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Pain Medication

Pain medication – a short summary by Dr Lucy Williams is a Specialist in Anaesthesia and Pain Medicine at The Great Western Hospital, Swindon.

Last updated 28th June 2023

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A note from Pete Moore

I get many emails from people about pain medications and I am unable to answer. So, I thought it would be useful if to ask a Pain Healthcare Professionals to write a short and easy to understand guide.

Before we begin

It always best to discuss to talk to a GP, Pain Doctor, Prescribing Pain Nurse or Pharmacist, BEFORE taking any pain medication (prescribed or over the counter).

Introduction

Pain medication can help pain but rarely takes it away completely
Medication should be part of a plan, not the only tool used to manage pain
Side effects and loss of effectiveness over time are common

Ways to take pain medication

As required – when the pain is bad or before doing something likely to increase pain levels
Regularly – ‘by the clock’ to try and provide consistent pain relief throughout the day
Some regular but with as required top ups
A combination of drugs working in different ways may be more effective than a single drug

Types of drugs for pain

Paracetamol
NSAIDS (non-steroidal anti-inflammatory drugs)
Opioids – weak or strong
Adjuncts – drugs that are not ‘painkillers’ but can help as long term pain reducers

Paracetamol

Generally safe and well tolerated
Can usually be taken with other medication without interaction
Useful for mild to moderate pain and some people find it very effective
Reduce dose if you are under 50kg (8 stone)
Dangerous in overdose or if taking more than recommended daily maximum – can cause liver failure

NSAIDS

Large group of drugs but most commonly used are ibuprofen, naproxen and diclofenac
Lots of brand names e.g. Nurofen, Naprosyn, Voltarol. Check the actual drug name
Only take one NSAID at a time
Good for muscular and joint pains and mild to moderate pain
Lots of possible adverse effects. Commonly - indigestion but this can end up with bleeding from the stomach. Kidney damage, especially if you are ill, dehydrated or take blood pressure medication. Do not take with other drugs that thin the blood like warfarin or other anti-coagulants
Adverse events more common with increasing age and the longer you take the drug

Weak opioids

Codeine, tramadol and dihydrocodeine most commonly prescribed. Often combined with paracetamol
Tramadol is now a controlled drug
Used for moderate to severe pain
Common side effects – constipation, drowsiness
Tolerance develops as your brain gets used to the drug. The drug becomes less effective over time
Withdrawal can occur if you suddenly stop taking any opioid drug
Some people become addicted to weak opioids

Strong opioids

Morphine, oxycodone, buprenorphine, fentanyl. Available as slow release and immediate release tablets or medicine. Fentanyl and buprenorphine are available as patches. All are controlled drugs
Used for severe pain
Not good for long term use in most people. Tolerance develops and doses can quickly escalate
Side effects – constipation, dry mouth, drowsiness, nausea, sleep disturbance, reduced hormone levels, reduced immunity
The long term side effects of taking strong opioids are difficult to tell apart from the unwanted effects of pain – low mood, lack of motivation, poor quality sleep
Reducing and coming off strong opioids can improve quality of life without making the pain any worse
If you are taking strong opioid drugs but still have severe pain, they are not working and you should slowly come off them
Addiction is often not recognised

Adjuncts

Gabapentin and pregabalin work in the same way to calm down overactive nerves
They have this effect on the whole nervous system so the main side effects are drowsiness, and poor concentration and memory
They are most useful for nerve pain but have been used for many types of pain due to the lack of effective drugs for pain
They are controlled drugs and are drugs of abuse
They need to be taken regularly to maintain effectiveness but this can reduce over time
Amitriptyline, nortriptyline and imipramine are older anti-depressant drugs
They can be helpful for nerve pain and for improving sleep if it is very disturbed by pain
The main side effects are drowsiness and dry mouth. They can affect the ability to pass urine, especially in older men
These drugs should be used with caution in older patients

Summary

There are fewer drugs for pain than people realise
They often do not work well for persistent pain
It may be better to take no drugs and explore other ways to manage pain
Starting any drug should be considered a trial to see if it helps and to balance this against any side effects

If you have any issues with any medication, please contact the, Yellow Card Scheme,

Many thanks to Dr Lucy Williams for putting in information together.

Dr Lucy Williams is a Specialist in Anaesthesia and Pain Medicine at The Great Western Hospital, Swindon.

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Last updated 28th June 2023

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I was really nervous about the online workshop, what would Pete and the others attending be like?

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Research

Last updated 28th June 2023

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I was really nervous about the online workshop, what would Pete and the others attending be like?

Pete was lovely and so were the others and of course, like everyone else, we learnt very useful skills. Thank you Pete and everyone else who was on the workshop.

