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The NICE British National Formulary (BNF) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland).

If you are outside the UK, you can access BNF content by subscribing to Medicines Complete.

If you believe you are seeing this page in error, please contact us.

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The NICE British National Formulary (BNF) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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The NICE British National Formulary (BNF) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland).

If you are outside the UK, you can access BNF content by subscribing to Medicines Complete.

If you believe you are seeing this page in error, please contact us.

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The NICE British National Formulary (BNF) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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The NICE British National Formulary for Children (BNFc) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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What is Pain?

Pain is a complex phenomenon

Unique for each individual

Can be defined as - "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"

(from - Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommitte on Taxonomy. (1986) Apin (suppl 3) S1-226)

"Pain is what the patient says hurts"

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Acute Pain -

well defined onset

usually associated with subjective and objective physical signs

Usually responds to analgesia drug therapy and treatment of the underlying cause.

Chronic Pain -

persists over weeks or months

may be associated with changes of lifestyle, personality and/or ability to function.

management of this pain can be challenging.

Assessment of physical, social, psychological, spiritual (holistic) dimensions as these can contribute to pain and suffering.

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Adjuvants

Adjuvants in pain management are drugs or substances that are not primarily designed to control pain but are used to enhance the efficacy of analgesics or address associated symptoms. Examples include antidepressants or anticonvulsants used to treat neuropathic pain or corticosteroids for inflammatory pain.

Pharmacological Pain Relief

Pharmacological pain relief refers to the use of medications to reduce or manage pain. These include:

• Analgesics such as paracetamol, NSAIDs, and opioids.

• Adjuvants that complement analgesics.

The aim is to target specific pain pathways in the body to alleviate discomfort.

Non-Pharmacological Pain Relief

Non-pharmacological pain relief involves interventions that do not rely on medications but instead use physical, psychological, or lifestyle techniques. Examples include:

• Physical interventions: Heat/cold therapy, massage, or acupuncture, TENS machine.

• Psychological interventions: Cognitive-behavioural therapy, relaxation techniques, or mindfulness.

• Lifestyle modifications: Exercise and proper sleep hygiene.

Complementary Therapy

Complementary therapy encompasses non-conventional treatments that are used alongside standard medical care to manage pain and improve well-being. These therapies often aim to address emotional, spiritual, or physical aspects of pain. Examples include:

• Acupuncture.

• Aromatherapy.

• Yoga or meditation.

• Herbal remedies.

Each of these approaches plays a role in multimodal pain management strategies, often tailored to the patient’s specific needs and the underlying cause of the pain.

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Pharmacology in pain management is a multidisciplinary, systematic approach to alleviating acute or chronic discomfort using medication to

interrupt pain signalling pathways,

reduce inflammation, or

modulate nerve activity.

It involves tailoring drug selection—ranging from non-opioids to strong opioids and adjuvants—based on the type of pain (nociceptive or neuropathic), its intensity, and the patient's specific needs to maximize relief while minimizing adverse effects.

Key Pharmacological Categories -

Non-Opioid Analgesics: These are first-line treatments for mild-to-moderate pain, including acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and aspirin. They function by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin production responsible for inflammation and pain.

Opioid Analgesics: Used for moderate-to-severe pain, these drugs (e.g., morphine, fentanyl, oxycodone, tramadol) work by binding to opioid receptors (mu, delta, kappa) in the central nervous system (CNS), blocking pain transmission. They are generally reserved for acute, cancer, or palliative pain due to risks of dependence and addiction.

Adjuvant Analgesics: Originally designed for other conditions, these are crucial for chronic and neuropathic pain management. Examples include anticonvulsants (gabapentin, pregabalin) for nerve pain, antidepressants (amitriptyline, duloxetine) for pain modulation, and corticosteroids (dexamethasone) for reducing nerve compression inflammation.

Topical Agents: Applied locally (e.g., lidocaine patches, capsaicin cream) to treat localized neuropathic or musculoskeletal pain, offering relief with minimal systemic side effects.

Consider whether the route is suitable for the patient and/or condition.

