Opioid Analgesia for Acute Pain Management. Contents

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1 Opioid Analgesia for Acute Pain Management Classification: Policy Lead Author: Alison Dwyer Consultant Nurse Additional author(s): Fionn Murison Highly Speciality Nurse Dr Justin Turner, Pain Management Consultant, Clinical Lead Authors Division: Surgical Neurosciences Unique ID: Pha6(06)a Issue number: 1 Expiry Date: October 2016 Contents Section Page Who should read this document 2 Key points 2 Background/ Scope 3 What is new in this version 4 Policy/Procedure/Guideline 4 1 Opioid Analgesia and Formulary Recommendations 5 Codeine 5 Morphine 6 Oxycodone 7 Fentanyl 8 Buprenorphine 10 Tramadol 10 Pethidine- not used in SRFT 11 Entonox 11 Diamorphine 11 Using opioids in post-operative pain management 12 Adverse Effects of Opioid Analgesia 13 Opioid Toxicity Treatment of Opioid Toxicity (Naloxone) Opioid Withdrawal Opioid induced Hyperalgesia, Tolerance and dependency Explanation of terms/ Definitions 16 References and Supporting Documents 16 Roles and Responsibilities 17 Appendix 18 1 Pain Assessment Tools Analgesia Ladder 22 3 Clinical Opiate Withdrawal Scale (COWS) 23 Document control information (Published as separate document) Document Control/ Policy Implementation / Monitoring and Review Endorsement Equality analysis Page 1 of 21

2 Who should read this document? All clinical staff managing patients requiring oral analgesia for acute pain. Key Messages All patients should have a pain assessment using an appropriate tool (Appendix1) Analgesia should be prescribed according to pain assessment using the analgesia ladder (Appendix 2)- check for existing prescriptions to avoid duplication! Sustained release preparations, prescribed pre-admission, should be continued during a patient s admission, unless contraindicated, to prevent withdrawal and unrelieved pain. Opioids should be prescribed for the management of moderate to severe pain as part of a multimodal pain management strategy (Appendix 2) The oral route should be used whenever possible, Morphine is the analgesia of choice and should be used as first line strong opiate (for moderate to severe pain) unless contraindicated. Patients aged 70 years and over should be prescribed oxycodone for moderate to severe acute pain. Patients with renal impairment (AKI, Chronic renal failure) consider oxycodone for moderate to severe pain. Consider use of laxatives to address Opioid induced constipation Intravenous opioid titration may be required prior to oral administration to establish blood plasma concentration levels in acute pain. Post-Operative order sets are available for the prescribing of post-operative analgesia via EPMAR. The Post-Operative nausea and vomiting order set should be considered when prescribing opioids. Intravenous naloxone should be prescribed for the management of opioid toxicity. Page 2 of 21

3 For pre-operative review or advice regarding post-operative management please contact the Inpatient Pain Team. Background & Scope Opioids have a well-established role in the management of acute pain however, the need for on-going monitoring of treatment and identification and management of any problems related to opioid use must be considered. Patients should be advised of side-effects and the likelihood of experiencing them before commencing an opioid; 80% of patients taking opioids will experience at least one adverse effect. The most common side-effects of opioids include nausea and vomiting (particularly in initial stages), constipation, dry mouth, somnolence, itching, dizziness biliary spasm Larger doses may cause muscle rigidity, hypotension Sedation and respiratory depression. Tolerance to some side-effects usually occurs within the first few days of initiating treatment; however others including pruritus and constipation tend to persist. The National Patient Safety Agency (NPSA) has recommended that when prescribing, dispensing or administering opioids, the healthcare practitioner should: Confirm any recent opioid dose, formulation, frequency of administration and other analgesia medication prescribed for the patient. Ensure where a dose increase is intended, that the calculated dose is safe for the patient. Check the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, and common side-effects of that medicine and formulation. Sustained release preparations, prescribed pre-admission, should be continued during a patient s admission, unless contraindicated, to prevent withdrawal and unrelieved pain. Such preparations should not be used to manage episodes of acute pain or in patients whose analgesic requirements are changing rapidly, due to the delayed onset of analgesic effect. Page 3 of 21

