Acute Pain Management:

Scientific Evidence
Australian and New Zealand
College of Anaesthetists
and Faculty of Pain Medicine

Endorsed by:
FacultyofPainMedicine,RoyalCollegeof
Anaesthetists,UnitedKingdom
RoyalCollegeofAnaesthetists,
UnitedKingdom
AustralianPainSociety
AustralasianFacultyofRehabilitationMedicine
CollegeofAnaesthesiologists,
AcademyofMedicine,Malaysia
CollegeofAnaesthesiologists,
AcademyofMedicine,Singapore
CollegeofIntensiveCareMedicine
ofAustraliaandNewZealand

FacultyofPainMedicine,Collegeof
AnaesthetistsofIreland
HongKongCollegeofAnaesthesiologists
HongKongPainSociety
MalaysianAssociationfortheStudyofPain
NewZealandPainSociety
PainAssociationofSingapore
RoyalAustralianandNewZealandCollegeof
Psychiatrists
RoyalAustralasianCollegeofPhysicians
RoyalAustralasianCollegeofSurgeons

Recommended to members:
AmericanAcademyofPainMedicine

Also endorsed by:

International Association for the Study of Pain

Approved by the NHM RC on 4 February 2010

Acute Pain Management:

Disclaimer

have established it

Acute Pain:

iii

FOREWORD

The consistently high standards of

iv

FOREWORD

Australasian College of Surgeons, the Royal Australian and New Zealand College of Psychiatrists

Levels of evidence

Key messages

vi

New
nchanged
Strengthened

Weakened

Reversed

New,

Management of retracted publications

is

vii

along with a further two

Acute Pain

, an

Acute

Acute

of Pain Medicine
viii

References
Managing

Int J
:
34

BMJ
:

Contents
FOREWORD

iii

xix

6
7
8

36

43

47
47

73

77

89

97
98

and children

346

367

437

467
467

89

variables

Psychological aspects of acute pain

Progression of acute to chronic pain

S

Measurement

Outcome measures in acute pain management

N
N

N
N

N
N

N
N
N

N
S
N

S
N

S
N
N

N
N

N
N

N
N

N
N
S

S
N
N
N
W
N
N

S
N

R
N

N
S

N
S
N
N

N
R

N
N

N
N
N

N
N

N
N
N

N
N

N
N

N
N
N

N
S

N
S
S

Intrathecal analgesia
S
N

N
S

N
R

S
N
N

N
Q
N

N
N

N
S

Acupuncture
N

S
S
S

N
N
N

N
N
N
N

N
S
N

N
N

S
N

R
N

N
N

N
N
N

N
R

S
N

N
N

N
N

N
N
N

Acute cancer pain

S
N
S

N
S
N

Prehospital analgesia
N
N
N
N
N

Analgesic agents
R
N

N
N

Regional analgesia

nd

S
S
S

N
Q
N

S
N

N
N

Q
N
N

N
N

1.1

Applied

Peripheral nociceptors

physiology of pAin

TRP

TRPM8

cool

TRPA
acid sensing

H
P

serotonin

AMPA
kainate

IP

ATP

HA

serotonin
bradykinin

BI, B

cannabinoid

CB , CB
substance P, neurokinin A

tachykinin
PAR

Pain transmission in the spinal cord

Central projections of pain pathways

Descending modulatory pain pathways

Although

Sandkuhler,
Carlson et al,

1.2

psychologicAl

Aspects of Acute pAin

Attention

Learning and memory

Beliefs, thought processes

Nelson et al,

Brander

Patient-controlled analgesia

1.3

progression

of Acute to chronic pAin

Fassoulaki et

this was not seen in an earlier study

Inguinal hernia

Psychological vulnerability

1.4

pre-emptive

And preventive AnAlgesiA

analgesia has been

antagonists

at the

1.5

Adverse

physiologicAl And psychologicAl effects

of Acute pAin

II

Neural
and social factors
Metabolic

Source:

Insulin, testosterone

intolerance, insulin resistance

Source:

Hyperglycaemia

factors

neurons
endothelial cells
blood cells

Lipotoxicity

Protein catabolism

with

Basse

Andersen et al,

Cousins

1.6

phArmAcogenomics

And Acute pAin

Codeine

Tramadol

Methadone

NSAIDs

Rollason et al,

references

Pain

64

Pain

464

Acute Pain 4

46

Lancet

J Pain

77

Pain

Pain

46

63

Science

37

J Pain 6

Pain

Pain
6

76
Acute Pain 4

77

Pain

Pain

Pain
In:

Lancet
Lancet

367

Ann
J Pain 3

76
Ann

J Pain

Acta

Pain

77

Pain
Pain
Pain

3
66

Pain

Acta

Lancet 343

47

Pain
Lancet
BMJ

437
Pain

Pain

J Pain
Pain

Acute Pain

74

Pain Management

J Pain 7
46
Pain
Pain 33

JAMA

BMJ

Science

Pain

Pain
Pain

2.1

v
v
v
v
and
v

Assessment

2.2

at rest

meAsurement

Categorical scales

Numerical rating scales

Farrar et al,

Cook

Svensson et al,

2.3

outcome

meAsures in Acute pAin mAnAgement

Pain

v

relief

v


v

Moore

Physical functioning

v
v

Emotional functioning

Adverse symptoms and events

references

Pain

343
Pain
Pain

Pain
Pain

Pain

J Pain

Pain
Pain

BMJ

3
In:

JAMA

Pain
J Pain 4
Pain
J Pain 6
Pain

64

Pain

33

Management

Lancet

3.1

educAtion

v
v

or

children

v
v
v
v

II

Ray et

3.2

orgAnisAtionAl

requirements

N
N

references

34
BMJ

74

BMJ

34
7

Pain
Acute Pain

46

BMJ

Pain 4

63
Pain

36

Pain

4.1

opioids

Buprenorphine

Codeine

Dextropropoxyphene

Diamorphine

Dihydrocodeine

Fentanyl

Hydromorphone

Methadone

Morphine

Sia,

Oxycodone

Staahl et al,

Pethidine

of biliary colic

Tramadol

Patient age

Gender

Genetics
Psychological factors

to the

Respiratory depression

Cardiac effects

Nausea and vomiting

Marret et

Rusch

Habib

to the
et al,

Impairment of gastrointestinal motility

Urinary retention

Pruritus

Bonnet

Cognitive function and confusion

Tolerance and hyperalgesia

Chu et al,

Chang

N
N

N
N

N
N
N

N
S
N

4.2

pArAcetAmol,

non-selective non-steroidAl Anti-

inflAmmAtory drugs And coxibs

Zacharias et

Hynes et al,

Adverse effects

Mahe

renal colic

Marret et al,

to the

clearly

Adverse effects

Bone healing

77

Adverse effects
Renal function

refer to the

to the

78

Moore

79

Targownik et al,

Bone healing

S
N
N

N
N

N
N

N
N

N
N
S

4.3

AdjuvAnt

Nitrous oxide

In adults, N

drugs

In children, N

to N

Henderson et al,
Zier

Toh et al,

Myles et al,

given N
N
N

v
v
v
v
v

v

v

Ketamine

Hayes et al,

Dextromethorphan

87

Magnesium

Amantadine and memantine

S
N
N
N
W
N

N
88

TCAs
SSRIs

Pooled diagnoses
SSRIs
Pooled diagnoses

SSRIs
8

to the

89

Cardenas

S
N

R
N

Phenytoin

Hurley et

Lamotrigine

Bell et

Chiou-Tan et

N
S

Bernard
Aho

Calcitonin

Bisphosphonates

N
S
N
N

II

97

CAMs include:
v
v
v
v

N
98

references

73

Lancet

Pain

Pain

99

Pain

Pain

Pain

37

Pain

44

44
BMJ

Pain

Am J

63

Lancet

43

J Pain 7

33

63

36
33

Pain

Pain

J Pain

Pain
34

Pain 74

J Pain

44

BMJ 337

BMJ 333

67

Pain

Int

34

47

BMJ
J Pain

BMJ

BMJ
Pain

BMJ
3

Acute Pain

33

Pain

Acta

J Pain

Pain 64

Pain
In:

BMJ

Pain

47

Acta

Acta

47

44

Pain

77

Acute Pain

Pain

BMJ

Pain

Pain

Lancet
Pain

64

Management: Acute Pain

JAMA

Pain

44

7
3

63
JAMA

47
63

Pain
46

Pain

64

43
46

33

Pain

46

Pain

JAMA

Lancet

67

Pain
37

34
Pain

Pain

JAMA

337

46

HSS J 4

Acute Pain 7

J Pain

333

BMJ

37
64

44

J Pain
Pain

Life Sci

JAMA

BJOG
37

5.1

locAl

AnAesthetics

Epidural local anaesthetics

For

Peripheral local anaesthetics

II

Heid et

Ilfeld et

Direct toxicity

Systemic toxicity

II

II

Felice

Marwick

5.2

opioids

Intrathecal opioids

Hodgson

Epidural opioids

Ngan

Zeidan et al,

II

N
R

5.3

AdjuvAnt drugs

Neuraxial

Andrieu et al,

Plexus block

Intravenous regional anaesthesia

Intra-articular

Neuraxial

to the

Neuraxial

Peripheral sites

Clerc et al,

Topical

Tucker,

Ho

N
N

N
N
N

5.4

Anti-inflAmmAtory

Neuraxial

II

Peripheral sites

drugs

Bigat et al,

Topical

N
N

N
N
N

Peripheral sites
Colbert et

Topical

Zacher et al,

N
N

N
N

references

33

Acta

46

34

47

Pain
77

46

Ann

36

Acta

33

47

Acta

64

36

Acta

33

36

Pain
Pain

34

33
46

33

AANA J

BMJ

66

Ann

47

73

Pain

73

Pain

33

76

34

34
66

Pain

Science
Pain

Bandolier,

6.1

orAl

route

77

79

78

Placebo

Immediate-release formulations

v

v
v

v

Controlled-release formulations

6.2

intrAvenous

route

Intermittent intravenous bolus doses

Continuous infusions

Moller,

6.3

intrAmusculAr

And subcutAneous routes

Stuart-Harris

Tveita et
II

6.4

rectAl

route

Hahn, Mogensen et al,

6.5

trAnsdermAl

route

Sandler

Hong et
II
Turan

Poyhia

6.6

trAnsmucosAl

routes

Opioids

and T

II

Coda
et al,

Abboud et al,

Rickard et al,

Other analgesic drugs

Opioids

Sharar et al,

Other analgesic drugs

Chong

Opioids

Miner
Fulda et

Other analgesic drugs

N
N

references

76

Acute Pain
Pain

Acute Pain

Acute Pain

47

4
BMJ

44

Acute Pain

BMJ
J

of

47

Acta

46

37

34

of

oral

Pain

Manag 4
63
64

47

to
Acute Pain

Pain
76

76

36

47

Acute Pain

J Pain

7.1

pAtient-controlled

AnAlgesiA

Analgesia, patient preference and outcomes

Macintyre,

Cost of PCA

Opioids

Sinatra et al,

Fentanyl
Howell et
Howell et

Other comparisons

Adjuvant drugs

Ketamine

Michelet et

Sartain et al,

et

Bolus dose

Lockout interval

Concurrent background (continuous) infusions

Dose limits

Loading dose

Subcutaneous PCA

Oral PCA

Intranasal PCA
Striebel

Transdermal PCA

Programmable PCA pumps

Disposable PCA devices

Skryabina

device, which

Equipment-related complications

Patri,

Patient factors

Tsui et al,

Nursing and medical staff

Ashburn

7.2

epidurAl

AnAlgesiA

levels and

Schunn et al,

Level of administration

Local anaesthetics
For

Opioids

Local anaesthetic-opioid combinations

Curatolo

Adjuvant drugs

Comparison with continuous epidural infusions

II

II

Concurrent background (continuous) infusions

Drugs used in postoperative patient-controlled epidural analgesia

Neurological injury

Epidural haematoma

Epidural abscess

Ho

An
and
and

Respiratory depression

Hypotension

was not

,
,

Postdural puncture headache

Treatment failure

Other

N
S

N
S
S

7.3

intrAthecAl

AnAlgesiA

Local anaesthetics

Opioids

Hodgson et al,

Bailey et al,

Adjuvant drugs

S
N

7.4

regionAl

AnAlgesiA And concurrent

AnticoAgulAnt medicAtions

is not

7.5

Upper limb
Interscalene

other

regionAl And locAl AnAlgesic techniques

II

Lower limb

II

II
Morau

Chudinov

Thoracic

Needle and catheter localising techniques

Patient-controlled regional analgesia

Anticoagulation

