Pain medication side effects, pain ladder.

The treatment options with medication are different for acute wound pain and chronic wound pain.

The WHO pain ladder is recommended for the systematic management of continuous wound pain. Lidocaine and/or prilocaine (infiltration anaesthesia) are recommended as agents of first choice to combat local acute wound pain.

Older people experience more side effects from NSAIDs than younger people.  Increased caution when considering NSAIDs is especially warranted in people with low creatinine clearance, gastropathy, cardiovascular disease or congestive heart failure. A study of hospital admissions due to side effects of medicines in older people (≥65 years) showed that NSAIDs were involved in 23 out of 100 cases. The HARM (Hospital Admission Related to Medication) study (2008) showed that gastrointestinal bleeding was the most common reason for medication-related hospital admission. In older people, there is a risk of gastric bleeding with chronic use of an NSAID in combination with low-dose acetylsalicylic acid or other anticoagulants (de Abajo et al., 2001; McKellar et al., 2008). As a nurse you can check whether someone who is chronically using an NSAID also takes a stomach protectant and point out the importance of this.

Older people may also be at risk of gastric bleeding with chronic use of an NSAID in combination with low-dose acetylsalicylic acid or other antithrombotic agents. Because NSAIDs are freely available from pharmacies and (online) drugstores, it is important that, as a nurse, you identify their (chronic) use and possible side effects and discuss this with the client and prescriber or pharmacist.

WHO pain ladder

  • Step 1a: Paracetamol is the first choice.
  • Step 1b: NSAIDs.
  • Step 1c: Paracetamol and NSAID. 
  • Step 2: Switching or adding a weak opioid such as codeine and tramadol. 
  • Step 3: Opioids: morphine, fentanyl and oxycodone are preferred in vulnerable older people based on pharmacokinetic properties.

It is recommended to skip  step 1b and 1c  for older adults, because they cause many side effects in vulnerable older people. NSAIDs are only indicated for arthritis. NSAIDs are certainly not recommended for cardiovascular problems, cancer and kidney function disorders.

It is recommended to skip step 2 for older adults, because this medicine has many side effects and little effect in vulnerable older people. Tramadol can only be an alternative in older people with moderate chronic pain for whom paracetamol does not provide sufficient pain relief and NSAIDs are not suitable.

 

References:

Verenso 2016. Multidisciplinaire richtlijn pijn bij kwetsbare ouderen. Deel 2 VER-003-32-Richtlijn-Pijn-deel2-v5LR.pdf (verenso.nl)

Leendertse, A. J., Egberts, A. C., Stoker, L. J., van den Bemt, P. M., & HARM Study Group. (2008). Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Archives of internal medicine, 168(17), 1890-1896.

Federatie Medisch Specialisten. Richtlijn wondzorg. https://richtlijnendatabase.nl/richtlijn/wondzorg/wondzorg_pijnbestrijding.html