Pain; Roadside to Resus

So hi and welcome back to the Recess Ring Podcast. I'm Simon Lang. I'm Rob Fenwick. And I'm James H. And we're gonna have to start saying our names in a different way because it sounds identical every single time that we do that. We need to uh come up with a bit of spice into it. But anyway, welcome back to Pain and Roadside to Resus. The way you said that, Simon, it sounds like those two things.

pretty intrinsically linked, but that's not really what we mean, is it? The episode is covering pain, not that this is going to be painful. We hope. No, definitely not painful chaps, but it is gonna be long because I've had a little peek at a couple of the show notes we might have scribbled down to help keep us on track and my goodness, we might

it'd still be here in about four and a half years time. So my goodness. Then it will be painful, but it'll be more about pressure area cares than anything else. Yeah, absolutely. We do need to cover chronic pain management, so maybe that'll be useful in itself. Anyway, before we get into it a Huge thanks to Zol Medical Corporation for collaborating with us on the podcast and making this all free, open access and available to you in the pursuit.

of excellent patient care. And once you've had a listen to the podcast, make sure again you go over to their free CPD portal on our website and get a certificate for listening to it. So I think without further ado, let's crack in to the episode. So strangely we haven't actually talked about pain as a topic before, which is odd because it is a massive deal. Cause when you think about the patients that we see in urgent and emergency care, pain is really, really common.

About seventy percent of pre hospital patients have pain, and we know that somewhere between sixty to ninety percent of patients in the ED have pain as well, with pain being the primary reason for ED attendances in half of cases. Now that means that there are literally millions of people each year in Europe alone that are suffering from pain and presenting acutely to us, which means we need to get this right.

And to add some context, we've done episodes on things in the past like anaphylaxis, which is really important, but that pales into insignificance when you consider that that presentation is around one in two hundred of our ED visits. which makes pain one hundred times more frequent. We're all pretty acutely aware that we can't cure all the pathology that patients come to E D with. Whether that be an MI trauma, an abdominal catastrophe, but we can genuinely make a difference.

to a patient's pain and there are a number of ways that we can do that. Not just with that one to ten milligrams of morphine IV being written up on the drug chart. If you look at the data on how good we are at assessing pain, it's not a pleasant read.

We're pretty poor, both in ED and pre-hospitally. And whilst we might like to think we're just not that great at filling the audit tool out of the patient score, and actually we're pretty good at the clinical practice and addressing the issue case by case. I think if we're completely honest with ourselves, pain gets a bad deal in the emergency setting.

We also get a lot of patients with chronic pain presentations attending ED, and we might think that we get a lot of drug seeking behaviour as well, both of which affect our behaviour and approach to the patient. And we also know we've got other biases. Women receive less opioids than men, and there's a huge inequality in terms of ethnicity as well. In the US, African Americans are forty percent less likely to receive analgesia than others, which is pretty shocking.

So what does this all mean? Well, pain is a massive part of what we do and we can make a huge difference to patients' distress and experience. But At the moment, we're definitely not doing it as well as we'd like to. So in this episode we're going to run through all aspects of pain management, different strategies, consider current barriers to excellent care, and talk about different routes and pharmacological strategies to deliver the best care for our patients.

Geez, we certainly are, and we said it was going to be a rather large episode and even that outline is uh is pretty chunky, isn't it? So um So uh ideally we're gonna start with a definition,'cause we always do, and uh it would be really nice to keep this short and sweet, wouldn't it? Ja. actually pretty tricky because even from the get-go, pain is extraordinarily complex. And that's not just me trying to make excuses for why we're so bad at managing it or why this episode's gonna be so long.

But it really is a multidimensional construct which is influenced by biological, psychological, and social factors. But we've got to start somewhere. And, you know, for me, there's no better place than with the biology underpinning the pain experience. And this is often described as the pain pathway, and it consists of four parts. Firstly, we've got the transduction of a painful stimulus which occurs due to the nochceptors in the tissues firing off in response to a noxious stimulus.

We then get transmission of that nervous impulse to the spinal cord and then up the spinothalamic tract to the brain. Now, interestingly, in an attempt to allow us to sort of function enough to respond to the painful stimulus, we see an activation of descending pain modulating pathways, which can reduce some of those pain signals traveling up to the brain.

