Pain Killers

General

 Consider simple measures as well as taking pain killers. For recent injuries: P R I C E P - Protection, protect the injured limb from further injury, splint, strap avoid risky activity. R - Rest, resting the injured limb is good acutely, followed by relative rest. Relative rest - doing nothing is just as bad as doing too much. Soft tissues (ligaments and tendons) heal better if gently stressed in the normal plane of movement. If you keep over stressing them however tehy won’t heal well I - Ice, don’t apply ice directly onto to the skin of the affected area, don’t freeze the skin. Apply Ice pack with towel over skin to protect skin for 10 - 15 minutes every 3-4 hours. A bag of frozen peas works best conforming to the shape of your limb. C - Compression, gentle compression with an elastic compression bandage helps reduce the swelling E - Elevation, when swollen elevate the affected limb to the level of the heart or just above.

Medication

Advice below is for patients on no regular medication. If pain not responding to simple pain killers in acute injury seek medical attention. If in a cast or tight bandage see looking after your cast See post operative advice   If you are on a lot of regular medication it is a good idea to speak to your medical practitioner about the choice of pain killers. There are essentially 4 groups of painkillers. As with most things in life you have to work out what is right for you. NOTE: Some painkillers will have the same active ingredient yet different names, read the fine print as to the contents eg. Voltarol is the trade name for diclofenac sodium, Co-codomol contains paracetamol and codeine.

Four main goups of pain killer

1. Paracetamol 2. Non Steroidal anti-inflammatory drugs  - NSAID's (ibuprofen, diclofenac, naproxen 3. Opiates or opioids (morphine/ codeine compounds) 4. Other - nerve pain medication 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 and in combination. It is possible to mix all the above medication as long as they are in their pure form and using only one kind from each group. Read on the box or on the paper insert and  find out what the tablet is made up of. The "co "tablets ( Co dydramol, co codomol, co proxomal) are combination drugs usually paracetamol mixed with a drug from the opioid group. The “ Plus”  tablets ( Ibuprofen plus) often also combine the different groups. Some over the counter preparations of ibuprofen may contain paracetamol and or codeine.

1. Paracetamol

 Standard dose for an adult is 1 Gram of paracetamol every six hours ie 2 * 500mg tablets 4 times a day (Max 8 * 500mg tablets per day).  Paracetamol in the standard doses is pretty safe and has very few side effects.

 2. NSAID's - (Non Steroidal Anti

Inflammatories)

 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.  Asthma may be made worse by NSAID's, patients with severe brittle asthma are probably better off avoiding NSAID's. Some NSAID's are 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 o Standard dose 400mg 8 hourly best taken after meals. • Voltarol, Diclofenac - Slightly stronger than Ibuprofen, still well tolerated. Long acting versions available and combination compounds to help protect the stomach o Standard doses 50mg 8hourly or longer acting 75mg 12 hourly. • Naproxen, Naprosyn - Very good perhaps better choice for long term use (months/ years) o 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. o 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. • Cox 2 inhibitors - These are a subset of NSAID's said to be softer on the stomach. Recently they have been shown to significantly increase the risk of heart failure and heart attacks. The licence for several of them has been withdrawn

3. Opiates/ opioids

 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. Drink lots of fluid increase 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 possible, but not normally a problem in the acute situation. • Codeine phosphate - Very good, safe at standard doses Nausea, drowsiness and constipation are common side effects. o 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. o Standard dose 50mg to 100mg 6hrly • Morphine/ fentanyl pain patches - Pain patches very good for sustained long lasting pain control.

4. Other - Nerve pain medication

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. Ok to take one every now and then  when not had good nights sleep for few nights in a row. o Standard dose (for pain not epilepsy)10-25 mg at night • Carbamazepine o Standard dose 100mg 12hrly • Gabapentin - Gradually increase dose till effect noted. Avoid suddenly changing or stopping. o 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.