4 For pre-operative review or advice regarding post-operative management please contact the Inpatient Pain Team. Long Term Opioid Use The British Pain Society (BPS) has produced a patient information leaflet (PIL) which should be given to patients when commencing on a long term opioid: Opioids for persistent pain: information for patients. What is new in this version? This document replaces oral opioids to provide an overview of the use of opioids by multi-route for the management of acute pain. Policy/ Guideline/ Protocol The management of acute pain and trauma pain involves individual patient assessment and the use of balanced analgesia, often including opioid analgesia. The prescribing of opioids for acute pain requires a titration period to establish and then maintain analgesia. For post-operative pain management opioid analgesia along with appropriate adjuvants should be prescribed before or at the time of surgery to ensure they are available when they are needed. Many patients undergoing intermediate surgical procedures may manage well on a combination of Paracetamol and Codeine Phosphate +/- Non Steroidal Anti- Inflammatory Drugs (NSAID s), however, patients undergoing a major surgical procedure are at risk of experiencing severe pain and strong opioid analgesia will be required. Mild opioids include: Codeine or Tramadol. Strong opioids include: Morphine, Diamorphine, Oxycodone, Methadone and Fentanyl. N.B Morphine is less suitable for those aged 70yrs and over as they have increased risk of side effects from metabolites. This patient group and those with renal impairment should be prescribed an alternative such as Oxycodone. Opioid Analgesia and formulary recommendations First-line Oral Mild Opioid: Codeine Page 4 of 21

5 The oral route should be used whenever possible, when the patient is tolerating oral fluids. The response to medication should be monitored, and the dose titrated to effect. If analgesia is ineffective or not tolerated, consider the second line opioid, morphine. Codeine 60mg PO is equivalent to approximately 10mg morphine PO. Codeine is partially metabolised by CYP2D6 and so an estimated 7% of the Caucasian population lacking/deficient in this enzyme will not obtain adequate analgesic effect. Conversely, up to 1-2% of the Caucasian population are ultra-rapid metabolisers and are therefore at increased risk of developing side effects of opioid toxicity even at low doses. CODEINE INDICATION mild to moderate pain PHARMACOKINETICS Onset of action minutes, Peak ~ 1 hour, Duration 4-6 hours CAUTIONS impaired respiratory function (avoid in COPD) and asthma (avoid during acute attack), hypotension, urethral stenosis, shock, myasthenia gravis, prostatic hypertrophy, obstructive or inflammatory bowel disorders, diseases of the biliary tract, and convulsive disorders. A reduced dose is recommended in elderly or debilitated patients, in hypothyroidism, and in adrenocortical insufficiency. Caution is advised if prescribing for patients with a history of drug dependence. Avoid abrupt withdrawal after long-term treatment. CONTRA-INDICATIONS avoid in patients with acute respiratory depression; contraindicated in patients with raised intracranial pressure and in head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment). Comatose patients should not be treated with opioid analgesics. ROUTES use the oral route whenever possible, if the patient is tolerating oral fluids Oral: tablets, syrup IM: injection- rarely used, discuss with Pain Team DOSES Oral, adults: 30-60mg every 4 hours when necessary, to a max. 240mg daily DO NOT co-prescribe Tramadol and Codeine For complete information on any medicine please refer to the current BNF First Line Strong Opioid for moderate to severe pain: Morphine Morphine remains the most valuable opioid for severe pain, and the standard against which other opioids are compared, though it causes nausea and vomiting in up to Page 5 of 21