Nerve injury

Brull

Barrington et

Borgeat et al,

Toxicity

Auroy
Borgeat et

Infection

Neuburger

N
S

N
R

S
N
N

references

Acta

in
J

Acute Pain 4

Pain

Pain
46

74

37

37

Acta

47

34

47

46

63

64

64
Pain

9
33

44

rd

Pain

44

3
of

for

Pain 64

33

3
47

Acute Pain
44
44

JAMA
76

Acute Pain

Acute

Pain

literature

Pain
of

76

Acute Pain

for

63
76

76

43

47

73

46

J Pain

JAMA

Pain 64
Pain

43

8.1

psychologicAl

is

interventions

Relaxation

Hypnosis

Applying pain coping strategies within a cognitive-behavioural intervention

Redd

N
Q
N

N
N

8.2

trAnscutAneous

electricAl nerve stimulAtion

N
S

8.3

Acupuncture

Madsen

Acupressure

8.4

other

physicAl therApies

references

J Pain

Pain

37

Pain 47

36

47

of
BMJ
Pain

a
Pain
Pain Management

63

9.1

postoperAtive

pAin

Rowlingson

Bates

v

v

v

Prevention

Therapy

v
v

v
v
v
v

S
S
S

Post-thoracotomy pain syndrome

Senturk

Bong et

Postmastectomy pain syndrome

Fassoulaki

I
Postherniotomy pain syndrome

Aasvang et

Posthysterectomy pain syndrome

N
N

N
N

Adverse effects of pain

Analgesic drugs and techniques

v
v
v

Fong et al,

II

Ilfeld,

Ilfeld et

Swenson

Swenson et

Cheng et al,

Non-pharmacological techniques

Treatment of acute postoperative pain after cranial neurosurgery

Paracetamol

Sudheer

II

N
N
N
N

9.2

Acute

pAin following spinAl cord injury

Siddall

Above level
At level

Below level

Treatment of acute neuropathic pain after spinal cord injury

but

Ketamine

Chiou-Tan

Treatment of nociceptive and visceral pain after spinal cord injury

9.3

Acute

burn injury pAin

Cuignet et al,

Borland

have

Tosun et al,

N
S
N

N
N

9.4

Acute

bAck pAin

Australian Acute Musculoskeletal Pain

Australian Acute Musculoskeletal Pain

v
v
v

v

9.5

Acute

musculoskeletAl pAin

Australian Acute

Australian Acute Musculoskeletal Pain

9.6

Acute

medicAl pAin

Analgesia and the diagnosis of acute abdominal pain.

Renal colic

Biliary colic and acute pancreatitis

Rothrock

Irritable bowel syndrome and colic

Primary dysmenorrhoea

Abdominal migraine

S
N

Prevention of herpes zoster

Treatment of herpes zoster-associated pain

Shen et al,

Topical lignocaine

Aspirin

Prevention of postherpetic neuralgia

R
N

Cannon,

Sickle cell disease

Treatment of pain

Morrissey et al,

Inhaled N

Haemophilia

The porphyrias

Anderson et al,

Steiner

Episodic tension-type headache

Treatment
II

Migraine

Treatment

are either:
v
v
v

v

v

v

Silberstein

Triptans

SC
oral
oral
oral
oral
IN
oral
oral
oral
oral
oral
oral
oral

et al,

Brandes et al,

Bell et al,

Status migrainosis

Paediatric migraine

Menstruation-related migraine

Silberstein et

Migraine in pregnancy and breastfeeding

Cluster headache and other trigeminal autonomic cephalalgias

Triptans

Bahra et al,
Schurks et al,

Other treatments

Paroxysmal hemicrania and SUNCT

Postdural puncture headache

Sudlow

Other treatments

Rucklidge

Other headaches

Silberstein,

Complementary and alternative medicines and therapies

Opioids and acute headache

N
N

N
N
N

Multiple sclerosis

Central poststroke pain

II

Trigeminal neuralgia

Guillain-Barre syndrome

Acute postoperative dental pain

et

Chen et al,

Acute pain associated with pharyngitis

al,

Acute pain associated with sinusitis and otitis media

Hansen et al,

Acute post-tonsillectomy pain

Moiniche

Acute pain associated with oral ulceration, including mucositis

N
R

S
N

N
N

N
N
N

Breitbart et

with a substance abuse disorder, less educated individuals, and those with higher levels

