Your A to Z of pain relief
Your A to Z of Pain - booklet coverWhich pain medicines are you taking?
What this guide is about…
We are committed to providing you with a high standard of
care at The Christie.
As part of your overall care we will help manage any pain
problems you may have, along with your GP or Macmillan
nurse.
This guide includes:
- a list of medicines we commonly use for pain at The
Christie
- instructions on how and when to take them ■ a list of the most common side effects
- advice on what to do if pain is a problem at home
- useful contacts – where to get advice.
Types of painkiller
Weaker painkillers
For mild to moderate pain, for example, paracetamol,
codeine, low dose tramadol.
Anti-inflammatory
Inflammation causes pain. Certain painkillers work by
reducing the amount of inflammation in your body, for
example, ibuprofen, diclofenac.
Stronger painkillers
Morphine (or medicines that act like morphine such as
oxycodone, fentanyl patches and hydromorphone) is
commonly used to treat moderate to severe pain.
Usually you will be prescribed a long-acting ‘background’
strong painkiller and also a short acting medicine for ‘breakthrough pain’. (It is possible to have pain at times despite being on regular long-acting painkillers - this is known
as ‘breakthrough pain’).
Many people worry about morphine being ‘addictive’ or
that they will become ‘tolerant’ to its pain killing effects. In
fact, when morphine is used to treat pain, ‘addiction’ and‘tolerance’ are very unlikely.
There is no upper limit to the dose of morphine. Different
people vary in how much morphine they might need to
control their pain.
Other painkillers
- For nerve pain: for example, amitriptyline, gabapentin,
pregabalin or ketamine.
- For spasm pain: for example, Buscopan® (hyoscine
butylbromide).
Note: Sometimes your doctor will also prescribe a course of
steroids (for example, dexamethasone) to help with certain
types of pain.
Syringe drivers
In some cases, pain medicine is given via a small
syringe pump called a syringe driver. Syringe drivers
are sometimes used for ‘difficult to control’ pain or in
situations where there may be difficulties in swallowing
painkilling tablets.
Amitriptyline
When do we use it?
Amitriptyline is a commonly used for pain caused by damaged
nerves.
How should it be taken?
Amitriptyline is often taken at night, just before going to bed.
How much can I take?
You should not go beyond the dose prescribed. It may be
possible to increase the dose in steps as advised by your
doctor.
What are the most common side effects?
Amitriptyline sometimes causes drowsiness and can cause a
dry mouth. It can occasionally cause problems with passing
urine (hesitancy).
Can I take it with my other painkillers?
Yes. Amitriptyline can be taken alongside your other
painkillers.
Note: In higher doses amitriptyline is used as an antidepressant.
It has a separate effect on nerve pain and is used
in smaller doses for this.
Buprenorphine - (also called Temgesic® or Transtec®)
When do we use it?
Buprenorphine is used for moderate to severe pain.
How should it be taken?
There are two types of buprenorphine preparation: patches
(called Transtec®) and immediate release tablets (called
Temgesic®). Buprenorphine patches are applied to a clean, hair free
and dry area of skin. The patches release the medicine slowly
over 72 hours to keep pain away.
Buprenorphine patches are long-acting, so you will need a supply
of immediate release tablets for ‘breakthrough pain’ .
The immediate release tablets (Temgesic®) are placed under the
tongue to dissolve. They work quickly to relieve ‘breakthrough
pain’.
How much can I take?
After the dose has been decided by your doctor, a patch (or
more than one patch depending on the dose) is applied and then
changed every 72 hours. The new patch or patches should be
applied to a different area of skin.
Immediate release buprenorphine can be used as needed for‘breakthrough pain’. There is no real limit to how often these
can be taken, provided they are helping your pain. If you need
several doses each day to help your pain, your dose of patches
may need to be increased.
What are the most common side effects?
Buprenorphine can cause constipation, so you may need laxative
tablets or syrup. During the first few days, you may feel drowsy
or nauseated, but these effects tend to wear off. Some people
may need anti-sickness medicines to help the nausea.