6 40% of patients. In addition to analgesia, morphine can also produce a state of euphoria and mental detachment. Initial treatment should be titrated against patient response, including relief of pain, and side-effects; if the patient continues to experiences pain following an adequate dose, a further dose may be given as outlined below MORPHINE INDICATIONS Acute Postoperative/ Trauma Pain, severe and intractable (chronic) pain CAUTIONS see cautions for codeine; also pancreatitis, cardiac arrhythmias, severe cor pulmonale CONTRA-INDICATIONS see contraindications for codeine; also delayed gastric emptying, acute abdomen, heart failure secondary to chronic lung disease; phaeochromocytoma ROUTE Oral: Injection: Tablets, capsules, suspension, granules IV, SC, PCA, (intrathecal requires preservative free Morphine) DOSE: dependent on route and cause of pain; closely monitor pain relief and side-effects especially respiratory depression. ACUTE PAIN Oral, adults: 10-20mg Post-Operative Regimen to establish analgesia (EPMAR) 1hry for 3 doses then 3hrly as required. SC adults: initially 10mg every 3 hours (or more frequently during titration), adjusted according to response Slow IV, adults: IV Morphine should only be administered by staff trained to do so. Morphine should be titrated to effect to establish analgesia. THIS IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (Oral, SC, PCA, Continuous Infusion) Hepatic impairment: opioids may precipitate coma in patients with hepatic dysfunction and should be avoided or the dose reduced. Renal impairment: analgesic effect prolonged and increased in patients with renal impairment, there is increased cerebral sensitivity when opioids are used, doses should be reduced or avoided. For complete information on any medicine please refer to the current BNF Alternative Opioids: Oxycodone (1 st line over the age of 70yrs) Oxycodone is a semi-synthetic full opioid agonist with a high absolute bioavailability of up to 87% following oral administration compared to morphine, at approximately 30%. Patients having oral morphine before oxycodone therapy should have their Page 6 of 21

7 daily dose based on the following ratio 10mg of oxycodone is equivalent to 20mg of oral morphine. In elderly patients compared with younger patients, the clearance of oxycodone is only slightly reduced. OXYCODONE INDICATION moderate to severe pain in patients with cancer and post-operative pain CAUTIONS see cautions for codeine; also toxic psychosis; pancreatitis. Sunset yellow, a constituent of the 5mg capsule, can cause allergic type reactions such as asthma. This is more common in people who are allergic to aspirin. CONTRA-INDICATIONS see contra-indications for codeine; also acute abdomen; delayed gastric emptying; chronic constipation; cor pulmonale; acute porphyria ROUTE Oral: Injection: tablets (MR), capsules (IR), oral solution (IR) SC, IV injection or infusion DOSE: Oral, adults: 2.5-5mg Post-Operative Regimen to establish analgesia (EPMAR) 1hry for 3 doses then 3hrly as required. Slow IV, adults: IV Oxycodone should only be administered by staff trained to do so. Oxycodone should be titrated to effect to establish analgesia. THIS IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (Oral, SC, Continuous Infusion) SC, adults: initially 5mg every 3 hours (or more frequently during titration), adjusted according to response For complete information on any medicine please refer to the current BNF Suggested equivalent analgesic doses of opioid analgesia: Morphine Sulphate 10 mg IV is equivalent to 20 mg oral Morphine Morphine Sulphate 10 mg IV is equivalent to 10 mg oral Oxycodone Morphine Sulphate 10 mg IV is equivalent to 10 mg IV Oxycodone Morphine Sulphate 10 mg IV is equivalent to 100 micrograms IV Fentanyl Alternative Opioids: Fentanyl Fentanyl citrate is well established as an intravenous potent µ-opioid against for perioperative use, its low histamine release making it suitable for cardiovascular disease and patients with atopy. Page 7 of 21

