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KEEP ALL MEDICINES OUT OF THE REACH OF CHILDREN!  Why not take a second and check that yours are safely out of reach!

From personal experience, it can be suggested that Pain Clinic medication regimens differ from the more traditional prescribing of a local GP.  It would appear that the more specialist service provided from the Pain Clinic enables a wider range and combination of drug therapies.  On this web-page, you will find details of typical medication treatment regimens from GP.


Medication treatment regimens from GP

Finding a safe, effective medication can be rather 'hit & miss', and may take some time.  Analgesic medication can have different qualities, efficiency and effects on different people.  However, before prescribing any medication, your GP will firstly assess your condition.  To enable this to be done, it is important to inform him or her of any current medical conditions that may not be in your medical records and to indicate if you have any allergies to medication, or if you are taking any over-the-counter / homeopathic or herbal products. 

It is common practice for GP's to prescribe two types of medication for people suffering with chronic pain.  These are analgesics, which treat the pain itself and psychotropic agents such as antidepressants and anxiolytics (anti-anxiety drugs) to treat the associated problems of depression and anxiety.  

According to what is known as the "Three-Step Analgesic Ladder" model of the World Health Organization (WHO), analgesic medications for treating chronic pain on a maintenance basis may be effectively prescribed at one of three levels.   This systematically and incrementally increases to higher doses of more potent medications (i.e. opioid analgesics like morphine and tramadol ) if the pain worsens. 

The first step is the prescribing of relatively low doses of low-potency analgesic medications such as paracetamol, this may or may not include the prescribing of  non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.  

In step 2 if the pain persists or increases to mild-to-moderate levels of severity, the potency of the analgesic can be increased, i.e. codeine and paracetamol  or lower-potency opioid medication- and used either with or without NSAIDs. 

Finally in step 3,  if the pain persists or increases to moderate-to-severe levels, then high-potency opioid analgesics (again with or without NSAIDs) can be prescribed.  

According to WHO, the treating clinician must accept that chronic pain by definition does not go away, and therefore prescribing should be on an ongoing, maintenance basis  and at a sufficiently high dose level, to treat the chronic pain effectively.


Please note that between visits to the GP, your local community pharmacist can help you monitor the effects of any prescribed medication.

PLEASE ensure you strictly follow the GP's instructions for taking the medication.  To be effective, medication should be taken at the same time each day.  Remember if you are supposed to take your medication with food or liquid, to always do so.

The local community pharmacist can provide aids to ensure the correct medication is safely taken at the correct time if any communication or learning deficits exist, via such innovations such as large print labels, and individual blister packs.

It may be useful for people who suffer with regular bouts of intensified pain, to ask the GP what to do in such circumstances.  Inform your GP immediately if the pain medication is not relieving your pain, he/she may need to change the dosage or switch you to another type of pain reliever.  Never increase the dosage without first talking to your doctor.


Side effects

All medication causes side-effects in various degrees, of which some will be more serious than others.  Ask your doctor or pharmacist to tell you what side effects to expect from the medication you are taking.  Public Information Leaflets (PIL) are produced by pharmaceutical companies for insertion into packets of tablets/syrups etc.  If one is not present, please ask the Pharmacist. 

Common side effects of painkillers include constipation, nausea, dizziness, headache, drowsiness and vomiting.  Certain types of pain medications also can potentially cause physical dependence, although varying evidence suggests the rate of dependence with controlled drugs is as low as 0.1%.  Although uncommon, there is also a risk of seizures with some centrally-acting analgesic medications.  It is important to tell your GP if you previously have had a seizure and if you are taking opioid analgesics or medications commonly used to treat depression (i.e., amitriptyline, fluoxetine).  Please note that taking analgesia over and above the recommended dosage increases the risk of seizures.

NSAIDs can irritate the lining of the stomach and intestines in some users.  This irritation can lead to ulcers or gastrointestinal bleeding, and is a very serious side effect.  Therefore you need to inform your GP if your pain medication causes an upset stomach.  