Can I take it with my other painkillers?
Yes. Buprenorphine can be taken alongside your other painkillers.
Codeine
When do we use it?
Codeine is commonly used to treat mild to moderate general
pain.
How should it be taken?
Codeine can be taken to relieve pain as needed or regularly if
pain persists.
How much can I take?
You can take 30mg to 60mg every four to six hours if needed
for pain relief. You should not take more than 240mg in 24
hours
What are the most common side effects?
Codeine commonly causes constipation so you are likely to
need laxative tablets or syrup. During the first few days, you
may feel drowsy or nauseated, but these effects tend to wear
off.
Can I take it with my other painkillers?
Yes. Codeine can be taken alongside your other painkillers.
Co-codamol - (also called Tylex®, Solpadol® or Kapake®)
When do we use it?
Co-codamol is used to treat mild to moderate pain.
How should it be taken?
Co-codamol is available in two different strengths and both
are available as soluble tablets.
- 8/500 (where the 8 corresponds to 8mg of codeine and the
500 corresponds to 500mg of paracetamol in each tablet)
- and 30/500 (where the 30 corresponds to 30mg of codeine
and the 500 corresponds to 500mg of paracetamol in each
tablet)
Co-codamol can be taken to relieve pain as needed or
regularly if pain persists.
How much can I take?
You can take ONE or TWO tablets up to four times a day. You
must not take more than 8 tablets in 24 hours.
What are the most common side effects?
Co-codamol may cause constipation so you may need to take
laxative tablets or syrup. During the first few days, you may
feel drowsy or nauseated, but these effects tend to wear off.
Can I take it with my other painkillers?
Yes. Co-codamol can be taken alongside your other painkillers
as long as they do not contain paracetamol (for example,
paracetamol is contained in Tramacet® and co-dydramol).
Co-dydramol
When do we use it?
Co-dydramol is used to treat mild to moderate pain.
How should it be taken?
Co-dydramol can be taken as needed to relieve pain or used
regularly if pain persists.
How much can I take?
You can take ONE or TWO tablets up to four times a day. You
must not take more than 8 tablets in 24 hours.
What are the most common side effects?
Co-dydramol may cause constipation so you may need to take
laxative tablets or syrup. During the first few days, you may
feel drowsy or nauseated, but these effects tend to wear off.
Can I take it with my other painkillers?
Yes. Co-dydramol can be taken alongside your other
painkillers as long as they do not contain paracetamol (for
example, paracetamol is contained in Tramacet® and cocodamol).
Diclofenac - (also called Voltarol® or Diclofex®)
When do we use it?
Diclofenac is used for certain types of mild to moderate pain.
How should it be taken?
Diclofenac can be taken as needed to relieve pain in minor
conditions or regularly where pain persists.
How much can I take?
You can take up to 150mg in 24 hours in two or three divided
doses.
What are the most common side effects?
The most common tend to be indigestion and heartburn. If
you experience these symptoms, please consult your doctor
for advice.
Can I take it with my other painkillers?
Yes. Diclofenac can be taken alongside your other painkillers,
but not with other anti-inflammatories, for example,
ibuprofen, naproxen or ketorolac.
Dihydrocodeine
When do we use it?
Dihydrocodeine is commonly used to treat mild to moderate
general pain.
How should it be taken?
Dihydrocodeine can be taken to relieve pain as needed or
regularly if pain persists. It is available as tablets or syrup. If
you have a sore mouth the syrup should be diluted in a small amount of water to prevent it from stinging.
How much can I take?
You can take 30mg to 60mg every four to six hours if needed
for pain relief. You should not take more than 240mg in 24
hours.
Are there any side effects?
Dihydrocodeine commonly causes constipation, so you are
likely to need laxative tablets or syrup. During the first few
days, you may feel drowsy or nauseated, but these effects
tend to wear off.
Can I take it with my other painkillers?
Yes. Dihydrocodeine can be taken alongside your other
painkillers.
