Pain medicines

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Learn about pain relief medication and how to administer it, including patient controlled analgesia.

Key points

  • Common types of pain medication include acetaminophen and NSAIDs, opioids and local anaesthetics.
  • Medications can be given through the skin, in a suppository, under the skin and through a vein.
  • Follow the medication instructions from your child's health-care team and tell them about any other treatments, including over-the-counter or herbal remedies, that your child may be taking.
  • Pain medicines may not relieve all pain but can work well with physical and psychological approaches to reduce pain to an acceptable level.

During the last few decades many new pain relief medications have become available. The decision to use one particular type of medicine over another will depend on the age of your child and the severity and type of pain they experience. Some of these medicines are available without a prescription, while others require a prescription from the doctor.

Approaches to pain medicine

For most pain, doctors and nurses use a step-up approach to pain medicine. This means that usually, your child will be given weaker pain medication initially. If pain relief is not satisfactory, the medicine may be stepped up to larger doses of the same drug or to another, stronger type of pain medicine.

A combination of different types of pain relief medication will usually be used to relieve pain. This approach is called balanced analgesia. Using a combination of such medicines as non-steroidal anti-inflammatory drugs (NSAIDs) is often effective. If necessary, these can be combined with stronger pain medicines such as morphine. Using balanced analgesia will help relieve pain and reduce the amount of strong pain medicines needed. The result will be fewer and less severe side effects.

For post-surgical pain, health-care professionals use a step-down approach. Since pain from surgery can be very intense in the beginning, your child will be given stronger pain medicines immediately after the surgery. There will then be a step down to weaker medicine as recovery and pain relief progress.

There are several important things to keep in mind when treating pain.

  • Prevention is better than treatment. It is important to give pain medicines regularly to get on top of the pain and to prevent it from becoming unmanageable.
  • Successful management of pain is enhanced by a positive relationship between the health-care team and the child and their family.
  • Children and their families should be actively involved in pain assessment and management.
  • The right dose of pain medicine for a child is the dose that reduces the pain with the fewest side effects.
  • It may not be possible to eliminate all pain, but there are strategies (medicines, as well as physical and psychological means) that can reduce pain to acceptable levels.

For all pain medicine, it is important that your child does not take more than the daily dose that has been prescribed for them or as indicated on the medicine container.

Common types of pain relief medication

There are four main types of pain medicine:

  • non-opioids, such as acetaminophen and NSAIDs
  • opioids, such as codeine and morphine
  • local and regional anaesthetics, such as lidocaine and EMLA
  • adjuvant drugs, such as tricyclic antidepressants and anticonvulsants

Health-care professionals will assess your child's pain before deciding which medicines to use. The assessment will determine whether treatment for mild, moderate, or severe pain is required. For mild pain, acetaminophen and NSAIDs are used. When your child’s pain is moderate in intensity, these mild pain medicines will be used in combination with opioid medicines, such as codeine or a small amount of morphine, hydromorphone, or oxycodone. For more severe pain, medicines such as morphine​ will be used together with acetaminophen and NSAIDs.

Keeping health-care professionals informed about your child's medicines

Health-care professionals should be made aware of ALL medicines that your child is taking when they first come into hospital. This includes herbal remedies. A full disclosure of all treatments is needed to avoid any type of adverse drug or treatment interaction. Parents should always ask whether it is okay to independently give their child medicine at home. This includes additional medicine for pain relief and any other drugs.

Always follow instructions on the label when giving any medicine to children. In particular, always use the recommended dose and never exceed the daily dose. Additionally, parents should pay careful attention to how often their child can have the medication and any instruction about how it should be given, for example, with food. If the painful condition persists, your child should see a health-care professional.

Different ways to take medicine

There are many ways your child can be given medicine. In most cases, the best way to take medicine is by mouth, or orally. Taking pain medicine regularly by mouth is simple. Many oral medicines are available in liquid or tablet form.

Sometimes it is not possible to administer pain medicines orally to your child because of your child's condition or age. For example, young children may not be able to swallow or chew a tablet. Also, not all methods for giving medicines are available for all medicines. However, health-care professionals will recommend the best method available considering both the child's preference and the medical situation. Whenever possible, injections or needles will be avoided. These are some of the other ways that pain medicine can be delivered into the body:

  • transdermally: The medicine is delivered through the skin using a patch or cream
  • rectally: The medicine is delivered through the child’s rectum using a suppository
  • subcutaneously: The medicine is injected just under the skin using a small needle
  • intravenously: A tiny plastic tube is slipped through the skin into a vein and attached to a tube and a bag containing liquid pain medicine, which drips directly into the bloodstream

Each of these methods has its advantages and disadvantages. For example, the intravenous route acts the fastest, but it requires a needle stick and restricts movement because the child usually remains attached to an intravenous pump.