Important - you should call your doctor immediately if you you have vomited blood, noticed blood in a bowel movement - for example, bright red or black, tarry stools - or if you develop persistent stomach pain, or experience shortness of breath.  


Non-steroidal anti-inflammatory drugs (NSAIDs)

If taken in regular doses, NSAIDs have a lasting pain-killing (analgesic) and anti-inflammatory effect.  This makes them very useful in the treatment of pain associated with inflammation, and means that NSAIDs are more appropriate than paracetamol or the opioid analgesics in the inflammatory conditions such as rheumatoid arthritis and in some cases of advanced osteoarthritis.  They may also be of benefit in conditions such as back pain and soft-tissue disorders.

The differences in anti-inflammatory activity between different NSAIDs are small, but there is considerable variation in individual tolerance and response.  As a result, about 60% of patients will respond to any NSAID.  Those who do not respond to one may well respond to another.

Naproxen

Ibuprofen


Naproxen 250 mg tablets

This prescription only medication comes in tablet form -  in strengths of either 250  mg or 500  mg naproxen BP. Naproxen has analgesic, anti-inflammatory and anti-pyretic actions.  Therapeutic indications: Naproxen is used in the treatment of rheumatoid arthritis and other rheumatic or musculoskeletal disorders.  In rheumatic disorders the usual initial dose of naproxen is 250  mg, twice daily, adjusted to 500  mg to 1  g daily in two divided doses by oral administration.

Contra-indications

  • In patients with acute peptic ulceration.
  • In patients with known hypersensitivity to naproxen or naproxen sodium formulations.
  • Since the potential exists for cross-sensitivity reactions, naproxen should not be given to patients in whom aspirin or other non-steroidal anti-inflammatory/analgesic drugs induce asthma, rhinitis, or urticaria.

Special warnings and precautions for use: Naproxen has been found to be well tolerated by patients exhibiting dyspepsia with other similar agents. None the less, episodes of gastro-intestinal bleeding have been reported in patients with naproxen therapy. Naproxen should be given under close supervision to patients with a history of gastro-intestinal disease. Bronchospasm may be precipitated in patients suffering from or with a history of bronchial asthma or allergic disease. Naproxen decreases platelet aggregation and prolongs bleeding time.

Use in patients with impaired renal function: As naproxen is eliminated to a large extent (95%) by urinary excretion via glomerular filtration, it should be used with great caution in people with significantly impaired renal function. Naproxen should not be used chronically in patients having baseline creatinine clearance less than 20  ml/minute. Certain patients, specifically those where renal blood flow is compromised, such as in extracellular volume depletion, cirrhosis of the liver, sodium restriction, congestive heart failure and pre-existing renal disease should have renal function assessed before and during naproxen therapy. Some elderly patients in whom impaired renal function may be expected, could also fall within this category. A reduction in the daily dosage should be considered to avoid the possibility of excessive accumulation of naproxen metabolites in the patients.

Use in patients with impaired liver function: Chronic alcoholic liver disease and probably other forms of cirrhosis reduce the total plasma concentration of naproxen but the plasma concentration of unbound naproxen is increased, so caution is advised when high doses are required.

Pregnancy and lactation: Good medical practice indicates minimal drug usage in pregnancy and the use of this class of therapeutic agent requires cautious balancing of possible benefit against potential risk to mother and foetus, especially in the first and third trimesters. Naproxen has been found to affect the human foetal cardiovascular system (closure of the ductus arteriosus).  Naproxen delays the onset and increases the duration of labour.  The use of naproxen should be avoided in patients who are breast-feeding.

