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      CHAPTER 6  5.  Rectal administration of single doses of paracetamol results in highly variable plasma  concentrations that often remain subtherapeutic (N) (Level II).  6.  Intermittent subcutaneous morphine injections are as effective as intramuscular injections  and have better patient acceptance (U) (Level II).  7.  Intranasal opioids, in particular the more lipid‐soluble drugs such as fentanyl, are effective  for the management of acute pain (N) (Level II).  8.  Continuous intravenous infusion of opioids in the general ward setting is associated with  an increased risk of respiratory depression compared with other methods of parenteral  opioid administration (U) (Level IV).   The following tick boxes  represent conclusions based on clinical experience and expert  opinion.  Other than in the treatment of severe acute pain, and providing there are no  contraindications to its use, the oral route is the route of choice for the administration of  most analgesic drugs (U).   Titration of opioids for severe acute pain is best achieved using intermittent intravenous  bolus doses as it allows more rapid titration of effect and avoids the uncertainty of drug  absorption by other routes (U).  Controlled‐release opioid preparations should only be given at set time intervals (U).  Immediate‐release opioids should be used for breakthrough pain and for titration of  controlled‐release opioids (U).  The use of controlled‐release opioid preparations as the sole agents for the early  management of acute pain is discouraged because of difficulties in short‐term dose  adjustments needed for titration (U).  Neither oral transmucosal fentanyl citrate nor fentanyl buccal tablets should be used in the  management of acute pain because of safety concerns and, in most countries, lack of  regulatory approval for use in other than opioid‐tolerant patients (N).  REFERENCES 9.  Transdermal fentanyl should not be used in the management of acute pain because of  safety concerns and difficulties in short‐term dose adjustments needed for titration;  furthermore, in most countries, it lacks regulatory approval for use in other than opioidtolerant patients (S) (Level IV).  Abboud TK, Zhu J, Gangolly J et al (1991) Transnasal butorphanol: a new method for pain relief in postcesarean section pain. Acta Anaesthesiol Scand 35(1): 14–8.   Anderson B, Kanagasundarum S & Woollard G (1996) Analgesic efficacy of paracetamol in children using  tonsillectomy as a pain model. Anaesth Intensive Care 24(6): 669–73.  Anderson BJ, Holford NH, Woollard GA et al (1999) Perioperative pharmacodynamics of acetaminophen  analgesia in children. Anesthesiology 90(2): 411–21.  Ashburn MA, Lind GH, Gillie MH et al (1993) Oral transmucosal fentanyl citrate (OTFC) for the treatment  of postoperative pain. Anesth Analg 76(2): 377–81.  Aubrun F, Monsel S, Langeron O et al (2001) Postoperative titration of intravenous morphine. Eur J  Anaesthesiol 18(3): 159–65.  164  Acute Pain Management: Scientific Evidence 
      Acute pain management: scientific evidence  165  CHAPTER 6  Azevedo VM, Lauretti GR, Pereira NL et al (2000) Transdermal ketamine as an adjuvant for postoperative  analgesia after abdominal gynecological surgery using lidocaine epidural blockade. Anesth Analg 91(6):  1479–82.  Bandolier (2003) Acute Pain. www.ebandolier.com. Accessed January 2009.  Barden J, Edwards JE, McQuay HJ et al (2004) Pain and analgesic response after third molar extraction  and other postsurgical pain. Pain 107(1‐2): 86–90.  Beck DH, Schenk MR, Hagemann K et al (2000) The pharmacokinetics and analgesic efficacy of larger  dose rectal acetaminophen (40 mg/kg) in adults: a double‐blinded, randomized study. Anesth Analg  90(2): 431–6.  Bell JG, Shaffer LE & Schrickel‐Feller T (2007) Randomized trial comparing 3 methods of postoperative  analgesia in gynecology patients: patient‐controlled intravenous, scheduled intravenous, and scheduled  subcutaneous. Am J Obstet Gynecol 197(5): 472 e1–7.  Birmingham PK, Tobin MJ, Fisher DM et al (2001) Initial and subsequent dosing of rectal acetaminophen  in children: a 24‐hour pharmacokinetic study of new dose recommendations. Anesthesiology 94(3):   385–9.  Blumenthal S, Min K, Marquardt M et al (2007) Postoperative intravenous morphine consumption, pain  scores, and side effects with perioperative oral controlled‐release oxycodone after lumbar discectomy.  Anesth Analg 105(1): 233–7.  Borland ML, Bergesio R, Pascoe EM et al (2005) Intranasal fentanyl is an equivalent analgesic to oral  morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study.  