Page 74 - Psychology of Wounds and Wound Care in Clinical Practice ( PDFDrive )

Pain Management 47

management of both acute and chronic pain and wounds,
being used continuously with consistent chronic pain or 1 h
before a dressing change (if pain is only experienced during
dressing change). Additionally, non-steroidal anti-
inflammatory drugs (NSAIDs) have an analgesic and anti-
inflammatory effect, reducing the sensitisation to pain. They
can be used in conjunction with paracetamol as no compati-
bility issues have been discovered and, again, can be used to
treat both continuous background and dressing procedural-
related pain for all types of wounds. However, NSAIDs have
been found to have side-effects including gastric irritation
and the potential for cardiac and renal compromise (Upton
2011a , b ).
Next on the WHO ladder is the addition of weak opioids
such as codeine. If a combination of paracetamol and
NSAIDs are not sufficient in managing background wound
pain, the addition of a weak opioid at a dosing frequency rela-
tive to the management of pain should be administered.
However, codeine can have variable efficacy due to it being a
pro-drug requiring modification into an active drug before
effect using the enzyme CYP2D6 (Stamer and Stuber 2007 ).
This particular enzyme, however, is not active, or is signifi-
cantly lower, in some patients proving ineffective in approxi-
mately 10 % of the population or even as high as 40 % with
highly stressed populations (Poulsen et al. 1998 ). Hence, if on
repeat doses clinicians become aware of non-deliverance of
analgesia, alternative weak opioids such as tramadol need to
be administered.
Finally, at the top of the WHO analgesic ladder is the
strong opioid, Morphine, and is only administered if pain has
not be adequately relieved via the combined analgesia sug-
gested by the previous WHO steps. Morphine can be admin-
istered via all routes being flexibly dosed at a quantity
suitable for individual patients. However, only on rare occa-
sions should morphine be administered for wound-related
background pain. Clinicians need to be aware of patient’s
healing progress in order to reduce its dosage as soon as the
pain lessens. It can also be used for dressing change-related