Undesirable effects: Occasional skin rashes and angio-oedema have been reported.  Side effects which occasionally occur are nausea, vomiting, abdominal discomfort, epigastric distress, headache, inability to concentrate, insomnia, tinnitus and vertigo. Rarely, thrombocytopenia, granulocytopenia, jaundice, aplastic anaemia, haemolytic anaemia, peptic ulceration, fatal hepatitis, hearing impairment, cognitive dysfunction, anaphylactic reactions to naproxen, and nephropathy. Mild peripheral oedema has been observed. Sodium retention may occur in patients with questionable or compromised cardiac function when taking naproxen.

Overdose Significant overdosage of the drug may be characterised by drowsiness, heartburn, indigestion, nausea or vomiting. Should a patient ingest a large amount of naproxen the stomach may be emptied and usual supportive measures employed (it is not known what dose of drug would be life threatening). 

Special precautions for storage: Store in a dry place below 25C. Protect from light. Keep container tightly closed.


Ibuprofen Tablets BP 400mg

Available either over the counter or as an oral prescription only medication, Ibuprofen is a propionic acid derivative, having analgesic, anti-inflammatory and antipyretic activity.  It is primarily prescribed due to  its analgesic anti-inflammatory effects in the treatment of rheumatoid arthritis, ankylosing spondylitis and osteoarthritis.  Ibuprofen is also indicated in conditions such as frozen shoulder, bursitis, migraine,  tendonitis, low back pain and soft tissue injuries such as sprains and strains.

The recommended dosage is 1200-1800mg daily in divided doses. Some people can be maintained on 600-1200mg daily. In severe or acute conditions, it can be advantageous to increase the dosage until the acute phase is brought under control, provided that the daily dose does not exceed 2400mg in divided doses.  No special dosage modifications are required in the elderly, unless renal or hepatic function is impaired, in which case dosage should be assessed individually.  However the  elderly are at increased risk of the serious consequences of adverse reactions. If an NSAID is considered necessary, the lowest dose should be used and the patient should be monitored for GI bleeding for 4 weeks following initiation of NSAID therapy.

Contra-indications

  • Hypersensitivity to any of the ingredients.
  • Patients with a history of, or existing peptic ulceration.
  • Patients with a history of bronchospasm, rhinitis, urticaria, particularly associated with therapy with aspirin or other non-steroidal anti-inflammatory drugs.
  • Special warnings and special precautions for use. Caution is required if administered to patients suffering from, or with a previous history of, bronchial asthma, since NSAIDs has been reported to cause bronchospasm in such patients.  NSAIDs should only be given with care to patients with a history of gastro-intestinal disease.  Caution is required in patients with renal, hepatic and cardiac impairment since the use of NSAIDs may result in deterioration of renal function. The dose should be kept as low as possible and renal function should be monitored in these patients.
  • NSAIDs should be given with care to patients with a history of heart failure or hypertension since oedema has been reported in associated with NSAID administration.
  • If symptoms persist for more than 3 days consult your doctor. Undesirable effects may be minimized by using the minimum effective dose for the shortest possible duration. As with all pain relievers, if you are receiving regular treatment from your doctor consult him before taking this medicine.  Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma or allergic disease. Caution is required in patients with renal, cardiac or hepatic impairment since renal function may deteriorate. The dose should be as low as possible and renal function should be monitored.
  • The elderly are at increased risk of the serious consequences of adverse reactions.
  • Do not use if you have ever had a stomach ulcer or are allergic to ibuprofen or aspirin.
  • If you are allergic to or taking any other pain killer, pregnant or suffer from asthma, speak to your doctor before taking ibuprofen.
  • Do not exceed the stated dose.
  • If symptoms persist consult your doctor.
  • No adverse effects known on ability to drive and to use machines

