PORTSMOUTH HOSPITALS NHS TRUST

CLINICAL GUIDELINE

TITLE / PAIN MANAGEMENT GUIDELINE
REFERENCE NUMBER /
TO BE CONFIRMED AFTER RATIFICATION
MANAGER RESPONSIBLE / Rosy Barnes - Acute Pain Clinical Nurse Specialist
DATE ISSUED / 14 June 2012
REVIEW DATE / June 2014
Equality Impact Assessment has been applied to this policy / Rosy Barnes - Acute Pain Clinical Nurse Specialist
AUTHOR / Rosy Barnes - Acute Pain Clinical Nurse Specialist
RATIFIED BY / Nursing and Midwifery Committee
AMENDMENTS RECORD
DATE / PAGE(S) / COMMENTS / APPROVED BY
CONTENTS LIST:
1.Introduction
2.Status
3.Purpose
4.Scope/Audience
5.Definitions
6.Clinical Process
7.Supporting Evidence
8.Training
APPENDICES:
APPENDIX 1: Use of the Abbey Pain Scale
APPENDIX 2: Paediatric Pain Tools FLACC and Wong and Baker
APPENDIX 3: Inpatient referrals to the Chronic Pain Service
APPENDIX 4: Palliative Care referral tool
APPENDIX 5: Basic analgesia competency
  1. Introduction/Background

Most patients experience pain or discomfort. The presence of pain causes distress and anxiety for patients. Managing patient’s pain is vitally important and Portsmouth Hospital NHS Trust considers that pain should be monitored and managed as the 5th vital sign. PHT believes that it is the right of all patients to receive adequate and appropriate pain relief.

  1. Status

This is a corporate clinical guideline

  1. Purpose

The relief of pain and discomfort should be a fundamental objective of any health service. Accurate assessment of patient’s pain and appropriate intervention reduces the risk of pain limiting an individual’s daily function. Good management reduces post-op complications and facilitates early or timely discharge.

This guideline describes the standards of care to be provided to Portsmouth Hospitals NHS Trust patients experiencing pain or discomfort.

  1. Scope / Audience

This guideline applies to all staff involved in the direct care of patients. It is intended to be used in conjunction with specialized guidelines provided by The Acute, Chronic Pain and End of Life and Palliative care services. It is used for guidance only and is not ‘set in stone’.

  1. Definitions

Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” International Association for the Study of Pain (IASP)

Acute pain

Pain associated with acute injury or disease

Chronic Pain

Pain that has persisted for longer then 3 months or past the expected time of healing following injury or

disease.

Palliative Care

Palliative care is the active total care of patients and their families, usually when their disease is no longer responsive to potentially curative treatment, although it may be applicable earlier in the illness.

Pain Management

Pain management is a multidisciplinary approach to the assessment and treatment of patients with pain.

(Pain Management Services: The RoyalCollege of Anaesthetists and the Pain Society)

Health Care Professionals

Registered Practitioners Band 5 – 9

Non-registered Practitioners

Practitioners Band 2 - 4

Wessex Pain Score

0 = no pain at rest or on movement

1 = no pain at rest, mild pain on movement

2 = moderate pain at rest or on movement

3 = severe pain at rest

  1. Clinical Process

The provision of pain management for patients in PHT is underpinned by the following principles:

Pain management is the responsibility of all members of the multidisciplinary team.

Pain will be anticipated wherever possible and appropriate prophylactic interventions applied e.g. for procedures.

All patients will receive an initial and ongoing pain assessment as part of their treatment and care.

All patients with pain will have evidence of pain management and a plan recorded in their notes.

Pain presence will be recorded as the 5th vital sign.

Pain intensity will be measured using the Wessex Pain Score (Verbal rating Score) and recorded on Vital Pac or the patients observation chart/record of care. (However some departments may use the verbal rating 1-10 score).This pain scale may not be appropriate for all patients, such as those with learning disabilities and/or dementia. In these cases the Abbey Pain Scale may be found to be more appropriate. (Appendix1). The FLACC and Wong and Baker Pain Scale are used for paediatrics. (Appendix 2)

Patient with a pain intensity of 2 or 3 will trigger pain relief intervention.

Pain will be reassessed and documented as part of each set of vital signs and:

Within an appropriate time after pain relief intervention (i.e. when pain relief action is anticipated)

After any procedure or activity anticipated being painful

At intervals determined by ongoing chronic pain issues

With each new report of pain

Pain assessment, intervention and effectiveness will be documented. Ineffective pain relief will be documented and acted upon.