But then the final step in the pathway is the perception of pain in the somatosensory cortex of the brain. And it's at this point that things start to get a little bit interesting, and we start to get a sense of why pain as an entity is really, really complicated. So the definition of pain as described by the International Association for the Study of Pain gives us a really good insight into some of this complexity.

Because they say that pain's an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. So only seventeen small words, but there is a lot of detail in there to explore within it. So one of the key underlying paradigms that have all that have been encapsulated within this definition is that the experience of pain is personal and always subjective.

And the definition says that this is an unpleasant sensory and emotional experience. So that's referring back to that subjective, individual experience that the patient's going through. Interestingly, the chair of the ISAP subcommittee on taxonomy That's a title. Um has been quoted as saying that pain's a psychological concept and not a physical measure, and that the experience of pain has to be completely distinguished from the noxious stimulation alone.

So I think that really takes us to the second key part of the definition, which is that pain can be associated with actual or potential tissue damage. or even just the experiences that resemble those associated with actual or potential tissue damage. So I think this is saying to us that although, as I've described to you, the physiological pain pathway and tissue injury, that is a common precursor to pain, but we can experience pain even when tissue damage isn't discernible.

And I think that really speaks to the sort of multidimensional aspects of pain and it also recognises chronic pain and the fact that it's more than just a symptom and it's a disease with its own clinical cause. So look, how do we summarise all of that? Well I think we've said pain is always a subjective experience and it's influenced by biological, psychological and social factors.

And the physiological phenomena of notchoception are different. And the experience of pain can't be reduced to activity in the sensory pathways alone. And I think finally and really importantly, as we progress through this episode. Because pain is subjective. A person's report of an experience of pain has got to be accepted as such and respected. And we shouldn't judge or second guess what a person is experiencing because the pain experience is completely unique.

to that individual. And we've got to manage that person's experience and not treat what we judge their experiences to be.

So, before we get into the real nitty-gritty of pain assessment and management, it's probably worth setting out some real key principles that are gonna underpin our practice moving forward. Oh my goodness, so much complexity. Honestly, my head's starting to hurt. I do have manflu anyway, so please send me your thoughts and prayers, but this is getting more and more complicated by the minute.

And that's painful, isn't it, Rob? And we need to appreciate that you were experiencing it as that as well, even if we wouldn't have done Indeed, you're right. I look forward to having some more sympathy thrown my way, or empathy or whatever it might be. So

All right, yeah. Look, let's start to think about what the principles of pain management are then, particularly in this emergency care setting,'cause as we say, in the emergency care setting that might be very different from the chronic pain settings. and the pain specialists that we deal with. Let's focus in on this area. Well, firstly, the evidence out there says that we should be focusing on the underlying causes of acute pain and we should be always addressing and treating those first.

So really simple. First thing in the back of our mind for all cases is address the underlying causes. Really simple stuff. Now next, what the guidance says is that pain should be addressed as soon as possible. And I think we all absolutely agree with that. We don't want to see patients having delayed treatment for this. But the primary aim here is to provide a treatment that reduces the patient's pain. Okay, so that's the first thing, but has minimal side effects.

but also allows them to maintain function. So there's three key bits. So we want to reduce their pain, we want to have minimal side effects and have a treatment that allows the maintenance of function.

So all really straightforward and absolutely no problems with any of that. We'll touch on all this later. Now, the secondary aim that we should be looking to do well that is to prevent chronification of pain and this is really done in an emergency care setting by managing that acute presentation really really really really well.

So those are our overarching games. But next well What the guidance says is that the reassessment of pain should take place at a frequency guided by that patient's pain severity, with more frequent assessments as pain severity increases. So now what we're saying actually is that good pain management involves an assessment of how well that intervention has worked. Not just that single episode. And this is one of the key recommendations by Arkham, which Simon will be discussing shortly.

Now finally, an almost an imperative element for me is that for clinicians they need to reassure patients. that their pain is understood and will be taken seriously. And I really, really like this point because it often comes up how patients, particularly chronic pain sufferers, feel like they haven't been heard and they don't feel validated. So in practice, I think this is just such an important part of what we do with our consultations. I mean, personally I like to say to patients,

I believe you that you are in lots of pain and I can see that and I'm gonna help you with that. And just taking a few seconds to reassure that patient that you are on the same page of them and you aren't fobbing them off can be hugely important to validate in their concerns and the pain that they're in.