Many children will object to use of the rectal route out of fear, discomfort, or embarrassment.

Not all methods for giving medicines are available for all medicines. However, health-care professionals will recommend the best method available considering both the child's preferences and the medical situation.

For children who are staying in hospital, a continuous intravenous infusion, patient-controlled analgesia, or epidural infusions can be used.

Continuous intravenous pain relief medications

Pain medicines may be given to your child intravenously using a pump that is programmed by the nurse. This special pump is used to give a small amount of pain medicine all the time. The pain is continuously being treated because a constant amount of pain medicine is being delivered to child's bloodstream. This steady flow of medicine controls pain better than receiving medicine intermittently, which can lead to the pain coming back before the next dose.

The continuous intravenous infusion of pain medicine is used when we know that the pain will be continuous. This is the case with pain following surgery, a sickle cell crisis, or cancer pain. As your child recovers, the dose of medicine will be decreased slowly and eventually switched to oral or intravenous medicine in small doses every few hours as needed.

Patient-controlled analgesia

Patient-controlled analgesia, or PCA, is a way to deliver intravenous pain medicines that allows children to control the timing and amount of pain medicine they receive within safe limits. Often PCA is used after surgery when your child may not be drinking or taking medicine orally.

PCA is delivered by a small pump that releases pain medicine through the child's intravenous line at the push of a button. The PCA pump has a small computer that keeps track of how much pain medicine the doctor wants delivered, and it makes sure the child does not get too much medicine. The amount of medicine the child can get with each push of the button is controlled. Also, the total amount that can be delivered over a certain length of time is fixed so as to be safe for their age, weight, and condition. Parents therefore do not have to worry that the child using PCA will get too much medicine.

As an alternative, the PCA pump can be programmed to provide a small amount of pain medicine continuously. The child can also push the button for an extra dose of medicine if they are moving or doing something that makes them feel more pain. This "background" medicine works continuously. It can be especially useful when the child is sleeping and avoids them waking up in pain.

Most children aged seven years and older can understand the connection between pushing the button and getting pain medicine and relief. They can also understand that they cannot give themselves too much medicine. Parents should understand that it is up to the child to push the button when needed. If a child is not allowed to take charge of the PCA, much of the positive psychological effect of being in control is lost. The child may then have less pain control and require more medicine. This system ensures that the child actually receives, and feel they are receiving, just the right amount of medicine to help relieve their pain.

Epidural infusions

Another way to provide medicine to control pain is by an epidural infusion. The medicine is given through the lower back into the space around the spinal cord that is called the epidural space. This space runs from the bottom of the skull to the tip of the tailbone and the nerves responsible for pain travel through it.

Epidural infusions are most commonly used to provide pain relief following abdominal and lower limb surgery. As part of the anaesthetic technique, the anaesthetist may place a very thin plastic tube into the lower back. This tube is called an epidural catheter and remains inserted in the epidural space while medicine is being given through it.

The epidural catheter is connected to a special pump called an electronic syringe pump. This pump is always putting some of the pain medicine – usually local anaesthetics with or without opioids – into the catheter. This then flows into the back where it bathes the nerves. The child receives this medicine continuously during and after the operation until the epidural catheter is no longer needed.

Usually, epidural infusions are continued from one to three days. The length of time will depend on the type of operation and the amount of pain the child has. After this time, the catheter will be gently pulled out of the child's back. This does not hurt. They will then take their pain medicine intravenously or as a pill or liquid that can be swallowed. Because epidural infusions work on nerves that help control movement as well as pain, some children may have trouble moving their legs following the removal of the catheter. This effect is considered normal and tends to dissipate quickly. These side effects are generally mild but can be helped by other medicines.

In general, side effects depend on the kind and amount of medicine that is received. The child may feel sick to their stomach or may throw up. Their face, neck, or chest may feel itchy. Because epidural infusions work on nerves that help control movement as well as pain, some children may have trouble moving their legs. There may also be problems with their peeing.

Incident/breakthrough pain

Your child may require constant pain medicine to control their pain. However, there may be times when they experience more pain, or when the pain "breaks through" their otherwise controlled pain and becomes more intense. This extra pain may happen when, for example, they move or cough. If this source of pain is not treated, your child may refuse to move or cough because they know that the pain will get worse. Your child's doctor will order a "breakthrough" dose of medicine which can be taken by mouth (tablets or liquid) or given intravenously. This often consists of an additional but smaller dose of the same medicine your child is already taking. It is important to encourage your child to use the extra dose if needed. They should be told not to hold out or wait until the pain gets worse because then the pain may be more difficult to bring under control.

Your health-care professional may ask you to record how many "breakthrough" doses your child uses in each 24-hour period. Sometimes, the need for the extra doses means that the overall amount of medicine is not enough to control the pain and that the dose may need to be changed.

Last updated: September 21st 2009