8 Fentanyl is a highly lipid soluble analgesic with a rapid onset of analgesia and a short duration of action. It is approximately 100-fold more potent than morphine as an analgesic. Fentanyl is most commonly used as a peri-operative analgesic used IV and in PCA for post operative and trauma pain management (this is an unlicensed use). Fentanyl is available as a lozenge- for acute pain this is on formulary for the management of procedural pain only Fentanyl is also available in a transdermal form (Fentanyl Patch) for the management of chronic intractable / cancer pain where opioid requirements are stable. FENTANYL- Acute Pain Management INDICATION Moderate to severe post-operative pain CAUTIONS see cautions for codeine; also diabetes mellitus, impaired consciousness, cerebral tumour CONTRAINDICATIONS see contra-indications for codeine ROUTE Injection: Slow IV injection or infusion or PCA epidural injection or infusion DOSE: Oral, adults: Refer to the Fentanyl Lozenge policy Slow IV, adults: IV Fentanyl should only be administered by staff trained to do so. Fentanyl should be titrated to effect to establish analgesia- this is usually only administered in this way in the theatre, critical care or by the pain management team following opioid titration guidelines IV titration IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (PCA or Continuous Infusion) Hepatic impairment: see notes on Morphine. Renal impairment: see notes on Morphine. Less than 10% of fentanyl is excreted unchanged by the kidney and, unlike morphine, there are no known active metabolites eliminated, it is therefore potentially a safer opioid to be used in the renal impaired patient. Page 8 of 21

9 Elderly: monitor closely for potential sensitivity or adverse effects. A reduced dose may be needed due to fentanyl prolonged half-life in this group of patients. For complete information on any medicine please refer to the current BNF Chronic intractable pain, Fentanyl Transdermal Patch, Adults Not suitable for acute pain management or opioid naïve patients- seek pain team advice Currently treated with a strong opioid analgesic, initial dose based on previous 24-hour opioid requirement NB: A fentanyl patch provides continuous systemic delivery over the 72 hour administration period at a relatively constant rate. As the concentration gradient between the matrix and skin drives drug release, serum fentanyl concentration increase gradually, generally levelling off between 12 and 24 hours, and remaining relatively constant for the remainder of the 72-hour application period. By the second application, a steady state serum concentration is reached and is maintained during subsequent applications of a patch the same size. After a fentanyl patch is removed, serum fentanyl concentrations will gradually decline, falling about 50% in about 17 hours following a 24 hour application. Following a 72 hour application the mean half-life ranges from hours. Transdermal: monitor patients using patches for increased side effects if fever present (increased absorption possible); avoid exposing application site to external heat Risk of fatal respiratory depression particularly in patients not previously treated with a strong opioid analgesic; manufacturer recommends only use in opioid tolerant patients NB-If admitted for surgery with Fentanyl Patch for analgesia this should be continued. Inform the pain Team as further advice on analgesia management may be required post op. Alternative Opioids: Buprenorphine Buprenorphine is a partial mu opioid agonist but has antagonist actions at kappa and delta opioid receptors. It has a slow onset of action. It is most commonly available as a patch (BuTrans or Transtec) for chronic pain management. If using patch it may take up to hours to reach onset of action. Half-life is about 12 hourly. Inactive when taken orally due to first pass metabolism therefore required route is sublingual or via a patch. Page 9 of 21

10 BUPRENORPHINE INDICATION moderate to severe chronic pain (not used for acute pain management) CAUTIONS see cautions for codeine; also impaired consciousness; effects only partially reversed by naloxone; monitor liver function Transdermal: monitor patients using patches for increased side effects if fever present (increased absorption possible); avoid exposing application site to external heat CONTRA-INDICATIONS see contra-indications for codeine ROUTE Transdermal: Change every 96 hour (Transtec ) or 7 day (BuTrans ) patch NB-If admitted for surgery with Buprenorphine Patch for analgesia this should be continued. Inform the pain Team as further advice on analgesia management may be required post op. For complete information on any medicine please refer to the current BNF Alternative/Additional Opioids: Tramadol Tramadol is currently non formulary. This can be continued if prescribed as a preadmission medication. It is most commonly used second line to Codeine where the clinician wishes to avoid traditional strong opiates Tramadol is a weak opioid agonist which is extensively metabolised by enzyme CYP2D6 after oral administration. This enzyme is absent in 5-10% of Caucasians, the so-called poor metabolisers, in whom the concentrations of the pharmacologically active metabolite are reduced. Compared to morphine, tramadol does not show respiratory depression when given within the analgesic dosage interval. The effect of tramadol is considered 1/10 to 1/6 the effect of morphine. The gastrointestinal motility is not affected. Pre-admission prescriptions of tramadol should be continued unless contraindicated. Page 10 of 21