Fentanyl patches -
(also called Durogesic® or
Durogesic® D-trans®)
When do we use it?
Fentanyl is used for moderate to severe pain.
How should it be taken?
Fentanyl patches (also called Durogesic® D-trans®) are
applied to a clean, hair-free and dry area of skin. The patches
release the medicine slowly through the skin and into the
body over 72 hours.
You will also need a supply of immediate release painkiller
(such as Oramorph®) to take for ‘breakthrough pain’.
How much can I take?
After the dose has been decided by your doctor a patch (or
more than one patch depending on the dose) is applied and
then changed every 72 hours. The new patch or patches
should be applied to a different area of skin.
What are the most common side effects?
Fentanyl can cause constipation so you may need laxative
tablets or syrup. During the first few days, you may feel drowsy
or nauseated, but these effects tend to wear off. Some people
may need anti-sickness medicines to help the nausea.
Can I take it with my other painkillers?
Yes. Fentanyl can be taken alongside your other painkillers.
Gabapentin -
(also called Neurontin®)
When do we use it?
Gabapentin is commonly used for pain caused by damaged
nerves.
How should it be taken?
Gabapentin is usually taken three times a day
How much can I take?
The dose of gabapentin is increased gradually over the first
few days. The dose may be increased further if needed to
help with pain control. You must not go beyond the dose
prescribed by doctor/nurse.
What are the most common side effects?
Gabapentin sometimes causes drowsiness, a dry mouth,
nausea and vomiting and diarrhoea. Occasionally gabapentin
causes swollen legs.
Can I take it with my other painkillers?
Yes. Gabapentin can be taken alongside your other painkillers.
Note: Gabapentin is also used as an anti-epileptic. It works
in a similar way when used for nerve pain. It dampens down
signals from damaged nerves.
Hydromorphone -
(also called Palladone®)
When do we use it?
Hydromorphone is occasionally used as an alternative to
morphine for moderate to severe pain.
How should it be taken?
There are two types of hydromorphone preparation: slow
release (called Palladone® SR) and immediate release
(just called Palladone®). Slow release capsules work
slowly through the day and night to help keep pain away.
Immediate release capsules work quickly for ‘breakthrough
pain’. Both types of capsule can be swallowed
whole or sprinkled onto soft cold food.
How much can I take?
Your slow release hydromorphone capsules (Palladone® SR)
should be taken twice a day and not more. Only increase the
dose on advice from your doctor or nurse.
Immediate release hydromorphone (Palladone®) capsules
can be taken as needed for ‘breakthrough pain’. There is no
real limit to how often these can be taken, provided they are
helping your pain. If you need several doses each day to help
your pain, your slow release hydromorphone dose may need
to be increased.
What are the most common side effects?
For the first few days hydromorphone may make you feel
drowsy or nauseated, but these effects tend to wear off.
Some people need anti-sickness medicines to help the nausea.
Many painkillers can cause constipation so you may need to
take laxative tablets or syrup.
Can I take it with my other painkillers?
Yes. Hydromorphone can be taken alongside your other
painkillers.
Hyoscine Butylbromide -
(also called Buscopan®)
When do we use it?
Buscopan® is commonly used to treat spasms or cramping
pain.
How should it be taken?
Buscopan® can be taken to relieve pain as needed or regularly
if pain persists.
How much can I take?
You can take ONE or TWO tablets up to four times a day.
What are the most common side effects?
Occasionally a dry mouth.
Can I take it with my other painkillers?
Yes. Buscopan® can be taken alongside your other painkillers.
Ibuprofen -
(also called Brufen® or Nurofen®)
When do we use it?
Ibuprofen is used for certain types of mild to moderate pain.
How should it be taken?
Ibuprofen can be taken as required to relieve symptoms in
minor conditions or regularly where symptoms persist.
How much can I take?
Do not exceed the recommended daily dose prescribed by
your doctor or nurse.
What are the most common side effects?
