Chronic non-cancer pain

DESCRIPTION

Pain that is present for more than 4 weeks.

It can arise from:

  • tissue damage (nociceptive pain), e.g. arthritis, lower back pain, pleurisy; or
  • injury to nerves (neuropathic pain) e.g. post herpetic neuralgia (pain following shingles), trigeminal neuralgia, diabetic neuropathy, HIV related peripheral neuropathy, drug induced peripheral neuropathy or phantom limb; or
  • Pain experienced in the absence of tissue damage, inflammation nor nerve damage (central pain) e.g. fibromyalgia, irritable bowel syndrome.

Assess pain severity, functional status, medication use including self-medication, co-morbid illnesses, etc.

Actively look for concomitant depression and anxiety/somatoform pain disorders.

GENERAL MEASURES

  • Lifestyle adjustments.
  • Occupational therapy and physiotherapy as appropriate.
  • Address psycho-social problems e.g. stress, anxiety, sleep disturbances.

MEDICINE TREATMENT

The principles are the same as with cancer pain relief. Analgesics should be given by mouth, regularly, in a stepwise manner to ensure adequate relief. Neuropathic and central pain are best treated with analgesics in addition to tricyclic antidepressants.

It is useful to combine different classes of analgesics for the additive effects, depending on pain severity.

Mild pain:

Children

Chronic non-cancer conditions such as genetic conditions, nerve damage pain, chronic musculoskeletal pain, and chronic abdominal pain:

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly when requiredSee paediatric dosing tool.

LoEIII [7]

Adults

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum dose: 4 g in 24 hours.

Pain associated with inflammation:

Adults

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

LoEIII [8]

OR

Combine paracetamol and ibuprofen at the above dosages.

Moderate pain:

Adults

If still no relief to simple analgesics (paracetamol and/or ibuprofen), as above

ADD

  • Tramadol, oral, 50 mg, 4–6 hourly as a starting dose (Doctor prescribed).
    • May be increased to a maximum of 400 mg daily.

Adjuvant therapy:

Adults

In addition to analgesia as above:

  • Amitriptyline, oral, 25 mg at night (Doctor initiated).
    • Titrate up to a maximum of 75 mg at night.

Under-recognition of pain and under-dosing of analgesics is common in chronic pain.
Analgesics should be given regularly rather than only when required in patients with ongoing pain.

REFERRAL

  • Pain requiring strong opioids.
  • Pain requiring definitive treatment for the underlying disease.
  • All children.