| Class | Drug | Type of pain | Dose* | Special points and common side effects | Routes of administration |
| Simple analgesic | Paracetamol | Mild | 1g qds, maximum 60 mg/kg per 24h |
Good antipyretic, not anti-inflammatory Potential hepatotoxicity in overdose | PO, PR, IV |
| - | NSAIDs |
Mild/moderate especially
superficial pain, musculoskeletal and with inflammatory component IV diclofenac effective in renal colic but check renal function |
Diclofenac 50 mg tds Ibuprofen 200–600 mg tds (maximum 2.4 g in 24 hours) | Risk of renal failure especially in the elderly and dehydrated. Increased bleeding tendency and ulcer or GIB – use omeprazole 20 mg prophylaxis in high risk. Avoid in high risk patients – elderly, previous history of GIB/PUD, IHD and in the first 24 hours after major surgery | PO, PR, topical and rectally thought to have less GI s/e IV – can cause thrombophlebitis No evidence that NSAIDs given PR or IV are better than the same drug at the same dose given PO |
| Weak opioids | Codeine | Moderate Minor surgical procedures |
15–60 mg qds, max 240 mg/24 hours | Good in combination with paracetamol s/e constipation, N/V dizziness | Oral IM (avoid if possible) |
| - | Tramadol | Moderate | 50–100 mg qds | Not with other opioids. Less addictive therefore very useful in problem drug users s/e dizziness, dysphoria esp. in elderly | Oral, IV, IM |
| Strong | Morphine | Severe, visceral and for deep structural procedures | 0.05–0.1 mg/kg IV* 0.1–0.2 mg/kg IM 0.2–0.4 mg/kg PO | IV route best for immediate pain relief s/e respiratory depression, N/V constipation, confusion and decreased consciousness | Oral, sublingual (buprenorphrine) IM, IV, patient-controlled analgesia (cont IV/bolus) Epidural and spinal |
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Intravenous Analgesics Pain control following surgery is a major priority for both you and your doctors. While you should expect to have some pain after your surgery, your doctor will make every effort to safely minimize your pain. We provide the following information to help you understand your options for pain treatment, to describe how you can help your doctors and nurses control your pain, and to empower you to take an active role in making choices about pain treatment. Be sure to inform your doctor if you are taking pain medication at home on a regular basis and if you are allergic to or cannot tolerate certain pain medications. Why is pain control so important? In addition to keeping you comfortable, pain control can help you recover faster and may reduce your risk of developing certain complications after surgery, such as pneumonia and blood clots. If your pain is well controlled, you will be better able to complete important tasks such as walking and deep breathing exercises. What kinds of pain will I feel after surgery? You may be surprised at where you experience pain after surgery. Often times the incision itself is not the only area of discomfort. You may or may not feel the following: * Muscle pain - You may feel muscle pain in the neck, shoulders, back, or chest from lying on the operating table. * Throat pain - Your throat may feel sore or scratchy. * Movement pain - Sitting up, walking, and coughing are all important activities after surgery, but they may cause increased pain at or around the incision site. What can I do to help keep my pain under control? Important!: Your doctors and nurses want and need to know about pain that is not adequately controlled. If you are having pain, please tell someone! Don’t worry about being a “bother.” You can help the doctors and nurses "measure" your pain. While you are recovering, your doctors and nurses will frequently ask you to rate your pain on a scale of 0 to 10, with "0" being "no pain" and "10" being "the worst pain you can imagine." Reporting your pain as a number helps the doctors and nurses know how well your treatment is working and whether to make any changes. Keep in mind that your comfort level (ie, ability to breathe deeply or cough) is more important than absolute numbers (ie, pain score). Who is going to help manage my pain? You and your surgeon will decide what type of pain control would be most acceptable for you after surgery. Your surgeon may choose to consult the Acute Pain Management Service to help manage your pain following surgery. Doctors on this service are specifically trained in the types of pain control options described on the next several pages. You are the one who ultimately decides which pain control option is most acceptable. The manager of your post-surgical pain -- your surgeon or the Acute Pain Management Service doctor -- will review your medical and surgical history, check the results from your laboratory tests and physical exam, then advise you about which pain management option may be best suited to safely minimize your discomfort. After surgery, you will be assessed frequently to ensure that you are comfortable and safe. When necessary, adjustments or changes to your pain management regimen will be made. Types of Pain-Control Treatments You may receive more than one type of pain treatment, depending on your needs and the type of surgery you are having. All of these treatments are relatively