Treatment of HIV/AIDS-related pain

Piscitelli et al,

McCance-

Patients with a history of substance abuse

Breitbart et al,

N
N
N

9.7

Acute

cAncer pAin

Miaskowski et al,

Radiotherapy

Bisphosphonates

Pavlakis et al,

Percutaneous vertebroplasty

Malignant bowel obstruction

Mucositis

S
N
S

9.8

v
v
v

v

Acute

pAin mAnAgement in intensive cAre

Manley

Carrer

N
S
N

9.9

Opioids

Acute

pAin mAnAgement in emergency depArtments

Fulda et

Tramadol

Mahadevan

and biliary colic

Inhalational analgesics
N

Ketamine

Abdominal pain

Renal colic
Biliary colic and acute pancreatitis
Acute cardiac chest pain
Acute pain and sickle cell disease
Migraine

Shrestha et

II
II
II
II
II
II
I

Fractured neck of femur

Wounds

9.10

prehospitAl

AnAlgesiA

Rogovik

Rickard

Opioids and tramadol

Bruns et

Bounes et al,

Rickard

Inhalational agents

another series N
N

children receiving N

Ketamine

Barker et al,

Acute cardiac pain

Abdominal pain

Patients with a head injury

N
N
N
N
N

N
N

references

Pain

44

63
3

Pain

34

37

34

BJOG

J Pain 7

Pain

JAMA

Acta

Pain
Pain

Pain
Pain 76

64

34

Pain

73

Pain

Acute Pain

34

47
3

Acute Pain

63

BMJ
a

BMJ 336

Pain

33
J

63
JAMA

47

Pain

33

Acute Pain 4

43
3

46

J Pain
Pain

Manage

37
46

34

33
J

Pain

Pain

Lancet

37

3
6

33

J Pain

Pain

37

34

46

33

Int

43

The

Pain

Pain

J Pain

3
Acute Pain 4

BMJ

Lancet

33
333

Pain

76

Lancet

Pain
J

Pain
Pain

37

Lancet

Pain 43

Management: Acute Pain

(
J Pain

Pain

Pain

74

Manage
67

Pain 36

63

33

JAMA

a
Pain

33

JAMA

66

37
6

Pain

JAMA
67
34

J Pain

63
Pain 67
Pain

Pain

Pain

Pain

33

Pain

44

Pain

Acta

47

Pain

Pain

77
JAMA

Pain

J Pain

a
44

33

44
63

Pain

44

J Pain

44

47

37
Pain

JAMA

Pain

44
67

44

47

7
Pain

36

3
BMJ

37

43

77
J Pain

Pain

Am J

34
a

Lancet 367

37

37
A
:

33
7

37

JAMA

36

Pain

BJOG

10.1

developmentAl

neurobiology of pAin

Mellon et

10.2

long-term

consequences of eArly pAin

And injury

10.3

pAediAtric

pAin Assessment

Falanga et

Physiological measures

Howard et

Behavioural measures

v
v
v intensive care

v
v
v
v

Hicks et

v
v
v

Hunt et

not shown
to child

behavioural state
heart rate
brow bulge
nasolabial furrow
Neonatal Infant Pain
cry