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For Professionals

We have also produced a Pain Toolkit Handbook, specifically for Healthcare Professionals which can be obtained by ordering via the store.

Last updated 28th June 2023

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Lets get started with some simple information you may need

It can be useful to use the two questions below to help identify more complex pain.

Question 1
During the past month, has it often been too painful to do many of your day-to-day activities?

Question 2
During the past month, has your pain been bad enough to often make you feel worried or low in mood?

If the patients answers yes to both questions then using the Persistent Pain Cycle tool to guide a fuller assessment and care planning over the next consultation or two.

How to use the Persistent Pain Cycle

Ask the patient to circle 2-3 main problems they have at the moment, then jointly write a shared action plan.

A collaborative person centred approach focused on the individual’s physical, emotional and life issues is starting point.

This can identify factors likely to predict persistent pain, disability and distress.

Factors linked to increased pain related disability

Modifiable factors

Body Symptoms: higher pain intensity or longer pain duration; multi-site pain; higher physical disability.
Moods: depression; anxiety including Post Traumatic Stress Disorder; anger and perceived injustice; low confidence to self manage.
Cognitions: catastrophic thinking patterns about pain experience; self perceived poor health.
Behaviours: passive management; on-going pursuit of cure “quick fix”.
Look for with the patient for their stress factors that contribute or worsen the stress of pain.

Non modifiable factors

Age, Sex, Cultural background.
Socio-economic background.
Injury or interpersonal violence/trauma.
Heritable factors.

A useful tool is the Persistent Pain Cycle tool, which helps both clinicians and patients explore currently the way pain is affecting the person and their life in many ways. It helps shift the conversation for some patients from a “seek, fix and cure” to a more “cope, control and manage” approach. This applies to those with emerging risk of persistent pain where using the Start Tool and the identified psychosocial factors means taking an active approach in enabling the person to:

Build fitness (NHS Fitness Studio) and confidence.
Reduce focus on pain itself.
Maximise function and aspects of life such as work, study.

The Patient Health Questionnaire (PHQ-9) is also a useful tool for assessing depression.

Using consultation time

It can be very difficult in the short consultation to identify when pain is already or becoming a major health problem. Many patients are managing their pain and their health well and we do not want to over-medicalise them. However, there are many who will require additional help to support them to minimise the risks of long-term pain.

Experienced GP’s share that several consultations are needed. These then gives continuity and emphasis on empathy, therapeutic relationship and coaching / supporting self-management which makes the difference to patient outcomes. Research evidence from patients say exactly the same thing and it leads to up to 50% reduction in GP consultations and attendance in the long term.

Dr Tim Williams a GP and Community Pain Specialist from Sheffield has developed video called ‘Top Ten Tips for Primary Care Management’ to support GP’s & Health care professionals. Tim’s tips are to help the GP when seeing patients with pain.

What is persistent pain?

This is a “tricky” condition to explain to patients, as changes in the pain nerve system function are multiple.

These include:

Increase sensitivity of pain receptors in skin, muscles, joints and other areas.
“Windup” process of multiplication of the messages at the spinal cord dorsal horn area.
Loss of synchronisation of neural process in the brain to handle pain messages effectively. Loss of inhibition of pain messages input into brain i.e. the descending spinal nerve inhibition.

The Explain Pain leaflet is a good resource to give patients, to help them understand why pain persists. It and can be downloaded here.

A useful video to recommend to the patient is the “Understanding Pain:” It is has a very simple messages about how pain works, and what to do about it. Many clinicians have found viewing this resource themselves is informative. It is useful as it enables a common and clear understanding between clinician and patient of the faulty neural processing system problems in persistent pain. It can form a common consistent language to help manage the complexity of pain.

Within the patient section of this site are same video links so patients can see to learn more about processing problems of faulty pain systems. Here is a useful video based explanation about faulty pain systems by Lorimer Moseley ‘Body in mind - the role of the brain in chronic pain’.

Aspects of pain management in primary care

Focus on self-management using the Pain Toolkit with patients is crucial.
Share consistently core messages about maintaining and building fitness.
Reducing or stopping smoking.
Healthy eating (Mediterranean diet).
Key self-management skills including, goal setting/action planning, pacing activities, fitness, (NHS Fitness Studio) graded activity, relaxation and of course having fun goals.

Self-management of course also includes:

Trial of useful medication options to reduce some of the pain experience.
Regular medication reviews including reviewing medication’s actual use, timing, dosage etc.
Assessing and managing moods, depression, anxiety, anger and others including drug treatment and/or talking therapies referral or link to counselling service. Bereavement /grief at loss of self-identity and struggling to find / develop new sense of self can benefit from talking therapies such as counselling.
Setback support and planning; acceptance; setbacks happen and support robust plans to self-manage can be crucial to reduce their severity and duration and use of health care.