Burns 31(7): 831–7.  Borland M, Jacobs I, King B et al (2007) A randomized controlled trial comparing intranasal fentanyl to  intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg  Med 49(3): 335–40.  Bounes V, Ducasse JL, Bona AM et al (2009) Nebulized morphine for analgesia in an emergency setting.  J Opioid Manag 5(1): 23–6.  Bulow HH, Linnemann M, Berg H et al (1995) Respiratory changes during treatment of postoperative pain  with high dose transdermal fentanyl. Acta Anaesthesiol Scand 39(6): 835–9.  Cashman JN & Dolin SJ (2004) Respiratory and haemodynamic effects of acute postoperative pain  management: evidence from published data. Br J Anaesth 93(2): 212–23.  Chong C, Schug SA, Page‐Sharp M et al (2009) Development of a sublingual/oral formulation of ketamine  for use in neuropathic pain: preliminary findings from a three‐way randomized, crossover study. Clin  Drug Investig 29(5): 317–24.  Christensen KS, Rogers E, Green GA et al (2007) Safety and efficacy of intranasal ketamine for acute  postoperative pain. Acute Pain 9: 183–92.  Christensen KS, Cohen AE, Mermelstein FH et al (2008) The analgesic efficacy and safety of a novel  intranasal morphine formulation (morphine plus chitosan), immediate release oral morphine,  intravenous morphine, and placebo in a postsurgical dental pain model. Anesth Analg 107(6): 2018–24.  Christrup LL, Foster D, Popper LD et al (2008) Pharmacokinetics, efficacy, and tolerability of fentanyl  following intranasal versus intravenous administration in adults undergoing third‐molar extraction: a  randomized, double‐blind, double‐dummy, two‐way, crossover study. Clin Ther 30(3): 469–81.  Coda BA, Rudy AC, Archer SM et al (2003) Pharmacokinetics and bioavailability of single‐dose intranasal  hydromorphone hydrochloride in healthy volunteers. Anesth Analg 97(1): 117–23.  Collins SL, Edwards JE, Moore RA et al (2000) Single dose dextropropoxyphene, alone and with  paracetamol (acetaminophen), for postoperative pain. Cochrane Database Syst Rev(2): CD001440.  Collins SL, Moore RA, McQuay HJ et al (2000) Single dose oral ibuprofen and diclofenac for postoperative  pain. Cochrane Database Syst Rev(2): CD001548.  Colucci RD, Wright C, Mermelstein FH et al (2009) Dyloject®, a novel injectable diclofenac solubilised with  cyclodextrin: reduced incidence of thrombophlebitis compared to injectable diclofenac solubilised with  polyethylene glycol and benzyl alcohol. Acute Pain 11: 15–21. 
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        Acute Pain Manageme
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    iv  Acute pain manage
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    vi  Acute Pain Manage
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    viii  Acute Pain Mana
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    INTRODUCTION  References
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    CONTENTS  3.  PROVISION
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    CONTENTS  7.  PCA, RE
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    CONTENTS  9.10 Prehospi
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    CONTENTS  List of tab
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    Adverse physiological a
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    SUMMARY  14.  The inc
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    SUMMARY  The informat
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    SUMMARY  Cannabinoids 
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    Anti‐inflammatory drugs
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    SUMMARY  8.  There is
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    SUMMARY  Other regional
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    SUMMARY  4.  Ketamine,
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    SUMMARY  4.  Therapeuti
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    SUMMARY  Acute headache
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    15.  Steroids may red
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    The ideal prehospital
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    Caudal local anaesthe
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    SUMMARY  3.  Reported
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    SUMMARY  The patient 
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    CHAPTER 1  is the C
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    CHAPTER 1  receptor. 