So basically what we're saying here is address the underlying causes, address pain as soon as possible, thinking about both those primary and secondary aims. We need to reassess pain and as clinicians we need to let patients know that we are taking their pain seriously. So it's as simple as that. Really, really easy. But

I also want to drop in here the World Health Organization analgesia ladder into the mix. I mean, I'm not sure how we've got so far into this episode and we still haven't mentioned the Who Analgesia ladder, but you know, that ladder, it was originally designed for cancer pain by the way. And it's basically got three steps to it. So not necessarily immediately transferable to the emergency care setting.

But it's got three steps to it and it suggests some treatments at each stage, with the inference that this is probably a linear process. So as in, it's a ladder, you do step one, step two, and then step three. However I've always felt that really this needs to be balanced against the pain that this patient is in and the condition that they have when you see them. So for example, if you've got a patient with a displaced fracture dislocation of the ankle,

Well, I'm not too sure that sauntering up to step one and step two and step three of the analgesia ladder is what I'd be wanting. I think I'd probably be wanting someone to jump in it. Step three and then step down. But anyway. I think you're right, Rob, aren't you? I think you know, se sequencing our analgesia is really important, isn't it? And we're gonna talk a bit more about that as we move through this episode.

But I think what the Who ladder does is it does kind of set out some clear aims for sort of each level of pain relief. And I suppose what we can do is to tap into each of those at the right time for the right pace. Yeah, absolutely. And there's a few principles that they say go alongside this ladder. So, you know, principle one, all administration of analgesics should be considered wherever possible.

That sounds reasonable. Point two analgesics should be given at regular intervals with the duration and dose supporting the patient's level of pain. Fine, you know, analgesic should be prescribed according to the pain intensity and it should be that characterized by the patient and be free from judgment of the clinician. The dosing should be adapted to the individual, and I think that's reasonable. And finally, consistent administration of analgesics is vital for effective pain management.

I definitely get what you're saying and look I guess my take on the Who Pain Ladder is that there are some reasonable principles in here and that a stepwise progression might be the right thing to do in some cases. But just thinking back to those primary aims that I mentioned a few minutes ago.

Some of the cases we see, well, this just doesn't translate one hundred percent across, does it? So think maybe about this fractured femur. Well, working up the pain ladder here is gonna lead to significant delays in the provision of other treatments like splinting.

So f you know, for these cases I think that it's very likely that we'll be jumping, you know, straight in at step three, knowing that after that initial treatment we can s then step down to less potent analgesics. But You know, the key take home for me I think is that we should follow the principles of pain management.

But that we really, really as clinicians, we make our money by ensuring that we're providing a patient focused approach, i.e., what I'm saying here is that there isn't a one size fits all approach. We have to do it based on the patient in front of us, the condition that they've got and the analgesia options that are available to us at that time. Well following on from that'cause

Rob's told me that I now need to mention it. Uh Arkham have got their best practice guidelines, haven't they, for management of pain in adults. It's a really good document actually and has got some great stuff in there. And they've got a list of seven recommendations in there that we should be aiming for. But I think it's probably worth mentioning the first three which are Firstly, that recognition and alleviation of pain should be a priority when treating the ill and injured.

Now this should start at triage, be monitored during their time in the ED, and continue through to admission or discharge, ensuring adequate analgesia is provided at all times, including beyond discharge where appropriate. Secondly, all emergency departments should ensure patients with moderate and severe pain receive adequate analgesia within fifteen minutes of arrival. And thirdly, all emergency departments should ensure patients in severe pain

have the effectiveness of their analgesia reevaluated within fifteen minutes of receiving the first dose of analgesia. So if I was attending an emergency department or one of my family was, I think those are pretty fair recommendations. But Rob, how do you think we're doing with these targets?

Doesn't matter how I think we're doing, all I've got is some figures from Arkham for you to tell us how we're doing. And uh it's not a great reading, I've got to be perfectly honest with you. So an audit back in two thousand and twenty one Well only forty nine percent of adult patients presenting had their pain assessed within fifteen minutes. only fifteen percent of those patients received appropriate analgesia within half an hour.

And only three percent in total had re-evaluation within fifteen minutes of receiving that first dose of analgesia. So I think it would be fair to say that these are absolutely targets we should be aiming for. But the nuance comes down to and how on earth do you deliver them within a system that is absolutely maxed out at the moment. And I would love to open it as a little bit of a discussion for a few minutes, boys. So what are the barriers here? What are stopping us?

achieving these amazing aims. Yeah, well I went to the vet on Friday and I not as a patient. Not as a patient. I've had my fur chopped off recently to be a bit undercover. Um And it's amazing, isn't it, how phenomenal you can deliver a system when you've got a low number of patients. Talking about my dog here.

