The pain step-ladder

Pain is a very common presenting problem in general practice. In the older population, some form of chronic pain seems quite hard to avoid. Whether it be from a dicky back, arthritic hips or aching hands, most people have to put up with some form of pain in their daily lives.

How does one manage pain?

The first step is an accurate diagnosis. If that diagnosis is a non-concerning musculoskeletal pain, where to from there?

Try the basics first…

Sometimes a simple solution is best:

• Massage
• Wheat bags
• Relaxation

and other pain management skills can be very effective and may be all that is required. Even with simple pain, it may have accumulated over time, so it may take more than one massage, or five minutes with a wheat bag to do the trick.

If something more powerful is required

Now you are onto the pain ‘step-ladder’ of medication. The following are chosen for relative strength and seriousness of side effects.

Rung one

Rung one on the step-ladder is paracetamol. It is relatively weak pain relief, but its effect may be all that is required to make a walk bearable for example. The effectiveness of paracetamol is increased for most people by taking it regularly at good doses (eg 2 tablets every 4 hours). It is safe for most people at most ages and is worth a try in most circumstances.

Rung Two

Second rung (to be used on top of the first rung) are anti-inflammatories, like Nurofen. These can be very effective, especially for musculoskeletal pain, but if you are taking it regularly, you should discuss it with your doctor. This is especially true if you have had previous bleeding problems, heart problems or kidney problems, or are taking other medications.

Rung Three

The third rung comprises the weak opioids (morphine like medicines). The most commonly used on this rung are codeine and tramadol, and each are infamous for causing problems at other ends of the gut (codeine constipation and tramadol vomiting). Both can cause drowsiness and have addictive qualities and the potential for abuse. However, a low dose at night might just help you get that all-important sleep when arthritic hips flare up.

Rung Four

The top rung of the pain step ladder are the strong opioids – morphine, oxycontin and the like. These medicines are usually left for severe pain or short-term pain management. For someone with long-term back pain, there is no evidence that they are any more effective three months into it than paracetamol. The same problems exist as per weak opioids. Over time, many notice that they need a higher dose of the drug to have the same effect. The withdrawal syndrome can actually worsen your pain in the short term when you try to come off it.

This ladder describes by far the most commonly used pain medicines. They are not cures and often they do not even take away the pain completely, but may ease suffering just enough for normal life to resume again.

By Dr Davis Hassan

General Practitioner 

I am interested in providing a real perspective on health and medicine and aim to focus on the things that matter when considering a health issue, and what has worked with my patients.

Read more from Dr David Hassan here