Principles of Pain Pharmacology

Multimodal Approach: Combining different classes of analgesics (e.g., NSAIDs + Opioids) to act on different pain pathways, enhancing effectiveness while allowing lower doses of each drug to reduce side effects.

WHO Analgesic Ladder: A tiered strategy beginning with non-opioids, advancing to weak opioids, and finally strong opioids for moderate-to-severe pain.

Individualization: Tailoring medication to the patient's age, comorbidities (e.g., kidney/liver disease), and pain type, rather than a one-size-fits-all approach.

Common Side Effects and Safety
Pharmacological management requires careful monitoring for adverse events, which are common, particularly in the elderly. Key risks include:

NSAIDs: Gastrointestinal bleeding, renal impairment, and cardiovascular risks.

Opioids: Constipation, sedation, nausea, and respiratory depression.

Adjuvants: Dizziness and drowsiness are common with anticonvulsants, while tricyclic antidepressants can cause anticholinergic effects.

The goal of pharmacological pain management is often not just to eliminate pain, but to restore function and improve the patient's quality of life.

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Many busy clinicians struggle with finding the time to conduct a thorough assessment of the pain patient, especially the patient with chronic pain. This article reviews how to properly assess a patient with chronic pain.

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NICE Guidance - How should I assess someone with chronic pain?

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NICE Guidance - How should I assess someone with chronic pain?

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

CKS content is produced by Clarity Informatics Ltd (trading as Agilio Software | Primary Care). It is available to users outside the UK via subscription from the Agilio | Prodigy website.

If you believe you are seeing this page in error please contact us.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. CKS content is produced by Clarity Informatics Ltd (trading as Agilio Software | Primary Care). It is available to users outside the UK via subscription from the Agilio | Prodigy website.

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British Sign Language - Learn BSL Online

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British Sign Language online course, free resources, games, information, and greeting cards. Learn British Sign Language today.

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Widgit Symbol Resources | Ready-Made Teaching Materials

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Widgit Symbol Resource Packs, hundreds of symbol resource packs, created in partnership with professionals

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Makaton uses signs and symbols to help people communicate. It is designed to support the development of spoken language.

Makaton signs are based on the gestures used in BSL (British Sign Language - the language of the Deaf community). However, unlike BSL, Makaton signs are used in conjunction with speech at all times and in English grammatical word order.

With Makaton, children and adults can communicate using signs and symbols. Many people then drop the signs or symbols naturally at their own pace, as they develop speech. Makaton is extremely flexible as it can be personalised to the individual's needs and used at a level that is suitable for them.

Who uses Makaton?

Today, over 100,000 children and adults use Makaton symbols and signs, either as their main method of communication, or as a way to support speech. Makaton is the UK's leading language programme used by adults and children with learning or communication difficulties and by everyone who shares their lives.

Increasingly, Makaton is being used in an inclusive way with all children, not just for those with communication difficulties. Lots of parents of typically-developing children and settings such as nurseries, mainstream schools and Children's Centres use it with their children too. It is beneficial for children with EAL (English as an additional language) as a way to help those children develop their spoken English skills.

Using signs can help children who are non-verbal (either because they have communication difficulties or because they are little babies/toddlers) by promoting their communication development. Many children's understanding develops ahead of their spoken language. Signing can help little children express themselves during this time and prevent or alleviate their frustrations caused by their current inability to communicate.

Makaton can help children/young people & adults to:

Communicate what they need, want, think or feel

Make themselves understood by using signs / symbols

Develop their attention, looking and listening skills

Develop their understanding of speech and promote their communication development

Develop their language & literacy skills

How to use Makaton

Use the sign/symbol for the keyword (most important information-carrying word in the sentence. E.g. Would you something to eat?

Remember to always speak at the same time as signing - the signs are there to support (augment) speech, not replace it

Use clear, short sentences

Make sure you use eye-contact, facial expression and body language to convey the meaning of your communication

Use objects of references (props/toys/pictures/photos) to give additional visual cues

You can do 'hand-over-hand' signing to help encourage your child to make the relevant gesture/sign

Reward all attempts to communicate! Even if their sign is not quite right, encourage them and then model the correct sign yourself (as you would with speech). Their signing will improve with time & practice

Have fun with signing! Sing, read stories and play games - make the learning experience as enjoyable as possible.

