Selected topics in acute pain management for primary care

There are a multitude of causes of acute pain, however, the approach to management will often be similar; assessment guides prescribing choices, and an analgesic plan provides patients with the confidence and knowledge to appropriately manage their symptoms. This series provides an overview of the principles of acute pain management in primary care and explores more specific issues where there may be clinical uncertainty, such as paracetamol dosing in overweight children, when to consider tramadol as an analgesic, and how to provide a “safety net” when prescribing strong opioids in primary care.

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The principles of managing acute pain in primary care

The primary aim of acute pain management is to provide treatment that reduces the patient’s pain, with minimal adverse effects, while allowing them to maintain function. A secondary aim is to prevent acute pain from progressing to chronic pain. Use multi-modal analgesia, provide an analgesic plan and consider other treatments or techniques which will optimise resolution of pain.

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Paracetamol dosing for children in primary care

Paracetamol dosing errors can lead to acute liver failure in children. Calculation of a paracetamol dose in children should be based on body weight rather than age, and regularly updated as children grow. Caregivers should be given clear instructions on how to measure and administer doses.

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Prescribing tramadol appropriately

Tramadol is an atypical opioid used for moderate pain when paracetamol and/or a NSAID is not adequate. There is no evidence that tramadol provides superior pain relief compared to other weak opioids, such as codeine. Tramadol is associated with less risk of respiratory depression and constipation than codeine, but has an increased risk of serotonin toxicity.

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When to consider strong opioids for patients with acute pain

There are few indications for prescribing a strong opioid for acute pain in a primary care setting. If a strong opioid is required, morphine is first-line and treatment should ideally be prescribed for a few days only. An analgesic plan should be provided to the patient, and weaker opioids and/or paracetamol/NSAIDs prescribed to provide analgesic cover as the pain resolves and the strong opioid is withdrawn.

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Thank you to Dr Chris Cameron, General Physician and Clinical Pharmacologist, Chair, Medicines Committee, Capital & Coast DHB, Wellington Hospital for expert review of this article.

N.B. Expert reviewers are not responsible for the final content of the article.

Published: 23 February 2018 | Updated:

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