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    CHAPTER 1  Descending m
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    8  Acute Pain Managem
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    10  Acute Pain Manage
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    1.3.2 Mechanisms for the pr
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    A systematic review (
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    CHAPTER 1  as the m
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    Figure 1.3   Proposed
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    CHAPTER 1  1.5.4 Acute
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    2007; Anderson & Palm
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    2. ASSESSMENT AND MEASUREME
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    CHAPTER 2  consistent
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    over the previous 24
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    2.3 OUTCOME MEASURES IN ACU
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    CHAPTER 2  Myles PS,
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    CHAPTER 3  Others hav
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    some institutions, the
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    CHAPTER 3  Key messag
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    CHAPTER 3  Shuldham C
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    Cosmo et al, 2008 L
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    CHAPTER 4  patients’
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    their opioid dose or
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    CHAPTER 4  Efficacy Cox
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    CHAPTER 4  Gastrointest
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    CHAPTER 4  al, 2007
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    CHAPTER 4  • administ
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    CHAPTER 4  performed 
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    Amitriptyline also prov
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    CHAPTER 4  with place
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    4.3.6 Alpha-2 agonists CHAP
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    4.3.10 Complementary and al
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    100  Acute Pain Manag
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      214  Acute Pain M
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      Wu CL, Cohen SR,
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      In some patients,
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      behavioural intervent
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      8.4 OTHER PHYSICAL THER
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      Sullivan MJ, Thorn
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    9.1.2 Acute postamputation
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    Key messages  1.  Con
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    days (Fassoulaki et a
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    CHAPTER 9  The manage
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    CHAPTER 9  Table 9.1
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    physiotherapy, and poss
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    The following tick bo
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    Primary dysmenorrhoea NsNSA
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    and 52% of patients
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    Key messages   1. 
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    • Step‐up across at
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    CHAPTER 9  Treatment 
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    CHAPTER 9  Triptans 
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    CHAPTER 9  Other trea
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    Postdural puncture head
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    (either alone or in
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    CHAPTER 9  children (
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    Mucositis  10. Opioids,
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    inhibited by methadone,
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    Percutaneous vertebroplasty
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    9.9 ACUTE PAIN MANAGEMENT I
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    CHAPTER 9  analgesia 
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    Key messages  Abdominal
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    CHAPTER 9  prehospital
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    Acupressure performed b
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    CHAPTER 9  Wu CL, R
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    10.2 LONG-TERM CONSEQUENCES
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    A reduced scale with
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    Key messages  The fol
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    Table 10.3  Self‐repo
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    CHAPTER 10  pain scor
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    CHAPTER 10  2007 Leve
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    has not been confirme
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    (Allegaert et al, 200
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    10.6.2 Patient-controlled a
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    with cancer (Miser et
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    CHAPTER 11  (NAS) req
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    Table 11.2  Categorisat
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    Drug  Cat  Comments 
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    CHAPTER 11  Level II)
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    11. Patient‐controlled
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    Drug  droperidol, halop
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    loss and the incidenc
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    Physiological process 
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    Level III‐2). After
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    (using familiar words
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    volume of local anaes
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    11.3 ABORIGINAL AND TORRES
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    Key messages  1.  Pat
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    11.7 THE OPIOID-TOLERANT PA
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    CHAPTER 11  DeGaetano,
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    CHAPTER 11  advantage
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    CHAPTER 11  • complic
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    APPENDIX A THE WORKING PART
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    Multidisciplinary consultat
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    APPENDIX A  Area of
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      contributors. Contrib
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      Name  Simon van R
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      NHMRC (1999) A Gu
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      ABBREVIATIONS  nsNSAI
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      INDEX abdominal migra
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      INDEX  drugs used .
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      INDEX  older patien
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      subcutaneous route ..
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Acute Pain - final version - Faculty of pain medicine - Australian and ...

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