Side effects

  • Gastrointestinal: the most commonly observed adverse events are gastrointestinal in nature. Nausea, vomiting, diarrhoea, dyspepsia, abdominal pain, melaena, haematemesis, ulcerative stomatitis and gastrointestinal haemorrhage have been reported following ibuprofen administration. Less frequently, gastritis, duodenal ulcer, gastric ulcer and gastrointestinal perforation have been observed.
  • Hypersensitivity: hypersensitivity reactions have been reported following treatment with ibuprofen. These may consist of (a) non-specific allergic reaction and anaphylaxis, (b) respiratory tract reactivity comprising asthma, aggravated asthma, bronchospasm or dyspnoea, or (c) assorted skin disorders.
  • Cardiovascular: oedema has been reported in association with ibuprofen treatment.
  • Other adverse events reported less commonly and for which causality has not necessarily been established include:
  • Renal: nephrotoxicity in various forms, including interstitial nephritis, nephrotic syndrome and renal failure.
  • Hepatic: abnormal liver function, hepatitis and jaundice.
  • Neurological and special senses: visual disturbances, optic neuritis, headaches, paraesthesia, depression, confusion, hallucinations, tinnitus, vertigo, dizziness, malaise, fatigue and drowsiness.
  • Haematological: thrombocytopenia, neutropenia, agranulocytosis, aplastic anaemia and haemolytic anaemia.
  • Dermatological: photosensitivity (see 'hypersensitivity' for other skin reactions).
  • Gastro-intestinal: Abdominal pain, nausea and dyspepsia. Occasionally, peptic ulcer and gastro-intestinal haemorrhage.
  • Hypersensitivity: Hypersensitivity reactions have been reported following treatment with ibuprofen. These may consist of (a) non-specific allergic reactions and anaphylaxis, (b) respiratory tract reactivity comprising asthma, aggravated asthma, bronchospasm or dyspnoea, or (c) assorted skin disorders, including rashes of various types, pruritus, urticaria, purpura, angioedema and less commonly, bullous dermatoses (including epidermal necrolysis and erythema multiforme).
  • Haematological: Thrombocytopenia.
  • Renal: Papillary necrosis which can lead to renal failure.
  • Others: Rarely hepatic dysfunction, headache, dizziness, hearing disturbance.

Overdose  Symptoms include nausea, vomiting, dizziness and, rarely, loss of consciousness. Large overdoses are generally well tolerated when no other drugs are involved. Treatment consists of gastric lavage and if necessary correction of serum electrolytes. No specific antidote is available and otherwise supportive therapy only is indicated.


Opioid Analgesics

Opioid analgesics are usually used to relieve moderate to severe pain.  Apart from exceptions such as Tramadol, these are usually prescribed as Controlled Drugs and require a hand written prescription indicating the drug/strength/amount/frequency of dose.  Please click on the following medications to find out more about them.  

Tramadol

Morphine salts


Tramadol Hcl Tablets 50mg

Tramadol hydrochloride is used in the management (treatment and prevention) of moderate to severe pain.  Tramadol capsules are white capsules imprinted with T 50 on the top.

Recommended dosage for pain associated with chronic conditions: Use an initial dose of 50mg and then alter dose according to severity of pain. The need for continued treatment should be assessed at regular intervals as withdrawal symptoms and dependence have been reported (see section 'Special Warnings and Precautions for Use'). A total daily dose of 400mg should not be exceeded except in special clinical circumstances.  Tramadol is not recommended for patients with severe renal impairment.

Contra-indications  Tramadol hydrochloride should not be administered to patients who have previously demonstrated hypersensitivity to it or in cases of acute intoxication with alcohol, hypnotics, centrally active analgesics, opioid or psychotropic drugs. In common with other opioid analgesics it should not be administered to patients who are receiving monoamine oxidase inhibitors (MAOIs) or within two weeks of their withdrawal

Special warnings and special precautions for use  At therapeutic doses, Tramadol hydrochloride has the potential to cause withdrawal symptoms. Rarely cases of dependence and abuse have been reported. At such doses, withdrawal symptoms have been reported at a reporting frequency of 1 in 8,000. Reports of dependence and abuse have been less frequent.  Tramadol hydrochloride should be used with caution in patients with head injury, increased intracranial pressure, severe impairment of renal and hepatic function and in patients prone to convulsive disorders or in shock.  Convulsions have been reported at therapeutic doses and the risk may be increased at doses exceeding the usual upper daily dose limit. Patients with a history of epilepsy or those susceptible to seizures should only be treated with tramadol if there are compelling reasons.  The risk of convulsions may increase in patients taking tramadol and concomitant medication that can lower the seizure threshold (see 'Interactions with other Medicaments and other forms of Interaction').

