• Pain is a complex and dynamic experience and all clinicians should place the requirements and needs of the individual at the forefront of all assessments. Ideally, multidisciplinary assessment ascertains the most appropriate and efficient course of treatment in both acute and chronic pain conditions, but limited resources in the pre-hospital environment can make comprehensive assessment a challenging task.

• The pain experience of individuals is influenced by bio-psycho-social factors, such as:

  • the nature of any underlying medical condition

  • age, gender, genetics

  • prior pain experience, culture, beliefs

  • environment and social conditions.

• When managing pain for any patient, clinicians should provide pain control interventions or administer analgesia and other treatments based on the needs of the individual patient. Clinicians should be aware of the risks of unconscious bias and should not manage any patient based on a stereotype based on age, gender, sexuality, ethnicity, or any other characteristic. There are a wide range of expressed emotions in patients from all backgrounds. Care must be taken not to treat an individual in pain as ‘stoical’ or ‘highly expressive’ based on their perceived ethnic group or other characteristic as this may lead to either ineffective or excessive pain relief.

• Treat the individual in front of you using a structured approach using a focussed history and clinical examination, irrespective of your perception of their patient group.

• To ensure every patient receives appropriate pain relief, explore pain descriptors carefully, giving extra time to consider individual patient needs.

• Although different scoring systems are used to gauge the intensity of pain, patients’ experiences cannot be objectively validated in the same way as other vital signs. JRCALC recommend the 0–10-point verbal numerical scale in which 0 refers to no pain and 10 is the worst imaginable pain. In most pre-hospital situations, this score is suitable to assess severity of pain and the response to treatment. As there is inter-individual variability, the trend in the scores is more important than the absolute value in assessing efficacy of treatment. Apart from initial assessment and scoring, subsequent periodic measurement after each intervention is a recommended practice. However, no pain assessment tool is set in stone and the patient’s needs should always be considered above the findings of the assessment tool.

• Scoring can be difficult in patients with dementia, cognitive impairment, altered level of consciousness or communication difficulties. In these scenarios, pain is assessed through behavioural cues. Remember: no behaviour is unique to pain; behaviour is unique to individuals.

• The prevalence of persistent pain in older adults is high, with the main causes originating as a result of degenerative changes. In both sexes, incidence of arthritis increases with age. Both osteoarthritis and osteoporosis are more common in women. Due to unmet healthcare needs, other concurrent medical conditions or poor compliance with medications, managing pain in older adults is often suboptimal. This has adverse effects on mood, sleep and activity. Ageing-related alteration to pharmacokinetics, pharmacodynamics and polypharmacy also contribute to poorly controlled pain. Older adults may not complain or effectively communicate their needs. In addition, they may also be living with dementia. The process of assessing older adults should be the same as for younger people, utilising numerical or pictorial pain assessment scales. The Abbey Pain Scale can used to measure pain

Acute Pain

• Assessment and treatment of acute pain has to be immediate with minimal interruption to other aspects of the patient’s life. Poorly managed acute pain can result in certain changes in the nervous system, commonly described as ‘plasticity’, which predispose to development of chronic pain. Knowledge of exacerbating and relieving factors can complement pain management.

• A commonly used mnemonic in acute pain assessment is SOCRATES:

  • Site (e.g. calf pain due to deep venous thrombosis; associated chest pain may be due to pulmonary embolism).

  • Onset (acute onset or progressive worsening of an underlying condition).

  • Character (aching pain with movements can be musculoskeletal; burning pain, pins and needles can be neuropathic).

  • Radiation (back pain radiating to legs can be due to nerve root irritation; chest pain with radiation to the left arm can be due to angina).

  • Associated symptoms (fever, chills, nausea may be due to infectious cause).

  • Time/duration.

  • Exacerbation and relieving factors (pain with movement may be musculoskeletal, pain associated with bowel and bladder disturbance may be due to abdominal problems).

  • Severity (scoring tools to assess baseline intensity and monitor progress).

• All patients with pain should have at least two pain scores taken, the first one before the treatment and the subsequent measurements after the treatment is commenced. Scoring and systematic assessment increases awareness of pain management, reveals previously unrecognised pain and improves analgesic administration.

Chronic Pain

• Chronic pain is not prolonged acute pain. The experience of pain is influenced by ‘bio-psycho-social’ factors, such as medical condition, mood, sleep, beliefs and behaviour, cultural and social factors.

• Patients with chronic pain may have heightened sensitivity of the nervous system and are prone to develop exacerbation episodes necessitating a call for urgent help.

• The fundamental principles of assessing these patients are the same as described above, but consideration should be given to psychological and social factors. The challenges for paramedics include seeing these patients for the first time and hence difficulty in obtaining a global picture, and limited resources/time to conduct a comprehensive assessment. This may result in disbelief of the patient’s report of pain. Without precise knowledge of patient’s background medical history, malingering may be suspected and this impression may negatively affect the quality of care. A safer approach is to seek and accept the patient’s self report of their pain.

• Whenever possible, treat the cause (for example, glyceryl trinitrate sublingual spray for angina and oxygen for sickle cell crisis). When the cause is not readily treatable or if it is not apparent, then other analgesic interventions are necessary.

• The pain relief options are:

  • psychological (e.g. reassurance, distraction)

  • physical (e.g. dressing burns wound, splinting fracture)

  • pharmacological (e.g. paracetamol, NSAID, morphine).

• ‘Balanced analgesia’ with a multimodal pain plan is recommended by JRCALC in pre-hospital pain management and involves administration of analgesics with different mechanisms of action. The synergistic effects should improve effectiveness while limiting the side effects. An example is the combination of paracetamol and morphine. Studies show that the dose of morphine can be reduced by 40–50% when administered alongside paracetamol or ibuprofen. This complementary effect not only offers a more effective pain solution for the patient, but will also improve safety when paramedics administer morphine. Often, a combination of pharmacological and non-pharmacological methods may be necessary, for example, Entonox, morphine or ketamine may be required to enable the application of a splint for fractures.

• Treatment of acute pain may not follow the WHO analgesic ladder as closely as in other elective clinical scenarios. Initially, effective pain control is facilitated with stronger opioids and, wherever appropriate, local anaesthetic techniques. Entonox can be judiciously used for a short period until the other analgesics have had time to take effect. Once controlled, enteral options, such as regular oral opioid analgesics (codeine) and then simple analgesics (paracetamol, NSAID) are introduced.

• Any pain relief must be accompanied by careful explanation of the patient’s condition and the pain relief methods being used. Understanding the basic sites of action of different analgesics will aid in choosing the optimal combinations.

Choice of Analgesics

• Simple analgesics:

  • paracetamol, non-steroidal anti-inflammatory drugs (NSAID), e.g. ibuprofen, Diclofenac, Naproxen.

• Opioids:

  • codeine, morphine.

• Miscellaneous:

  • Entonox, Methoxyflurane, ketamine, local anaesthetic blocks.