11 TRAMADOL INDICATION moderate to severe pain CAUTIONS see cautions for codeine; impaired consciousness; excessive bronchial secretions; not suitable as a substitute in opioid-dependent patients CONTRA-INDICATIONS see contra-indications for codeine; do not use where the patient has a history of epilepsy ROUTE Oral: Injection: Capsules, oral drops Not used in SRFT DOSE: Oral, adults: mg not more often than every four hours; total of more than 400mg daily not usually required DO NOT co-prescribe Tramadol and Codeine! For complete information on any medicine please refer to the current BNF Medications not routinely used in the management of acute pain PETHIDINE Pethidine is not available as an analgesic in SRFT due to poor analgesic properties, high addictive potential and risk of toxicity and seizures due to metabolites. If patients request Pethidine an alternative opioid should be prescribed in accordance with pain assessment. Please alert the PAIN MANAGEMENT TEAM For complete information on any medicine please refer to the current BNF ENTONOX Entonox is used for the management of procedural pain only. This is not maintenance analgesia. In cases of prolonged use inform the Pain Team DIAMORPHINE Not routinely used in acute pain management. Page 11 of 21

12 Using Opioids in Post-Operative pain Management Where possible the oral route should be used. Alternative routes for major surgery include PCA and Epidural analgesia. Oral opioid analgesia will usually follow a period of IV titration of opioids to establish analgesia effect/ response but may be prescribed following: IV opioid titration in recovery, Discontinuation of PCA/ opioid infusion Discontinuation of Epidural infusion On receiving maximum dose of weak opioid analgesia and patient reporting severe pain. Oral opioid prescriptions should incorporate a titration period to establish analgesia when commencing or converting to oral analgesia. It is important to note that IV titration of opioids is often required in the recovery room to quickly establish blood plasma concentration/levels. Oral opioid analgesia (Morphine and Oxycodone) for post-operative or trauma pain should be prescribed in EPMAR. The regimen can be found in the post-op order sets or by typing in Morphine or Oxycodone (70yrs and older, those with renal impairment or allergy). Select the post-operative order set. The first three doses can be titrated at hourly intervals as required. The prescription then automatically reduces frequency to 3hrly intervals as required. Once a patient has been commenced on an oral strong opioid, if the drug needs to be changed, e.g. from Morphine to Oxycodone the patient should not have a further period of 1 hourly dosing. The starting dose is based on patient assessment, but in fit healthy adults this is often 10-20mg of Morphine (or equivalent). Increasing on patient requirement or decreasing if the patient is frail or elderly. For patients 70yrs and older, those with renal impairment or allergy to morphine, Oxycodone should be considered. Doses up to 10 mg should be prescribed, though may need adjusting depending on individual assessment. If initial titration at hourly intervals remains ineffective (Patient continues to report severe pain and/or is unable to take a deep breath and cough effectively) advice should be sought regarding the dose/method of analgesia administered. The clinician needs to consider increasing the dose of opioid analgesia or giving an IV bolus dose (to establish effectiveness) or commencing a PCA. Staff who have completed enhanced role training can administer IV boluses. If PCA is required, oral opioid analgesia should be discontinued for the duration of the PCA infusion and recommenced as per protocol once PCA is no longer required. Page 12 of 21