safe, but like any therapy, they are not completely free of risk. Dangerous side effects are rare. Nausea, vomiting, itching, and drowsiness can occur. These side effects are usually easily treated in most cases. Intravenous Patient-Controlled Analgesia (PCA) Patient-controlled analgesia (PCA) is a computerized pump that safely permits you to push a button and deliver small amounts of pain medicine into your intravenous (IV) line, usually in your arm. There is no injection of needles into your muscle. PCA provides stable pain relief in most situations. Many patients like the sense of control they have over their pain management. The PCA pump is programmed to give a certain amount of medication when you press the button. It will only allow you to have so much medication, no matter how often you press the button, so there is little worry that you will give yourself too much. One way that you may get too much medication from the PCA pump is if a family member presses the PCA button for you. This removes the patient control aspect of the therapy, which is a major safety feature. Do not allow family members or friends to push your PCA pump button for you. You need to be awake enough to know that you need pain medication. Patient-Controlled Epidural Analgesia Many people are familiar with epidural anesthesia because it is frequently used to control pain during childbirth. Patient-Controlled Epidural Analgesia uses a PCA pump to deliver pain-control medicine into an epidural catheter (a very thin plastic tube) that is placed into your back. Placing the epidural catheter (to which the PCA pump is attached) usually causes no more discomfort than having an IV started. A sedating medication, given through your IV, will help you relax. The skin of your back will be cleaned with a sterile solution and numbed with a local anesthetic. Next, a thin needle will be carefully inserted into an area called the "epidural space." A thin catheter will be inserted through this needle into the epidural space, and the needle will then be removed. During and after your surgery, pain medications will be infused through this epidural catheter with the goal of providing you with excellent pain control when you awaken. If additional pain medication is required, you can press the PCA button. Epidural analgesia is usually more effective in relieving pain than intravenous medication. Patients who receive epidural analgesia typically have less pain when they take deep breaths, cough, and walk, and they may recover more quickly. For patients with medical problems such as heart or lung disease, epidural analgesia may reduce the risk of serious complications such as heart attack and pneumonia. Epidural analgesia is safe, but like any procedure or therapy, not risk free. Sometimes the epidural does not adequately control pain. In this situation, you will be given alternative treatments or be offered replacement of the epidural. Nausea, vomiting, itching, and drowsiness can occur. Occasionally, numbness and weakness of the legs can occur, which disappears after the medication is reduced or stopped. Headache can occur, but this is rare. Severe complications such as nerve damage and infection are extremely rare. Nerve Blocks You may be offered a nerve block to control your pain after surgery. Whereas an epidural controls pain over a broad area of your body, a nerve block is used when pain from surgery affects a smaller region of your body, such as an arm or leg. Sometimes a catheter similar to an epidural catheter is placed for prolonged pain control. There are several potential advantages of a nerve block. It may allow for a significant reduction in the amount of opioid (narcotic) medication, which may result in fewer side effects such as nausea, vomiting, itching, and drowsiness. In some cases, a nerve block can be used as the main anesthetic for your surgery. In this case, you will be given medications during your surgery to keep you sleepy, relaxed, and comfortable. This type of anesthesia provides the added benefit of pain relief both during and after your surgery. It may reduce your risk of nausea and vomiting after surgery. You, your anesthesiologist, and your surgeon will decide before surgery if a nerve block is a suitable pain management or anesthetic option for you. Pain Medications Taken by Mouth At some point during your recovery from surgery, your doctor will order pain medications to be taken by mouth (oral pain medications). These may be ordered to come at a specified time, or you may need to ask your nurse to bring them to you. Make sure you know whether or not you need to ask for the medication! Most oral pain medications can be taken every 4 hours. Important!: Do not wait until your pain is severe before you ask for pain medications. Also, if the pain medication has not significantly helped within 30 minutes, notify your nurse. Extra pain medication is available for you to take. You do not have to wait 4 hours to receive more medication. What are some of the risks and benefits associated with pain medication? Opioids (Narcotics) after surgery (medications such as morphine, fentanyl, hydromorphone): Benefits: Strong pain relievers. Many options are available if one is