What does the Makaton Charity do?

The Makaton Charity is responsible for developing and sharing the Makaton Language Programme. They provide:

Training for parents, carers and professionals

Resources in a wide range of printed and electronic formats

Online 'Sign of the Week' clips #wetalkmakaton

Information to help others make information & resources accessible

Support and advice to families and professionals

Influence society by working in partnership with other organisations to empower people.

We are both licensed Regional Makaton Tutors and can provide Makaton Training in and around SW London. Please contact us on info@singinghands.co.uk or call 020 8288 1706 if you would like Makaton Training in this area.

If we are not available, then other members of our local Makaton tutor network might be able to help and we can put you in touch with them. If you are further afield, please contact the Makaton Charity for further information and to find dates and locations of training courses nearest to you.
www.makaton.org
The Makaton Charity
Westmead House
Farnborough
Hampshire
GU14 7LP
Tel: 01276 606760
Fax: 01276 36725
Email: info@makaton.org

To join in with Makaton's "Sign of the Week" #wetalkmakaton
Please visit www.wetalkmakaton.org

For more information on using Makaton signs & symbols software on iPads,
With the MyChoicePad app
Please visit http://www.mychoicepad.com/

Find out more about how to create your own materials using Widgit software with Makaton line drawings and symbols
Please visit www.widgit.com

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Makaton uses signs and symbols to help people communicate. It is designed to support the development of spoken language. Makaton signs are based on the gestures used in BSL (British Sign Language - the language of the Deaf community). However, unlike BSL, Makaton signs are used in conjunction with speech at all times and in...

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Olaf is a three-year-old fox red Labrador therapist and a published author. He was invited to speak at the Cheltenham Literature Festival 2023. Olaf is a family pet registered with the Pets As Therapy (PAT) Charity. His job is to make people smile when, with his human mum (a specialist teacher and mindfulness coach), he visits hospitals and schools.

Every Thursday morning, Olaf goes to Battledown Special School. He enjoys his visits so much that he set his second book there! Team Olaf to the Rescue is a heartwarming story about his classroom adventures (it very cleverly rhymes!). With help from his merry band of canine mates, Olaf saves the school's Christmas celebrations and gives the children a party they will never forget. All the dogs in Team Olaf are Olaf's real friends whom he sees every day on his walks. They all play a vital role in the story, showing kindness, creativity, and bravery. Fun activities are added to stimulate the reader's imagination and memory.

Battledown School uses Makaton as part of their teaching and learning, so we included their symbols in the book to enable more of Olaf's human friends to enjoy it. We were delighted Makaton wanted to be involved in our project and are grateful to the Team for their expertise and patience. They provided symbols for the concepts/story words and explained where to place them on the page, so that the story makes sense to the Makaton reader.

Olaf's first book, Mr. Olaf the Therapist, is a mindfulness scrapbook, diarying his experiences in a mainstream school and his work in the NHS. As a PAT dog, Olaf visits Cheltenham General Hospital where he is a valued member of the Knightsbridge (Gastric) and Critical Care Teams. He has been doing this for over two years but is still banned from the staff rooms because of the doughnuts... It is a privilege and humbling to be welcomed so warmly by patients, their families, and Olaf's NHS colleagues. Olaf also shares his lifestyle wisdom with self-care activities and mindfulness questions to help us reflect on our own work/life balance.

Olaf gives all the proceeds from his books to the Pets as Therapy charity. He attends promotional PAT events e.g., Crufts and Goodwuff.

For more information about PAT and/or to buy Olaf's books, please visit Pets as Therapy.

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Makaton is a unique language programme that uses symbols, signs and speech to enable people to communicate. It supports the development of essential communication skills such as attention and listening, comprehension, memory, recall and organisation

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National paediatric early warning system (PEWS) observation and escalation charts

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PEWS chart have been collaboratively developed by clinical teams across England to standardised the approach of tracking the deterioration of children in hospital and are to be used on general children's wards.