13 Sedation and respiratory depression are recognised side effects of opioid analgesia and should not be confused with overdose which is an excessive and dangerous amount of a drug (Oxford English Dictionary). If opioid analgesia is administered as protocol and the patient is monitored as protocol then the dose is not excessive (recognised dose). Nor is it dangerous if the patient is monitored, resuscitation equipment should be available in all clinical areas along with Naloxone for the management of opioid related side effects. Nausea and vomiting is a common side effect of anaesthesia, surgery and analgesia. The PONV guidelines should be implemented for symptomatic management. Pruritus- Symptomatic management with Chlorphenamine. Constipation local guidelines should be followed depending upon surgical intervention. Naloxone is the reversal agent for opioid induced sedation and respiratory depression. Naloxone should be titrated as per APS guidelines. If long acting opioids have been administered an infusion of Naloxone may be required. Adverse effects of Opioid Analgesia Opioid Toxicity The dose of opioids causing toxicity varies between individuals and depends on medical comorbidities, particularly renal or hepatic impairment, and concomitant medication therapy, including over the counter medication and illicit drug use. Clinical features of opioid toxicity Pinpoint pupils Sedation Slow respiration Visible cyanosis e.g. lips, ears, nose Myoclonic jerks Snoring when asleep Agitation Confusion Vivid dreams, nightmares or hallucinations More severe cases: hypotension, coma convulsions Page 13 of 21

14 Treatment of Opioid Toxicity Intravenous Titration of Naloxone 1. Draw up 0.4mg (1ml) ampoule of Naloxone into a 5ml syringe 2. Make up to 4mls total volume with 0.9% normal saline 3. Administer 1ml increments of the diluted Naloxone solution (0.1mg) at 2 minute intervals until respiratory rate >12 and AVPUS (A) 4. Continue observations and prepare a solution of Naloxone for infusion if required. Continuous infusion of Naloxone 1. Draw up six 0.4mg ampoules of Naloxone into a 60ml syringe 2. Dilute to 60mls total volume using 0.9% normal saline 3. Infuse intravenously at 5mls hour according to respiratory rate and AVPUS score. 4. Contact pain team regarding advice or alternative or supplementary analgesia. 5. Refer to a senior anaesthetist regarding recommendation of length of infusion and continue hourly observations for at least four hours after stopping infusion. 6. If Naloxone is given ensure that the audit form is completed and sent to the acute pain team and an AIR form is completed on the Trust Datix system. Opioid Withdrawal Opioid withdrawal occurs when an opioid is stopped suddenly, the dose tapered too rapidly, or when an opioid antagonist (i.e. Naloxone) is given. Signs of opioid withdrawal (adapted from the BPS): Sweating Mydriasis Piloerection Yawning Abdominal cramps/vomiting/diarrhoea Bone and muscle pain Increase in usual pain Restlessness Anxiety Rhinorrhoea Lacrimation Tremor Page 14 of 21

15 Significant withdrawal symptoms may be experienced after discontinuation of tramadol, even after short periods of dosing. If opioid withdrawal is suspected, use the Clinical Opiate Withdrawal Scale (COWS) to assess severity; (Appendix 3) Opioid induced Hyperalgesia, Tolerance and dependency Opioid induced Hyperalgesia, a state of abnormal pain sensitivity, has been demonstrated following prolonged use of opioids. Clinically presenting with increased pain, this may be qualitatively distinct from pain related to disease progression or to breakthrough pain resulting from development of opioid tolerance, and is managed by opioid dose reduction or changing to an alternative opioid preparation. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug s effects over time, developing within a few days to opioids. Clinical experience suggests that immediate release preparations are more commonly associated with tolerance and problem drug use. Physical dependence refers to a state in which drug withdrawal causes adverse physiological effect(s) and occurs to some degree after morphine has been given for a few days. Explanation of terms & Definitions Awake and Responsive, Responds to Verbal, Responds to Painful Stimulus, Unresponsive, (AVPU) Adverse Incident Report (AIR) Intravenous (IV) Subcutaneous (SC) Electronic Prescribing and Medicines Administration Record (EPMAR) Post Op Nausea and Vomiting (PONV) Patient Controlled Analgesia (PCA) Salford Royal NHS Foundation Trust (SRFT) Chronic Obstructive Pulmonary Disease (COPD) Modified Release (MR) Immediate Release (IR) Page 15 of 21