And I compared that in my mind to how it was in an emergency department and phenomenal one to one care, amazing treatment, amazing analgesia, amazing documentation and all this sort of stuff. But you're right, it is so difficult to achieve Excellence throughout all of emergency care. And I get that pain is clearly phenomenally important. But I'm gonna be honest, I think before we spent the time on the topic, thinking about it in such detail

It's one of those things that you go, Oh, okay, well, we need to do an ECG first because we could miss something medically here. Yeah. But actually with pain, is it going to lead to a bad outcome? They're going to have not very nice experience. But it's not gonna be a catastrophic error. I need to reflect on on even thinking like that, I think. But I don't think I'm totally out there on my own. But somehow we need to really try and streamline our systems, don't we? So that

Those people that are triaging don't then have to go and find another prescriber to then to be able to get the analgesia. The analgesia's in a in a sort of a convenient place. It's not locked behind four doors and a key code and a pass which has run out of date. Yes. And w there are bits that we could do aren't there to chip away at this, but they are hugely ambitious targets that we've got in Arkham. I don't think they should be taken away, but you know, they're tough.

Yeah, I definitely agree. I think they are ambitious and I think there are a multitude of reasons why we fail. I think, you know, we ul ultimately have to look at ourselves a little bit as well as to how quickly and effectively we uh consider pain management being one of the the priorities.

it's a difficult thing to incentivize because, you know, you're incentivized by things like responses to complaints and by prevention of pressure sores and stuff like that which ultimately have, you know, have got very hard end points, whereas someone waiting an additional ten to fifteen minutes for pain relief isn't necessarily something that we can sort of, if you like, tangibly see as being a problem, but

I I think it it comes down to fundamentally the pressures within the system that means that we have to reevaluate the way that we do these things. And just speaking from my own experience, you know, when we've moved senior Nurses to the very front door before the patient even books in, you know, and they've got that ability to assess them. I think there's there's two problems that we see when we do that.

Firstly, there's a lot of misunderstanding I think from the public about the fact that they can present to the emergency department having had a lot of analgesia at home. They don't have to wait for us to give it to them. So there is that element. The second element is that actually when when you move people to different places, and this comes down to stuff like meds management. You know, if you wanted to have some paracetamol and ibuprofen.

put at that front door, you know, you have to have a locked box It can't be in the pocket of a nurse because it doesn't meet the meds management requirements because it's not at the right right temperature and there's just lots of layers of difficulty. Whereas, you know, just to have a nurse at the front door giving out two paracetamol and ibuprofen for anyone that comes with mild or moderate pain, that would be great. But to actually achieve it in practice is so difficult

and so clunky and cumbersome that it just means that it's not a quick win, whereas it should be a quick win and it should be achievable really promptly. But yeah, I don't know what your thoughts are on it as well, guys, James. Yeah, I mean I I think that's really interesting to hear you talking about that and I think, you know, reflecting on my own experiences and and I think probably Simon with his initial statement alluded to it.

I I I wonder how much formal training we've all actually received on the management of acute pain. You know, understanding what it truly is and and all the different management options that we've got available to us. Um, you know, and I think that goes for your undergraduate training and your kind of ongoing mandatory training within your systems and organisations.

And I think the problem that sort of is exacerbated by that is that sometimes I guess if you're feeling uncertain about a topic, uh, you know, or you haven't covered it regularly, uh, or you need some some support, then you probably fall back on your protocols and your guidelines, don't you? And For me, I've got to be honest, I was looking at the JR C out guidelines, which are the UK ambulance practice guidelines, and I think they fall really short in supporting us in our decision making.

I think one example of that is that they talk about mild, moderate and severe pain. That's absolutely fine. But it allocates a pain score to each of those.

And interestingly that's been sort of pretty controversial when you look in the literature. And certainly, you know, we've talked about the subjective nature of pain, haven't we? And so I I think allocating a score alone just isn't holistic enough. But I think worse than that When you look at the recommendations for mild, moderate and severe pain, I I think the recommendations within JR Calc promote oligoanalgesia because for example, moderate pain, they suggest that you give paracetamol.