causing significant side effects. Risks: May cause nausea, vomiting, itching, drowsiness, and constipation. The risk of becoming addicted is extremely rare. Opioids (Narcotics) at home (Percocet®, Vicodin®, Darvocet®, Tylenol ®) Benefits: Effective for moderate to severe pain. Many options available. Risks: Nausea, vomiting, itching, drowsiness, constipation. Stomach upset can be lessened if the drug is taken with food. Should not drive or operate machinery while taking these medications. Note: These medications often contain acetaminophen (Tylenol®). Make sure that other medications that you are taking do not contain acetaminophen, as too much of it may damage your liver. Be sure to tell your doctor about all medications (prescribed and over-the-counter), vitamins and herbal supplements you are taking. This may affect which drugs are prescribed for your pain control. Non-Opioid (Non-narcotic) Analgesics (Tylenol®, Feverall®) Benefits: Effective for mild to moderate pain. They have very few side effects and are safe for most patients. They often decrease the requirement for stronger medications, which may reduce the incidence of side effects. Risks: Liver damage may result if more than the recommended daily dose is used. Patients with pre-existing liver disease or those who drink significant quantities of alcohol may be at increased risk. Nonsteroidal Anti-inflammatory Drugs (NSAIDS) ibuprofen (Advil®), naproxen sodium (Aleve®), celecoxib (Celebrex®) Benefits: These drugs reduce swelling and inflammation and relieve mild to moderate pain. Ibuprofen and naproxen sodium are available without a prescription, but you should ask your doctor about taking them. They may reduce the amount of opioid analgesic you need, possibly reducing side effects such as nausea, vomiting, and drowsiness. If taken alone, there are no restrictions on driving or operating machinery. Risks: The most common side effects of nonsteroidal anti-inflammatory medication (NSAIDS) are stomach upset and dizziness. You should not take these drugs without your doctor's approval if you have kidney problems, a history of stomach ulcers, heart failure or are on "blood thinner" medications such as Coumadin® (warfarin), Lovenox® injections, or Plavix®. Are there ways I can relieve pain without medication? Yes, there are other ways to relieve pain and it is important to keep an open mind about these techniques. When used along with medication, these techniques can dramatically reduce pain. Relaxation tapes or Guided Imagery is a proven form of focused relaxation that coaches you in creating calm, peaceful images in your mind -- a "mental escape." For the best results, practice using the tape or CD before your surgery and then use it twice daily during your recovery. The ________ Clinic has had great success with this relaxation program. You can get relaxation tapes at a bookstore, or rent them from your library. Guided Imagery tapes are available for _______ at the ________ Clinic Gift Shop. Finally, you can bring a battery operated tape recorder or CD player to the hospital to play prior to surgery and during your hospital stay. Listening to soft music, changing your position in bed, or tuning in to channel 36 (the _______ Clinic’s in-hospital relaxation channel) are additional methods to relieve or lessen pain. At home, heat or cold therapy may be an option that your surgeon may choose to help reduce swelling and control your pain. Specific instructions for the use of these therapies will be discussed with you by your surgical team. If you have an abdominal or chest incision, you will want to splint the area with a pillow when you are coughing or deep breathing to decrease motion near your incision. You will be given a pillow in the hospital. Continue to use it at home as well. Lastly, make sure you are comfortable with your treatment plan. Talk to your doctor and nurses about your concerns and needs. This will help avoid miscommunication, stress, anxiety, and disappointment, which may make pain worse. Keep asking questions until you have satisfactory answers. You are the one who will benefit. How can I control pain at home? You may be given prescriptions for pain medication to take at home. These may or may not be the same pain medications you took in the hospital. Talk with your doctor about which pain medications will be prescribed at discharge. Note: Make sure your doctor knows about pain medications that have caused you problems in the past. This will prevent possible delays in your discharge from the hospital. Preparation for Your Discharge: Your doctors may have already given you your prescription for pain medication prior to your surgery date. If this is the case, it is best to be prepared and have your medication filled and ready for you when you come home from the hospital. You may want to have your pain pills with you on your ride home if traveling a long distance. Check with your insurance company regarding your prescription plan and coverage for your medication. Occasionally, a pain medication prescribed by your doctor is not covered by your insurance company. If you haven't received your prescription for pain medication until after the surgery, make sure a family member takes