16 References and Supporting Documents Acute Pain Management Scientific Evidence 3rd Ed 2010). Australian and New Zealand College Of Anaesthetics and Faculty of Pain Medicine. Aderjan RE, Skopp G (1998) Formation and clearance of active metabolites of Opiates in Humans (Proceedings Of The Fifth International Congress Of Therapeutic Drug Monitoring And Clinical Toxicology) Therapeutic Drug Monitoring, Lippincott Williams and Wilkins Inc. Vol 20 (5) Davis MP Vargan J, Dickerson, D, Wals D, LeGrand SB, Lagman R (2003) Normal release and controlled release Oxycodone: pharmacokinetics, Pharmacodynamics and controversy Support Cancer Care 11: McQuay H (1999) Opioids in pain management. Lancet Vol 353 June Oxford English Dictionary NPSA- RAPID RESPONSE REPORT: NPSA/2008/RRR05 Reducing Dosing Errors with Opioid Medicines July 2008 Roles and responsibilities Consultant Pain Nurse. Accountable to the Executive Nurse Director & Trust Board for review and maintenance of this policy standard. Pain Management Team. are responsible for checking that their activities comply with the guidance in this policy. for training and assessing link nurses and other identified staff in the use of this policy. monitoring and recording practice to ensure all SRFT staff comply with this policy. reviewing this protocol regularly and making timely updates Link nurses and other identified staff with enhanced role. are responsible for complying with the protocol and reporting to the pain management team. Modern Matrons, Ward Managers are responsible for ensuring compliance with policy from all staff in surgical clinical areas. Page 16 of 21

17 Appendices Appendix 1 Pain Assessment Tools Pain the fifth vital sign! 1. Verbal Descriptor Scale- this is a self-report tool Ask the patient do you have any pain? Assess at rest and on Movement Ask if pain is mild moderate or severe Score as below No Pain 0 Mild Pain 1 Moderate Pain 2 Severe pain 3 2. Abbey Pain Assessment This is for patients who are unable to reliably self-report pain Page 17 of 21

18 Page 18 of 21

19 PAIN PERSISTING MOVE UP ONE STEP AT A TIME SIGNS OF TOXICITY OR SEVERE SIDE EFFECTS REDUCE THE DOSE OR MOVE DOWN A STEP Appendix 2 SALFORD ROYAL NHS FOUNDATION TRUST Analgesic Ladder (Adapted from World Health Organisation (WHO) Analgesic Ladder 1986) SEVERE PAIN STEP 3 STRONG OPIOIDS FOR SEVERE PAIN (e.g. Morphine Sulphate 1.R. Oramorph, Oxycodone I.R. See protocol) PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS (Non-steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS MODERATE PAIN STEP 2 WEAK OPIOID FOR MODERATE PAIN (e.g. Codeine Phosphate) PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS (Non steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS MILD PAIN STEP 1 NON-OPIOID PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS (Non steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS Page 19 of 21

20 Appendix 3 Clinical Opiate Withdrawal Scale (COWS) Patient s Name: Date: Medication : Last used : Resting Pulse Rate: (record beats per minute) Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate pulse rate pulse rate greater than 120 Sweating: over past ½ hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face Restlessness Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is Visible Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/ muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 Multiple episodes of diarrhea or vomiting Page 20 of 21

21 Tremor observation of outstretched hands 0 No tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching Yawning Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable anxious 4 patient so irritable or anxious that participation in the assessment is difficult Gooseflesh skin 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerrection Total scores Page 21 of 21

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