Staff should be appropriately trained in the effective management of pain. (See training section 9)

6.1Clinical Practice Guideline

All health care professionals are responsible for:

  • Assessment
  • Planning
  • Implementation of action plans
  • Evaluation
  • Clear documentation
  • Liaison with all members of the multi-professional team

All non-registered Practitioners

  • Assess the patient using the Wessex or other appropriate pain score
  • Report and document
  • Liaise with all members of the multi-professional team

Doctors, Dentists and Non medical Prescribers are responsible for:

  • The prescribing of appropriate medication and regular review
  • Provision of clear unambiguous prescription sheets (refer to Medicines Management Policy for completing prescription sheet)

All Health Care Professionals have a role in the

  • Initial and ongoing assessment of pain
  • Provision of non-pharmacological pain relief intervention
  • Administration of prescribed medication in a timely and non-judgemental fashion (HCSWs who have successfully completed the competency assessment for administration of medicines)
  • Monitoring effect of medication
  • Ensuring non registered practitioner given delegated tasks are competent to undertake said task
  • Provisions of therapies and aids to support pain relief

Pharmacists are responsible for ensuring correct prescribing practice is adhered to and drugs prescribed are available within The District Formulary.

For specialized areas of pain management,Portsmouth Hospitals NHS Trust provides an Acute Pain service, a Chronic Pain Service, End of Life and Palliative Care Service.

The Acute Pain Team provides an inpatient service to the following areas:

Surgical Unit, (including Head and Neck), Orthopaedic Unit,Renal/Urology and Gynaecology Unit Paediatrics and Maternity. Referrals may be made by phone on extension 5890 or via bleep 1645/1643 or 1838.

The Department of Pain Medicine, serves patients with chronic pain on an outpatient basis only (Referral document- See Appendix 3).

The Hospital Specialist Palliative Care Team is a specialist service, working within the hospital. They work with those patients who have a life limiting illness and are experiencing difficulties (such as pain management) at any stage. (See referral form – Appendix 4) Guidance can also be obtained from the green ‘Palliative Care Handbook’, which should be available in all clinical areas. Contact details are extension 61320900-1700 Monday – Fridayand out of hours The Rowans Hospice inpatient unit on 023 92 250001.

The End of Life Team can be contacted on Bleep 1384 or mob - 07818078876

Pain should be assessed, documented and responded to regularly, and a record made of the patient’s response to treatment.

6.2 Process

Pain can be managed by a variety of methods comprising pharmacological and non-pharmacological.

Non-Pharmacological Interventions

Non-pharmacological can be classified as cognitive behavioural approaches (education, relaxation, distraction) and physical agents (heat/cold, positioning, transcutaneous electrical nerve stimulation – TENS)

Non-pharmacological methods must be considered to be an important element of pain relief. These include simple repositioning or ambulating when possible, application of hot or cold packs, distraction or relaxation techniques including deep breathing. Consideration should be given to referring to Physiotherapy.

Approach / Intervention
Cognitive Behavioural Approach / Jaw and Progressive muscle relaxation / Use when patients express an interest in relaxation. Requires 2-3 minutes of staff time for instruction.
Effective in reducing mild to moderate pain and as an adjunct to analgesic drugs for severe pain. / Education/Instruction / Provision of patient information leaflets, thorough, clear and concise explanations
Simple imagery/Music
Cutaneous / Ice/Heat pads / Should be applied with caution following assessment of the patient to ensure that there are no contradictions. Heat stimulates the thermoreceptors in the skin and deeper tissues that can reduce pain by closing the gating system in the spinal cord (Gate –Control theory).
Cold will cause vasoconstriction and reduce swelling and should be applied (not directly to the skin) using ice packs or compresses.
Effective in treating mild to moderate pain and as an adjunct to analgesic drugs. / TENS and acupuncture / Needs specialized equipment and personnel to initiate treatment
Positioning / Elevation of limb

Pharmacological Intervention

Pharmacological methods range from simple oral medication to complex interventions including epidural infusions and patient controlled analgesia.

The WHO analgesic ladder is a recognised systematic approach to the majority of pain problems. It is a statement of principles that can be used with a varying degree of interpretation, rather than a rigid framework.

Regular analgesia should be given in timed intervals and on demand (PRN) analgesia should be given promptly when requested.