The most common tend to be indigestion and heartburn. If
you experience these symptoms, please consult your doctor
for advice.
Can I take it with my other painkillers?
Yes. Ibuprofen can be taken alongside your other painkillers
but not with other anti-inflammatories, for example,
diclofenac (Voltarol®), naproxen or ketorolac.
Ketamine
When do we use it?
Ketamine is occasionally used for pain caused by damaged
nerves. It can only be prescribed by specialist doctors or
nurses (pain or palliative care teams).
How should it be taken?
Ketamine is usually taken four times a day. It is only available
as a liquid. A supply of ketamine needs to be arranged
through your local chemist as it is not stocked routinely. Once opened, the Ketamine only lasts for a month, so you
may need to get a repeat prescription.
How much can I take?
You must not go beyond the dose prescribed by your pain
specialist doctor or nurse.
What are the most common side effects?
Ketamine sometimes causes vivid dreams or nightmares. You
may be prescribed a tablet at night to counteract this. It
occasionally causes hallucinations or an ‘odd’ feeling. If this
happens, stop taking the ketamine and seek advice as the
dose may need to be reduced.
Can I take it with my other painkillers?
Yes. Ketamine can be taken alongside your other painkillers.
Morphine
- Slow release: MST® or Zomorph®
- Quick release: Oramorph® or Sevredol®
When do we use it?
Morphine is frequently used for moderate to severe pain.
How should it be taken?
There are two types of morphine preparation: slow release
(called MST® or Zomorph®) and immediate release
(called Sevredol® or Oramorph®). Slow release tablets
work slowly through the day and night to help keep pain
away. Immediate release tablets or liquid work quickly for ‘breakthrough pain’.
How much can I take?
Your slow release morphine capsules or tablets (Zomorph®
or MST®) should be taken twice a day and not more. Only
increase the dose on advice from your doctor or nurse.
Immediate release morphine (Sevredol® / Oramorph®)
tablets or liquid can be used as needed for ‘breakthrough
pain’. There is no real limit to how often these can be taken,
provided they are helping your pain. If you need several doses
each day to help your pain, your slow release morphine dose
may need to be increased.
What are the most common side effects?
Morphine commonly causes constipation so you are likely to
need laxative tablets or syrup. During the first few days, you
may feel drowsy or nauseated, but these effects tend to wear
off. Some people need anti-sickness medicines to help the
nausea. Occasionally, the type of morphine tablet needs to be
changed to avoid side effects.
Can I take it with my other painkillers?
Yes. Morphine can be taken alongside your other painkillers.
Oxycodone
- Slow release: OxyContin®
- Quick release: OxyNorm®
When do we use it?
Oxycodone is often used as an alternative to morphine for
moderate to severe pain.
How should it be taken?
There are two types of Oxycodone preparations: slow release
(called OxyContin®) and immediate release (called OxyNorm®).
Slow release tablets work slowly through the day and night to
help keep pain away. Immediate release tablets or liquid work
quickly for ‘breakthrough pain’.
How much can I take?
Your slow release Oxycodone tablets (OxyContin®) should be
taken twice a day and not more. Only increase the dose on
advice of your doctor or nurse.
Immediate release Oxycodone capsules or liquid (OxyNorm®)
can be used as needed for 'breakthrough pain’. There is no
real limit to how often these can be taken, provided they are
helping your pain. If you need several doses each day to help
your pain, your slow release Oxycodone dose may need to be
increased.
What are the most common side effects?
Oxycodone commonly causes constipation so you are likely to
need laxative tablets or syrup. During the first few days, you
may feel drowsy or nauseated, but these effects tend to wear
off. Some people need anti-sickness medicines to help the
nausea.
Can I take it with my other painkillers?
Yes. Oxycodone can be taken alongside your other painkillers.
Paracetamol
When do we use it?
Paracetamol is often taken for headaches and mild pain.
However, it can also be used with stronger painkillers to
increase their effect.
How should it be taken?
Paracetamol is usually taken four times a day. Paracetamol
is available as a liquid, a soluble tablet or tablets that are
swallowed whole.