And codeine. I mean, nobody that I know of that doesn't work in a sort of a specialist role has access to codeine on the road, which means you're then giving paracetamol for moderate pain. That's rubbish. And then therefore, extrapolating that, morphine is only suggested for those with severe pain with a score between seven to ten out of ten.

And, you know, interestingly, if we compare that to Ambulance Victoria uh and their guidelines, which are available online, their moderate pain guideline has got no score associated with it, so it can be a subjective report from the patient. That suggests that they give Iv morphine or fentanyl,'cause they've got that available to them, as the first line.

with all patients also receiving oral paracetamol, and then it goes on to suggest a second line and a third line option if the pain isn't adequately controlled. So it's really nice, clear, well structured guideline and I think we would do well to learn from that because I think, you know, having those guidelines and protocols to to fall back on with our decision making can be really, really valuable.

I think the other thing which is really interesting is the cultural differences that we see with expression of pain and actually listening to how you described pain earlier, I was thinking about this. Because having moved from the Midlands down to the southwest and different cultures that are more prevalent in different areas, pain really can be expressed in a very different way, can't it?

Yes, I know I think you're absolutely right. And you know, it's really uncomfortable reading, I think, you know, reading about those disparities in care that the different ethnic groups receive. You know, longer times to analgesia, less effective pain relief and so on and

You know, I mean that's a whole topic on its own, uh and and it would be lovely to explore all of that. But I think, you know, for today we we have to own that problem and we have to accept it and we have to think of ways to address it, don't we? Because I think probably the key issue here, and it extrapolates beyond just ethnicities actually extrapolates into things like chronic pain. And that's around some of the clinician biases that we come with and sort of disbelieving patients.

And when you think about the the different ways in which pain is expressed I think like you say, they can vary hugely and then they clash with our expectation of how a patient should be acting. Um and I you know, I hold my hand up. I've definitely been there. You know, a patient is sitting there looking pretty comfortable and they say, Oh yes, I've got eight out of ten abdominal pain.

And you think, Whoa, you can't be having eight out of ten abdominal pain, but why can't they be? You know, that's just clashing with my expectation of what I think eight out of ten looks like. And so I think we've got to go back to to what I said quite a long time ago now is that the patient's report of an experience of pain has got to be accepted.

for what they're saying. And we've got to address the pain at that level and that patient's individual pain experience. We should not be projecting our own expectations of what that pain should or shouldn't look like.

Yeah, very interesting. I completely agree with you, James. I think, you know, if you're looking at this from the outside, the biggest problem that we've got here is underselling the analgesia rather than overselling it, I think. And Just coming back to that, I think, you know, the system th like, you know, I think one of the factors that I think does genuinely pay a factor at the moment is the

with our emergency departments being so busy, the analgesier options. So for example, if you come into my emergency department with eight out of ten abdominal pain and I haven't got a trolley to put you on

I can't give you Iv morphine as my first line treatment until I get you on a trolley. So then you you almost have to shift your analgesia options based on the pressures that are within the service, which isn't right, but at the same time I'm just trying to go some way to explain the challenges that we currently face at the moment and their unprecedented really, you know, and I think that that uh

often means that we explore options that are less than optimal but should hopefully still have some analgesic benefits. But It's a really tricky picture, but I think you yeah, I think you're quite right. The the only thing we can do is own this issue, isn't it? And try and find ways forward and find solutions. It's not it's not about hiding behind excuses. Uh we need to find suitable ways to provide appropriate analgesia and address these unmet pain needs.

I think you're absolutely right, and I think certainly from the pre hospital perspective, you know, from one of some of the situations you've described, Rob, I think we can strip those away because, you know, in some ways we're really lucky, aren't we? We're dealing with one patient at a time, often. And, you know, admittedly we've got a potentially slightly limited formulary, but we do have the time and the space and the equipment to deal with that patient in front of us. So, you know I

I think each one of us, wherever we're working, has got an opportunity to use this discussion, which could have gone on a lot longer, and there's so many barriers to to good pain relief. But I think individually we just need to reflect on our on our systems, our organisations and the way we practice.

to work out the best way to to deal with each individual patient we come across. But I guess that probably leads us out of these uh this barriers discussion and let's talk about positives. Uh let's talk about how we are gonna do this well.