Paediatrics: same principles, but drug doses depend on weight. (Refer to specific paediatric guidelines that can be found on the hospital intranet)

The following examples refer to patients who have acute pain or are experiencing an acute episode of their chronic pain. In certain palliative care situations the green ‘Palliative Care Handbook’ should be used for guidance on developing a treatment plan.

Below is a modified analgesic ladder for adultsused in Portsmouth Hospitals NHS Trust for acute or an acute exacerbation of chronic pain.

Chronic Pain, Non-Malignant Pain, Cancer Pain

Step 1
(Non-opioid analgesics/NSAIDS)
Mild Pain (1) / Step 2
(Weak opioids)
Moderate Pain (2) / Step 3
(Strong opioids, oral administration, transdermal patch, intravenous, subcutaneous, specialist local anaesthetic interventions)
Severe Pain (3)
 /  / 
Paracetamol
+/-
NSAID / Co-codamol (30/500)
+/-
NSAID / Morphine
10-15mgs IM regularly or
PCA or syringe driver if appropriate
 /  / 
Non-pharmacological interventions / If unresponsive add
Oral or Parenteral Opioids / + NSAID
+Paracetamol
+ Adjuncts
 / 
Non-pharmacological interventions / Epidural, Neurolytic block therapy or spinal stimulation

Acute Pain, Chronic Pain without control, acute crisis of Chronic Pain

Paracetamol

A maximumof 4 grams per day (8  500 mg tablets) Ensure patient is not already on a drug that contains Paracetamol (intravenous Paracetamol is available only for those patients unable to tolerate oral medication) Consider smaller doses if the patient weighs under 50kg for example 15mg/kg for under 50kg would be an appropriate dose.

Non Steroidal Anti-Inflammatory Drugs

Ibuprofen / (e.g. 400mg QDS)
Diclofenac / max 150mg per day (50mg TDS Oral/or PR)

Use with caution. May cause GI upset/ulceration, renal failure and impaired clotting. May exacerbate symptoms in sensitive asthmatics (10%)

Opioids

Codydramol / A maximum of 8 tablets per day
(paracetamol/dihydrocodeine) / Do not administer with Paracetamol
Cocodamol
(Paracetamol/codeine) / A maximum of 8 tablets per day. Do not administer with Paracetamol. (2 strengths 30/500 and 8/500. The 8/500 is no more effective than Paracetamol but consider its use in the elderly, frail patient)
Dihydrocodeine / 30mg every 4-6 hours oral or IM
Morphine Sulphate
(Oral morphine solution) / The bioavailability via the oral route is greatly decreased and the dosage when
converting from IV/IM must be increased by a factor of 3
Morphine IV (rarely IM) / 10-15 mg 2 hourly. Patient Controlled Analgesia (see PHNHST protocols - IV bolus 2mg every 5 min. (10mg in 10ml N/Saline).
MorphineSC / 2.5 – 5 mg bolus (if opioid naive)Titrate to pain score and side effects
Pethidine / Morphine is preferred drug of choice
Fentanyl/Alfentanyl / May be appropriate in patients with poor renal function for PCA’s or syringe drivers
Diamorphine / IV or SC
Oxycodone / For use in patients with intolerable hallucinogenic side effects to morphine. Oxycontin® 10mg bd. Oxynorm® – 5mg 4 hourly oral prn for breakthrough pain. These are initial doses -that should be titrated to pain score and side effects
Tramadol / Produces analgesia by an opioid effect and an enhancement of serotonergic and adrenergic pathways. It is contraindicated in patients on warfarin or with epilepsy and should be used with caution in patients on SSRI’s, with poor renal function or low blood sodium
Tapentadol / Tapentadol is a new molecular entity that is structurally similar to tramadol.It has opioid and nonopioid activity in a single compound. Its general potency is somewhere between tramadol and morphine in effectiveness

This is only a limited guide to some analgesics that are available. Other adjunct drugs (ie tricyclic antidepressants, anticonvulsants) should also be considered.

Entonox should also be considered as a stand alone or adjunct analgesic. (See Entonox policy -

Other supporting guidelines are:

Naloxone for the treatment of opioid overdose in adults –

Controlled drugs management –

Specialist local anaesthetic interventions

These include continuous or single shot epidurals, regional blocks or other local anaesthetic interventions. They may be performed by the anaesthetist as part of a patient’s anaesthetic and post-operative management or in an outpatient clinic such as the Chronic Pain Clinic.

