most analgesics have adverse effects, particularly as dose is increased
ASK patient if they want more or any pain management - many will prefer to have some pain rather than excessive analgesics
occult causes of pain (eg. HbS crises, sprained ankle with normal Xray) are often undertreated and thus staff may need to be aware of this tendency and give adequate relief.
agitated demented patients usually benefit more from analgesics than sedatives - remember to look for causes of occult pain such as acute urinary retention
propofol is NOT an analgesic, and use without analgesics for painful procedures may result in delayed post-traumatic stress type symptoms
do NOT routinely give prophylactic anti-emetics such as metoclopramide (Maxolon) as risk of adverse reactions (dystonic reaction, restlessness, agitation, abdominal cramps from bloating) generally outweigh its prophylactic benefit.
migraine headache is usually best Mx with iv chlorpromazine while opiates should be avoided
avoid opiates and tramadol in back pain as there is evidence suggests they are of little benefit over non-steroidal anti-inflammatory drugs (NSAIDs) and do more harm, especially for chronic pain, instead consider a stat dose of corticosteroids such as 75mg prednisolone if acute disabling pain
neuropathic pain is usually best managed by neural pain modulators rather than traditional analgesics
patients with chronic pain should be Mx with consideration of chronic pain factors
consider trying lignocaine IV 1-1.5mg/kg IV slow infusion (over 5-20 min.) for renal colic in patients for whom opiates and NSAIDs are high risk - a study from Iran suggested it works faster and better than iv morphine 1)
patient-controlled analgesia (PCA) - particularly for those going to wards with ongoing pain eg. fractured ribs
options for less severe pain
oral or rectal oxycodone - 5-10mg po 4-6hrly - better than panadeine forte or codeine
if discharging patient home on codeine, ideally should assess its efficacy in that patient (genetic issues) by observing for 1 hour post-dose in ED, and if no benefit, consider using oxycodone instead.
avoid tramadol and tapentadol in the elderly in particular as they have adverse effects and may not be better than placebo, but may consider it in younger patients if above fail and wish to avoid opiates and opioids