Care should be taken when treating patients with respiratory depression, or if concomitant CNS depressant drugs are being administered, as the possibility of respiratory depression cannot be excluded in these situations. At therapeutic doses, respiratory depression has infrequently been reported.

Side effects   Nausea, vomiting and occasionally dry mouth. Both diarrhoea and constipation have been reported. In controlled trials the incidence of constipation is lower than that of comparator agents.  Tiredness, fatigue, drowsiness, somnolence, dizziness, headache, confusion, hallucinations and rarely respiratory depression. Dependence, dysphoria and convulsions have been reported occasionally (see 'Interactions with other Medicaments and other forms of Interaction').  Dependence, abuse and withdrawal symptoms have been reported. Typical opiate withdrawal reactions include agitation, anxiety, nervousness, insomnia, hyperkinesia, tremor and gastrointestinal symptoms.  Dyspnoea, wheezing, bronchospasm and worsening of existing asthma.  Diaphoresis, urticaria and pruritus have been reported. Skin rashes, tachycardia, orthostatic hypotension, increase in blood pressure, bradycardia, flushing, syncope and anaphylaxis have been rarely reported. Cases of blood dyscrasias have been rarely observed during treatment with tramadol, but causality has not been established.

Overdose  Symptoms of overdose are typical of other opioid analgesics, and include vomiting, cardiovascular collapse, sedation and coma, seizures and respiratory depression.


Morphine salts

Morphine remains the most valuable opioid analgesic for severe pain although it frequently causes nausea and vomiting. It is the standard against which other opioid analgesics are compared. In addition to relief of pain, morphine also confers a state of euphoria and mental detachment.  Morphine is the opioid of choice for the oral treatment of severe pain in palliative care.

Contra-indications: avoid in acute respiratory depression, acute alcoholism and where risk of paralytic ileus; also avoid in raised intracranial pressure or head injury (in addition to interfering with respiration, affect pupillary responses vital for neurological assessment).

Use with caution in opiate dependent patients and in patients with raised intracranial pressure, hypotension with hypovolaemia, diseases of the biliary tract, pancreatitis, inflammatory bowel disorders, prostatic hypertrophy and adrenocortical insufficiency, acute alcoholism, and in patients with convulsive disorders

Special warnings and special precautions for use Morphine salts should not be used where there is a possibility of paralytic ileus (a type of intestinal obstruction) occurring. Should paralytic ileus be suspected or occur during use, morphine tablets should be discontinued immediately. Patients who are about to undergo pain relieving procedures should not receive morphine tablets for 4 hours prior to surgery. A reduction in dosage may be advisable in hypothyroidism, and in renal and chronic hepatic disease. 

Side effects - In normal doses, the commonest side effects of morphine are nausea, vomiting, constipation and drowsinessWith chronic therapy, nausea and vomiting are unusual with morphine but should they occur,  the tablets can be readily combined with an anti-emetic if required. Constipation may be treated with appropriate laxatives.  Dry mouth, sweating, vertigo, headache, disorientation, facial flushing, mood changes, palpitations, hallucinations, bronchospasm and colic may occur.  Micturition may be difficult. 

The effects of morphine have led to its abuse and dependence may develop with regular, inappropriate use. This is not a major concern in the treatment of patients with severe pain.

Overdose Signs of morphine toxicity and overdosage are pin-point pupils, respiratory depression and hypotension. Circulatory failure and deepening coma may occur in more severe cases.

  

 

 

 

 

 

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