legs
state of arousal

neonates

Neonatal Facial Coding

brow bulge

taut tongue

cries

cry

each scored as
total score

touch

Cry and Consolability

face

each scored on

legs
total score
cry
consolability
alertness

heart rate

total score

Faces Pain Scale Revised

graded faces with neutral anchors

and

Coloured Analogue
Scale

10.4

mAnAgement

above

of procedurAl pAin

Blood sampling and intravenous cannulation

Shah et al,

Lumbar puncture

Urine sampling

Ocular examination for retinopathy of prematurity

II

Venipuncture and intravenous cannulation

Henderson et al,

Hee et al,

Lumbar puncture and bone marrow aspiration

Schechter et

Crock et al,

and
Urethral catheterisation and micturating cystourethrogram
II

N
Butler et

Chest drain removal

Bruce et al,

Nasogastric tube insertion

Burns dressings

II

Schechter

II

Schechter
et
Boivin et al,

Laceration repair

Hock et al,

Burton et al,

Fracture pain and reduction

Borland et al,

Psychological interventions

10.5

AnAlgesic

Agents

Pharmacokinetics and pharmacodynamics

II

Adverse effects

II

Pharmacokinetics and pharmacodynamics

van der

Adverse effects
In large series of children with febrile illnesses, the risk of serious adverse events following

Allegaert,

II

Morphine

Anand et

Fentanyl

Saudan et

Codeine

Oxycodone

II

Other opioids

Tramadol

to

to

R
N

10.6

opioid

infusions And

pcA

II

Bellu et al,
Anand et

The PCA prescription

II

N
N

10.7

regionAl

AnAlgesiA

Royal Australasian College

Inguinal surgery

II

Tonsillectomy

dose

Caudal analgesia

Batra

Epidural analgesia

II

II

Outcomes

McNeely

under general anaesthesia in children, but there is no clear evidence that this obscures early

Intrathecal opioids

10.8

Acute

pAin in children with cAncer

references

Lancet 363
6

Pain

Manage

Semin

43

Pain

33

Pain
a

47

Pain
a

Pain

JAMA

46

46

a
Acute Pain

J Pain

Lancet
6

3
Am 47

J Pain

34

In:

33

Pain

Pain
6

Pain

Pain
or

Pain

JAMA
Pain

46

BMJ

Pain

43

JAMA

Pain

Pain
3
Pain

37

Pain

Pain 46

an

Pain 64

J Pain

Pain

Pain

33

44

Semin

6
7

Pain

Pain

Pain

Lancet

JAMA

Semin

44

36

Pain

Pain
an

Pain

J Pain
37

11.1

the

pregnAnt pAtient

Drugs used in pregnancy

Paracetamol

Rebordosa et al,

nd

Opioids

Farid et al,

Bakstad

Musculoskeletal pain syndromes

Borg-

Meralgia paresthetica

Symphysial diastasis

nd

Cat
C

codeine, dihydrocodeine

Paracetamol

Aspirin

C
of the fetal ductus arteriosus, delay labour and

C
cause closure of the fetal ductus arteriosus, fetal

C
A

C
sertraline

Cat
C

Cat

C
e

A
dolasetron, granisetron, ondansetron

Flink

Systemic analgesia in labour pain

Tuckey

Rosen,
I
II

Epidural and combined spinal-epidural analgesia for labour pain

II

II

Other regional techniques in labour pain

Complementary and other methods of pain relief in labour

Pain after Caesarean section

van

Ranta

Carvalho et

S
S
S

N
N

v
v

Opioids and tramadol

Baka et

Meny

Other medications related to pain relief

Paracetamol

Safe to use

Aspirin

Safe to use
s

Ketamine

long half-life

May be used
Should be safe to use

No data available

Safe to use

:
e

Safe to use

should not be a concern

Safe to use occasional doses

Perineal pain

Non-pharmacological treatments

Pharmacological treatments

Breast pain

Morland-

Snowden et al,

Uterine pain

N
Q
N

11.2

the

older pAtient

bolus

Fat

then

on total body weight or

lean body weight

Total body water

in clearance and oral

bioavailability

Phase II

dose

oral bioavailability

decade

rate

CNS

CNS

bolus dose during

unchanged

bolus dose during

Clinical implications

Cognitive impairment

Feldt et al,

Fong et

Bitsch

Measurement of pain

Other measures of pain

Burkhardt et al,

Miners et al,

Opioids and tramadol

Herrick

Local anaesthetics

Ketamine

Tricyclic antidepressants

Anticonvulsants

Mann et al,

Foss et al,

II

S
N

11.3

AboriginAl

And

torres strAit islAnder

peoples

11.4

different

ethnic And culturAl groups

Australian Bureau

Ng et al,

11.5

the

pAtient with obstructive sleep ApnoeA

Sabers

Chung,

II

Chung,

Reeder et al,

Q
N
N

11.6

the

pAtient with concurrent hepAtic or

renAl diseAse

v

v

v

v

v
v
v
v
v
v

Alfentanil
failure is severe

with dialysis

Codeine

dialysis

lead to CNS and cardiovascular

dialysis

Fentanyl
degree by dialysis

dialysis

Methadone
in faeces

water solubility would suggest

crosses the blood-brain barrier

failure

load
Pauli-Magnus et al,

dialysis

increased in endstage renal

disease

Pethidine

Sufentanil

chronic renal failure unless renal

doses are used

binding

May need to increase

dose interval if renal
Is dialysable

renal failure

Behaviour during dialysis not

Clonidine

Half-life is increased in severe

renal failure

the kidney
Tricyclic
agent

and increase the risk

dialysis

evidence to indicate need

dialysis

cleared by dialysis

cleared by dialysis

Alfentanil

life found in children undergoing

reduced clearance
Fentanyl
Methadone
chronic stable liver disease

Increased oral bioavailability of

via this route

Pethidine

Reduced clearance

Sufentanil
Reduced clearance
severe

infusion but not single dose

it should be used with

alcohol-related liver
Clearance is reduced

that it can be used safely

an unlikely cause of

Tricyclic
agent

11.7

the

opioid-tolerAnt pAtient

Tolerance

Clinical implications of opioid tolerance and opioid-induced hyperalgesia

Chang

v
v
v

v
v
v
v
Effective analgesia

Attenuation of tolerance and opioid-induced hyperalgesia

v
v
v
NMDA and opioid-receptor antagonists

Opioid rotation

Hadi et al,

Other adjuvants

Prevention of withdrawal

Carroll et

Management on discharge

N
N

11.8

due to:
v
v
v

the

pAtient with An Addiction disorder

v
v

v
v
v
v

v
v
v
v

and

Roberts,

Opioids

Cicero

Alcohol and benzodiazepines

Cannabinoids

Methadone

Peng

Buprenorphine

et

Alford

Naltrexone

references

Pain

Pain

6
Pain

36

37

64

63
Pain

Pain

J Hum Lact

J Pain

64

Lancet

63

Pain

67

76

Pain

J Pain

Pain 67
33
46

Pain

Pain

Pain
3

Pain
4

3
76

J Hum Lact

64

43

J Pain

34
4

343

64
J Pain

BJOG

J Pain

Pain

J Hum Lact

BMJ

J Pain 6
Pain

Age Ageing

BMJ

37
34

37

Pain 64

Management: Acute Pain

44

BJOG

34

J Hum Lact
J Pain

34

33

Pain 66

BMJ
Acta

46

43

JAMA

Pain
43

Pain

J Hum Lact
66

37

46

BJOG
46
4

33
Pain Management: Acute Pain

Acute Pain

63

Acute Pain

34

44

47

Manag

J Pain

37

Pain

Acute Pain
HSS J 4

J Pain
4

74

66
74

BMJ
3

J Pain 7

JAMA

Pain

the

working pArty, contributors And members of the

multidisciplinAry consultAtive committee

Adelaide