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The Modified WHO Analgesic Ladder: Is It Appropriate for Chronic Non-Cancer Pain?

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From 1986, the World Health Organization (WHO) analgesic ladder has been used as the simple and valuable pain-relieving guidance in the pharmaceutical pain management, however, with the development…

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Pain is common and it is estimated that 50% of older people experience chronic pain (in hospital this may be as high as 80%). Assessing pain and communicating it to… Continue reading Pain

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Developed by the University of Cumbria to enhance critical reflection and professional development.

It encourages individuals to analyse a situation by exploring the Problem, the Evidence, the Thoughts and feelings, the Actions taken, and the Learning outcomes, promoting deeper self-awareness and informed future actions in a structured yet flexible way.

The PETAL Framework Steps

1. Problem:

Describe the problem or situation you are reflecting on.

2. Evidence:

Identify the objective and subjective evidence that is relevant to the situation, including your role, the actions you took, and how others responded.

3. Thoughts & Feelings:

Explore the thoughts, feelings, and emotions you experienced during the situation, and consider how you interpreted them.

4. Actions:

Detail the actions you took in response to the situation and the thoughts and feelings you had.

5. Learning:

Determine what you have learned from the experience and how you can use this learning to improve future actions and professional development.

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Pain is a symptom that is often experienced by patients seeking healthcare. It can be the presenting symptom that prompts patients to seek medical attention, initiating the first contact with healthcare professionals.

Pain can be experienced suddenly and unexpectedly as a result of acute conditions such as trauma, acute illness or surgery. This is referred to as acute pain.

Pain can also be experienced as a result of longer‐term conditions such as osteoarthritis, rheumatoid arthritis, low back pain and sciatica, headaches or migraines, endometriosis, or irritable bowel syndrome. Pain may also be present in the absence of a diagnosis or identifiable cause. In these conditions, pain is often referred to as chronic, persistent or long term.

Pain is a complex subjective multidimensional experience. Effective assessment and management of pain can relieve suffering and can help to reduce patient anxiety associated with pain. While technological advances in other areas of nursing continue to refine the assessment and management of patients, to assess and manage pain effectively nurses will be required to utilize knowledge, interviewing skills and physical assessment skills due to the subjective nature of pain and pain assessment.

This chapter focuses on definitions of pain, anatomy and physiology related to pain, pain assessment, and pharmacological and non‐pharmacological approaches to pain management. It focuses primarily on acute and chronic pain. For the comprehensive management of cancer pain, see the chapter on pain assessment and management in The Royal Marsden Manual of Cancer Nursing Procedures (Lister et al. [97] ).

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You are viewing a javascript disabled version of the site. Please enable JavaScript for this site to function properly. Go to header Go to navigation Go to search Go to contents Go to footer Skip chapter table of contents and go to main content Pain is a symptom that is often experienced by patients seeking healthcare.

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Consider -

Absorption - absorption is the transfer of an unmetabolized drug from its site of administration (e.g., mouth, skin, muscle) into the bloodstream. It is the first stage of pharmacokinetics, determining how much drug reaches systemic circulation (bioavailability) and how quickly, which is crucial for therapeutic effect. Lipid solubility, surface area for absorption, gastric motility and emptying, first pass metabolism, time, blood flow.

Distribution - Distribution in pharmacology is the reversible movement of a drug between the blood plasma and various tissues (such as fat, muscle, and brain) after absorption. It determines how a drug is dispersed throughout the body, significantly impacting its effectiveness and toxicity.

Key aspects include - blood flow, protein binding, distribution barriers, volume of distribution.

Excretion - Excretion in pharmacology is the final process of drug elimination, where the body irreversibly removes active drugs or their metabolites from systemic circulation into external fluids (urine, bile, sweat, or exhaled air). Primarily managed by the kidneys, it prevents toxin build up and is crucial for determining drug duration of action

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Living Well with Chronic Pain - assessment tool

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Living Well with Chronic Pain - assessment tool