A useful resource to guide management of persistent pain is the Ten Top Tips summary by GP Dr Tim Williams who has special interest in managing pain.

Opiod Guidance

Visual resources to show patients

Pain & Self-Management Videos for patients (these are really good short engaging videos to show or signpost patients to)

Links

I was really nervous about the online workshop, what would Pete and the others attending be like?

Pete was lovely and so were the others and of course, like everyone else, we learnt very useful skills. Thank you Pete and everyone else who was on the workshop.

Resources

For Patients

These links and resources have been compiled and put together by the team at the Pain Toolkit for your reference and what we believe will help you in the self management of your pain.

Last updated 28th June 2023

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Retrain Pain - FREE Patient course

Tired of waiting for pain to go away? This FREE online course will teach you a science based approach to reducing symptoms and getting back to the life you want to live. To register and start the course, please click here.

Talking Health

Talking Health has over 20 years experience of supporting the development of generic and condition specific structured self-management education programmes.

NHS Pain Management Programmes (PMP's)

PMP's are in some areas. Your GP can help you find a local PMP. British Pain Society Pain Management Programmes for Adults Participant information

Remember, PMP's and SMP's can provide you with many self-management tools, but you have to do the work!

Community Based Pain Management Register

The Pain Tookit is collating information, as to where Community Based Pain Management Programmes, courses or workshops are being run. Click here to find out if one is being run in your area

NHS Patient Advice and Liaison Service (PALS)

This service can provide information that may help you in locating other support services. You can contact them via your local NHS Clinical Commissioning Group or visit NHS Choices and search via your postcode

Utilising Community Resources

Your local Library is a good starting point as they hold useful information (access to the internet, books, DVD's, CD's and cassettes) about other local health and community initiatives.

Making changes and becoming active

GP exercise on referral: If you are unsure about becoming active or exercising, your GP can refer you to their GP exercise on referral scheme. These types of schemes are run with local gyms and fitness centres and can include facilities for swimming and many other gentle, but beneficial exercise and keep fit regimes. Ask at your GP surgery for more information and about other pain management support available.

Walking for health - Remember: Walking is the cheapest and easiest form of exercise. You can find out more about 'Walking for health’, these are usually run locally by your local Borough Council. Please also visit the Walking Health Initiative website.

Exercise Programmes

Sometimes it can seem like there are as many exercise programmes as there are different makes of cars on the road. A few common ones include Yoga, Tai Chi and Pilates (pronounced Pil ar tes).

Please make sure that your teacher is a qualified and experienced in teaching people with persistent pain. Remember, you should be encouraged to exercise at a pace that feels right for you.

Some people go to a Gym to get fitter and because for them its social, but if you don’t want to, then you could attend the NHS Fitness Studio. They have visual stretching and exercising classes, including Tai Chi, Yoga and Pilates. And yes, all classes are free and available 24hours.

Body Care

Looking after your body is very important and you will need to think about the following;

Eating healthy food, Sleep (sleeping only at night and avoiding cat naps during the day), Hygiene, including washing and grooming your body daily.

Looking after your body is very important and so it is vital that you look at what you put in to it, that you get enough of the healthier types of food and the right amount of sleep and that you also keep yourself clean.

The pain question: Why does it hurt to get older? Why does it hurt at all?

Long term pain is more commonplace than you might think. But explaining why is also more complex. Click here to read this article

Pain and how Psychology can help

As part of Psychology Week 2020, the Australian Psychological Society hosted a free public online event on the topic of pain.

Chronic pain is a common problem. Its impacts are not just physical. It also impacts on emotional, mental and social wellbeing – and its effects touch both the individual and those close to them. Watch video here

Links

I was really nervous about the online workshop, what would Pete and the others attending be like?

Pete was lovely and so were the others and of course, like everyone else, we learnt very useful skills. Thank you Pete and everyone else who was on the workshop.

Resources

Videos

Last updated 28th June 2023

Links

I was really nervous about the online workshop, what would Pete and the others attending be like?

Pete was lovely and so were the others and of course, like everyone else, we learnt very useful skills. Thank you Pete and everyone else who was on the workshop.

Resources

Interviews

Last updated 28th June 2023

Links

I was really nervous about the online workshop, what would Pete and the others attending be like?

Pete was lovely and so were the others and of course, like everyone else, we learnt very useful skills. Thank you Pete and everyone else who was on the workshop.