6.3 Patients with Special Needs.

Paediatrics/Neonates

There are several categories of patients with special needs in pain management.

Paediatrics and neonates, differ from adults in their response to drugs. Special care is needed in the neonatal period due to immature metabolic and excretory pathways (first 30 days of life) . Doses in this patient group invariably require calculations which should always be checked. Where possible, medicines for children should be prescribed within the terms of the product licence. However, many analgesics are not specifically licensed for paediatric use (See unlicensed medicines policy -.

Medicines use.doc

Non-pharmacological interventions can be used with more success than perhaps in adults. Whenever possible, painful intramuscular injections should be avoided in children. The management of acute pain in children has been agreed at a multidisciplinary level (2005) under the umbrella of the Trust's Paediatric Clinical Governance Group which aims to ensure the highest standards of care for children undergoing surgery in Portsmouth and the recommendations and guidelines are available on the hospital intranet -

Other supporting guidelines are:-

The use of intranasal diamorphine in children-

The use of sucrose in neonates –

Older patients.

The physiological, psychological and cultural changes associated with ageing affect the perception and reporting of pain by elderly patients. Older people are at particular risk of under or over treatment, increased sensitivity to the analgesic and side-effects of opioids and gastric and renal toxicity from Non-steroidal Anti-Inflammatory Drugs (NSAIDs) because of reduction in renal clearance and other pharmacokinetic changes associated with getting older.

Because elderly patients often receive multiple drugs for their multiple diseases this greatly increases the risk of drug interactions as well as adverse reactions and may affect compliance.

If the patient has dementia the use of The Abbey Pain Scale may be more appropriate then the Wessex Pain Scale.

Other supporting guidelines are:-

Opioid tolerant patients/substance misuse disorder

Opioid tolerant patientsare those with chronic cancer or non-cancer pain being treated with opioids or patients with a substance misuse disorder either using illicit opioids or an opioid maintenance treatment program. These patientscan be complex to effectively manage their pain due to the presence of the drug (or drugs) of abuse, medications used to assist with drug withdrawal (ie buprenorphine) and the presence of tolerance, physical dependence and the risk of withdrawal. Opioid requirements are usually significantly higher in these patients.

For the patient on prescription opioids their usual regimens should be maintained where possible or appropriate substitutions made.

Effective analgesia may be required for longer periods and often requires a significant deviation from standard treatment protocols in the patient with a substance misuse disorder. Inappropriate behaviours can be prevented by the development of a respectful, honest and open approach to communication. If the patient is on a methadone program it should be continued as usual at the same dose and pain relief given for admission pain. Advice should be sought from the local substance misuse service where applicable.

Palliative Care

Accurate diagnosis of the cause(s) of pain is necessary for arational approach to therapy. It must not be assumed that pain has been caused by the primary diagnosis; debility, previous treatment and unrelated causes must also be considered. All pains have significant psychological component, and fear, anxiety and depression will all lower the pain threshold. Remember also the likely effects of life changes associated with terminal disease including loss of financial security, altered body image and compromised sexual function.

End of Life/Liverpool Care Pathway

The LCP generic document guides and enables healthcare professionals to focus on care in the last hours or days of life. This provides high quality care tailored to the patient’s individual needs, when their death is expected.The recognition and diagnosis of dying is always complex, irrespective of previous diagnosis or history. Uncertainty is an integral part of dying. There are occasions when a patient who is thought to be dying lives longer than expected and vice versa. Seek a second opinion or specialist palliative care support as needed.

Neuropathic Pain

Neuropathic pain develops as a result of damage to, or dysfunction of, the system that normally signals pain. It may arise from a group of disorders that affect the peripheral and central nervous systems. Common examples include painful diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia. People with neuropathic pain may experience altered pain sensation, areas of numbness or burning, and continuous or intermittent evoked or spontaneous pain. Neuropathic pain is an unpleasant sensory and emotional experience that can have a significant impact on a person's quality of life.

Neuropathic pain is often difficult to treat, because it is resistant to many medications and/or because of the adverse effects associated with effective medications. A number of drugs are used to manage neuropathic pain, including antidepressants, anti-epileptic (anticonvulsant) drugs, opioids and topical treatments such as capsaicin and lidocaine. Many people require treatment with more than one drug, but the correct choice of drugs, and the optimal sequence for their use, has been unclear.