tramadol)

Morphine is s a kind of opiate, several derivatives are available of varying strength. The main complication and side effects of the opioid analgesics are: drowsiness, loss of concentration, nausea, vomiting and constipation.  Generally the stronger the opioid in terms of pain killing effect the more the side effects.

The body does get used to the opioids and the side effects of nausea do decrease. Anti-sickness medication may be prescribed to take with the stronger opioids like morphine.

Ensure you actively take steps to avoid constipation.  Such as drinking lots of fluid, increasing the fibre in your diet, consider mild over the counter laxatives if becoming constipated.

Patients often worry about developing addiction to morphine and the opioids. This is not normally a problem in the acute situation.

• Codeine phosphate – Very good, safe at standard doses Nausea, drowsiness and constipation are common side effects. Standard dose 8mg to 60mg 6 hrly.

• Tramadol – Very good, safe at standard doses. Best avoided if history of seizures (fits) or history of epilepsy. Some patients feel “spaced out”, disconnected from the world.
  Standard dose 50mg to 100mg 6hrly

• Morphine/ fentanyl pain patches – Pain patches very good for sustained long lasting pain control.

4. Other

In certain circumstances medication that “calms nerves down” might be used. Often types of antiepileptic medication.

• Amitryptiline – Helps with pain and mild sedative to help patients struggling to sleep at night.

  Standard dose (for pain not epilepsy)10-25 mg at night

• Carbamazepine

  Standard dose 100mg 12hrly

• Gabapentin – Gradually increase dose till effect noted. Avoid suddenly changing or stopping.

  Standard dose 100mg 8hrly for 3 days then increase by 100mg every 3 days till target dose met or taking 1800mg per day in divided doses.