your prescription and either gets it filled at one of the _________ Clinic Pharmacies on campus or soon after your discharge from the hospital. It is important that you ARE PREPARED in case you have pain. Make sure you wear comfortable clothes and keep your coughing and deep breathing pillow with you. You may want to have your relaxation tapes and player available for your travels. If you are traveling by plane, make sure you have your pain pills in your carry-on luggage in case the airline misplaces your checked luggage. While at Home: Remember to take your pain medication before activity and at bedtime. Your doctor may advise you to take your pain medication at regular intervals (such as every 4 to 6 hours). Be sure to get enough rest. If you are having trouble sleeping, talk to your doctor. Use pillows to support you when you sleep and when you do your coughing and deep breathing exercises. Try using the alternative methods discussed earlier. Heating pads or cold therapy, guided imagery tapes, listening to soft music, changing your position in bed, and massage can help relieve your pain. NOTE: If you need to have stitches or staples removed and you are still taking pain medications, be sure to have a friend or family member drive you to your Clinic appointment. Commonly, you should not drive or operate equipment if you are taking opioid (narcotic)-containing pain medications. Check the label of your prescription for any warnings or ask your doctor, nurse, or pharmacist. Frequently asked questions I am nervous about getting “hooked” on pain pills. How do I avoid this? The risk of becoming addicted to pain medication after surgery is very small. The bigger risk is a possible prolonged recovery if you avoid your pain medications, and cannot effectively do your required activities. If you are concerned about addiction, or have a history of substance abuse (alcohol or any drug), talk with your doctors. They will monitor you closely during your recovery. If issues arise following surgery, they will consult the appropriate specialists. I am a small person who is easily affected by medicine. I am nervous that a “normal” dose of pain medication will be too much for me. What should I do? During recovery, your healthcare team will observe how you respond to pain medication and make changes as needed. Be sure to communicate with your doctors any concerns you have prior to surgery. The relatively small doses of pain medication given after surgery are highly unlikely to have an exaggerated effect based on your body size. I don't have a high tolerance for pain. I am afraid that the pain will be too much for me to handle. What can I do? Concern about pain from surgery is very normal. The most important thing you can do is to talk with your surgeon and anesthesiologist about your particular situation. Setting pain control goals with your doctors before surgery will help them better tailor your pain treatment plan. Treating pain early is easier than treating it after it has set in. If you have had prior experiences with surgery and pain control, let your doctor know what worked or what did not. As listed earlier in this document, there are usually many options available to you for pain control after surgery. I normally take Tylenol® if I get a headache. Can I still take Tylenol® for a headache if I am on other pain medication? As discussed earlier, before taking any other medication, be sure to talk to your doctor. Some of the medications prescribed for use at home contain acetaminophen (Tylenol®) and if too much is taken, you may become ill. In order to avoid getting too much of any medication, discuss this issue with your doctor BEFORE you leave the hospital. Ask your doctors and nurses about: * Pain and pain control treatments and what you can expect from them. You have a right to the best level of pain relief that can be safely provided. * Your schedule for pain medicines in the hospital. * How you can participate in a pain-control plan. Inform your doctors and nurses about: * Any surgical pain you have had in the past. * How you relieved your pain before you came to the hospital. * Pain you have had recently or currently. * Pain medications you have taken in the past and cannot tolerate. * Pain medications you have been taking prior to surgery * Any pain that is not controlled with your current pain medications. You should: * Help the doctors and nurses “measure” your pain and expect staff to ask about pain relief often and to respond quickly when you do report pain. * Ask for pain medicines as soon as pain begins. * Tell us how well your pain is relieved and your pain relief expectations. * Use other comfort measures for pain control -- listening to relaxation tapes or soft music, repositioning in bed, etc. Your doctors are committed to providing you with the safest and most effective pain management strategy that is most acceptable to you. Pain Facts * Pain is different for everyone. * Treating pain early usually brings quicker and better results. * Healing occurs faster when pain is under control. * Pain affects blood pressure, heart rate, appetite, and general mood. * Pain may be sharp, dull, stabbing, cramping, throbbing, constant, on and off, etc. |