How much can I take?
You must not take more than 4 grams of paracetamol in 24
hours (that is a maximum of 8 x 500mg tablets).
What are the most common side effects?
Paracetamol rarely causes side effects unless the maximum
dose is exceeded – an overdose can cause liver damage.
Can I take it with my other painkillers?
Yes. Paracetamol can be taken alongside your other
painkillers, so long as they do not contain paracetamol.
Do not exceed the maximum dose. Drugs which contain
paracetamol include Tramacet®, co-dydramol and cocodamol
Pregabalin -
(also called Lyrica®)
When do we use it?
Pregabalin is a commonly used for pain caused by damaged
nerves.
How should it be taken?
Pregabalin is usually taken two to three times a day.
How much can I take?
The dose of pregabalin is increased gradually over the first
few days. The dose may be increased further if needed to
help with pain control. You must not go beyond the dose
prescribed by your doctor/nurse.
What are the most common side effects?
Pregabalin sometimes causes drowsiness, a dry mouth,
constipation and nausea and vomiting.
Can I take it with my other painkillers?
Yes. Pregabalin can be taken alongside your other painkillers.
Note: Pregabalin is also used as an anti-epileptic. It works in
a similar way when used for nerve pain. It dampens down
signals from damaged nerves.
Tramadol
When do we use it?
Tramadol is commonly used for moderate to severe pain.
How should it be taken?
A number of preparations of tramadol are available:
- immediate release capsules (called tramadol, Zamadol® or
Zydol®)
- slow release capsules or tablets (called Dromadol® SR,
Zamadol® SR, Zydol® SR or Zydol® XL)
- effervescent powder sachets (called Tramake Insts®)
- a combination tablet containing tramadol and paracetamol
(called Tramacet®).
Immediate release capsules, effervescent powder sachets and
Tramacet® all work quickly for pain. Slow release capsules
and tablets work slowly through the day and night to help
keep pain away.
How much can I take?
You must not take more than 400mg in 24hours.
What are the most common side effects?
Tramadol sometimes causes nausea, abdominal discomfort
and diarrhoea.
Can I take it with my other painkillers?
Yes. Tramadol can be taken alongside your other painkillers.
Caution: Do not take extra paracetamol (or drugs containing
paracetamol such as co-codamol or co-dydramol) if you are
taking Tramacet® as this contains paracetamol (see above).
What to do if pain is a problem
at home…
- Take a dose of your ‘breakthrough’ medication.
If you do not have ‘breakthrough’ medication or you are
not sure, see the contact information below and ask for
advice.
- If this helps, use it as needed. Keep a note of how often
you need these extra ‘breakthrough’ doses to show to your
doctor or nurse.
- If the pain is no better after 30 minutes, take another ‘breakthrough’ dose.
- If the pain is not settling after 2 breakthrough doses:
between 9-5pm contact: your Macmillan Nurse or
your GP
after hours contact: the out-of-hours GP service (the
phone number should be on your local GP surgery’s
answerphone).
Remember to tell your doctor about any pain problems you
have had at home when you next visit The Christie.
Make a list of your pain medicines or bring them with you
to your next appointment.
What about complementary therapies?
Some people find that complementary therapies such
as massage, aromatherapy or relaxation can help their
pain. Complementary therapies are generally viewed
as therapies which are given alongside conventional
treatments. Complementary therapies are free to The
Christie inpatients and may be available for those coming
in on a daily basis for treatment and for outpatients when
attending appointments (Complementary therapy service
0161 446 8236).
Useful contacts and where to get advice
Contact numbers:
Contact numbers for general help and advice about
your pain medicines:
- The Christie Pharmacy - 0161 446 3433
- The Christie Palliative Care Team - 0161 446 3072
- Pain team - 0161 446 8050
- For general advice - www.macmillan.org.uk
The Christie Patient Information Service
February 2009 - Review February 2012
CHR/PALL/488-02/28.11.06