South Australia

Australia
Perth
Head, Acute Pain Service
Melbourne

Anaesthesia and Pain Medicine

Trust

Adelaide
South Australia

Melbourne

Melbourne

Alfred Health
Melbourne

Melbourne

Perth

Melbourne
Consultant

Sydney

Adelaide
South Australia

Sydney
Australia

Perth

Randwick

Professor Michael Cousins

Sydney
Senior Consultant
Flinders Medical Centre,
Bedford Park
South Australia

Melbourne

Perth

Melbourne

Brisbane

Consultant Neurologist

Clinical Associate Professor

Perth

Adelaide
South Australia

Brisbane

Footscray

Sydney
Head of Pain Services
Parkville

New Zealand

Footscray,

Parkville

Adelaide
South Australia

Sydney

Parkville

Melbourne
Clinical Associate Professor

Melbourne

Subiaco

Perth

Sydney

New Zealand

Northern Territory

Consultant Anaesthesiologist

Acute Pain Service

Professor Paul Rolan

Adelaide
South Australia
Aboriginal and Torres Strait

Aboriginal and Torres Strait Islander

Adelaide
South Australia

Australian Medicines
Handbook

Adelaide
South Australia

Burns Surgery
Adelaide
South Australia
Cardiology

Consultant Cardiologist
Adelaide
South Australia

Faculty of Health

Colorectal Surgery

Consultant Colorectal Surgeon

North Terrace
Adelaide
South Australia
Melbourne
Associate Professor
Research

Australia
Adelaide
South Australia
College of Medicine Biology and
Canberra
Cancer Council SA Professor of Cancer
Medicine
Adelaide
South Australia
Neurosurgery

Consultant Neurosurgeon

Adelaide
South Australia
Neurosurgery

Neurosurgeon
Brisbane

Nursing

Nursing

CPC, Acute Pain Service

Flinders Medical Centre
Adelaide
South Australia
Acute Pain Service
Adelaide
South Australia
Associate Professor
Health
New Zealand

Melbourne

Maroochydore

Brisbane

Adelaide
South Australia

Perth
Psychiatry

Pain Medicine

Penrith

Centre
Alfred Health
Melbourne
Assoc Prof Milton Cohen

and Pain Medicine

Medicine
Sydney

Medical Service
Mackay

Professor Paul Myles

Melbourne
Thoracic Surgery

Cardiothoracic Surgical Consultant

Adelaide
South Australia

process

report

the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, the

Competing interests

Levels of evidence

Key messages

New
nchanged
Strengthened

Weakened

Reversed

New,

Search strategies

Preferred evidence

and

were also included as

including those with the lowest

level of evidence designated as
were cited as

cited as

Quality scoring

and

Management of retracted publications

is

along with a further two

Acute Pain Management:

cute

, an

included in

Acute

th

th

Submissions

Boston
The Alfred
Melbourne

New Zealand

Cork
Ireland

Cairns

South Brisbane

Herston

New Zealand

Adelaide
South Australia

Comments

Topics raised
v
v
v
v
v
v
v
v
v

References
Managing

64

Pain

34

BMJ
Pain
:

ASIC

acid-sensing ion channel

CR

controlled-release

FBT

fentanyl buccal tablets

FPM

Faculty of Pain Medicine

IN

intranasal

N
NCA

nurse-controlled analgesia

NFCS

Neonatal Facial Coding Scale

NIPS

Neonatal Infant Pain Scale

RNA

ribonucleic acid

SC

subcutaneous

SR

slow-release

TdP

Torsades de Points

THC
T

tetrahydrocannabinol

See

adrenaline

children

calcitonin
cannabinoids
98

See
7

beliefs
biliary colic
adrenaline
See
allodynia

buccal route
regional anaesthesia
88

children

98

calcitonin

needle and catheter localising

children
thoracic

cannabinoids

children

78
children
78
caudal analgesia
children

intravenous
oral

children
analgesic agents

subcutaneous
cranial neurosurgery

87

central neural blockade

dihydrocodeine
nurse-controlled analgesia

See

cluster headache
codeine
children
drugs used

labour
intensive care

See adrenaline

Faces Pain Scale

fentanyl

intranasal route
intrathecal analgesia
children
drugs used
head and neck surgery

labour

headache
intravenous route

substance withdrawal
healing touch
heat

sublingual

learning

children
intrathecal

children

neurological disorders

See

cardiac
headache
neurological disorders
orofacial

See ethnic and cultural

sickle cell disease

88

7
See

children

intravenous
oral
rectal
subcutaneous

general

analgesic agents

children
choice
controlled-release
dose
children
neonates
inhaled
intranasal
intrathecal
intravenous
See
categorical scales
children

oral

rectal
sublingual

oral route

children
intravenous

oral

rectal

background infusion
bolus dose

intranasal
loading dose

regional

lockout interval

oral

children
intensive care
neonates

subcutaneous

children

rectal route

cranial neurosurgery

regional analgesia

day-stay or short-stay surgery

safety

renal colic

renal disease
intravenous
sickle cell disease
oral

subcutaneous

subcutaneous route

other drugs

sublingual route

See

7
tolerance

children
controlled-release

wounds