Right, yes, Jimbo, I think let's push on with this. So let's have a little think about how we are going to assess pain, which is clearly a very important thing if we're going to provide safe, effective and of course individualised pain management for our patient. Well our first job is going to be taking an effective

patient pain history and this has got several huge benefits. So firstly you are taking the patient seriously and you are validating their concerns if you are asking questions about it. It's as simple as that. Now secondly, it starts to enable us to build towards a pain differential diagnosis, i.e. that working out what it is that's causing that pain to start with.

And this helps with various things, but a key element for me is that allows treatments to be tailored specifically towards that patient's needs. So a really good example is the NSAED, so the non-steroidal anti-inflammatories for renal colic. So absolutely perfect treatment and really effective.

But you need to ask the right questions to get you to that differential. Otherwise, you might just end up throwing all manner of medications at them rather than giving them that one thing that makes a really big difference. So of course with regard to the patient pain histories, there are some acronyms that can help us structure our assessment of pain. So my personal favourite is Socrates.

As it always is, you know, I'm sure for everyone else. So I say you say your personal favourite like you invented it, Robert. No, no he's I just I'm a big fan of Socrates, what can I say? Or I've always said it. Big fan. Rob Fenwick, big fan of Socrates. That's how I'm known. He says the same about you, mate. Yeah. We're in it together, mate. It's mutually it's a mutually uh beneficial relationship we are there.

So Socrates, so this is the idea that you're asking the patient about the sight, the onset, the characteristics, the radiation, the associated symptoms, the timing, the exacerbating and relieving factors, and the severity.

So basically what you're doing here is just trying to establish what it is that might be causing that pain so that you can tailor that treatment to it. And of course there are others out there. I mean you could use something like the PQRST, but you know, have a quick look and pick the one that works best for you. I think following that history, you know, well then it's about the appropriate use of pain scales and there are a fair few options out there, I gotta tell ya.

So there are categorical pain scales, so this is basically using words to convey the degree of pain. So generally it's like a four or five descriptors which go from no pain all the way through to extract Excruciating pain, so that's the categorical pain scales. Then things that we're probably more familiar with, so numerical rating scales. So for example, you know, zero to ten, zero being no pain and ten being the worst pain imaginable.

And then that's broken down into three groups, so generally scores of one to three are regarded as mild, pain scores of four to seven are regarded as moderate, and pain scores of eight to ten are regarded as severe. From a research perspective, particularly things like visual analogue scales are really important, so this is essentially a ten centimetre like horizontal line and the patient marks where their pain is onto that.

And then basically you work out how far it has up or down that line. So a visual analog scale of seven centimetres or more is indicative of the need for morphine in the evidence and is also therefore considered an indicator for severe pain. So you know, pain scales are available. I think the question of which one you use is a little bit more tricky to be perfectly honest with you.

But the evidence out there suggests that a numerical rating scale and the visual analogue scale both perform in a similar manner. But that is in a post surgical setting, so that's not in an emergency care setting. And

Both of those two have got better sensitivity than that verbal descriptor or that categorical pain scale. So I think these scales are useful but they're not perfect and they should be used to help guide treatment. But that shouldn't override you know, patient preference and, you know, remember the biopsychosocial aspects of pain assessment should be thorough and holistic really, taking into account the whole overall picture that we've got. Interesting though.

certainly I I've always fallen into sort of the categorical pain scale descriptors when uh when I'm at home and I stub my toe. But the uh the words that you use there Not really ones that I identify with, so I may have to come up with the Langpain scale instead. I don't think it would be suitable for family friendly podcasts though, would it necessarily

Very badly stubbed toe, I must admit. Yes, I can imagine. Anyway, sorry, carry on, Rob. You were actually contributing something useful as opposed to my comment. Yeah, indeed. Thank you. Yes. So I think the last bit on assessment for me is about those special groups who actually, if you like, make up a huge number of our patients, but they aren't able to use these numerical scales.

specifically there's sort of three groups I've thought about. So there's the The pediatric patients who can't communicate, so those children who can't communicate Well the FLAC scale is really pretty useful and is in widespread practice most places that I've seen nowadays and this stands for facial expression, position or movement of the leg.

overall activity and the presence or degree of crying and then their ability to be consoled or comforted. So Flax scale really useful for pediatric patients who can't communicate. For pediatric patients with some ability to communicate, the Wong Baker faces pain scale is another useful tool that you can use.

And the other group of patients, you know, you consider to be challenging with regard to pain assessment are those with cognitive impairment. And something I hadn't come across before is the Abbey Pain Scale, which um assesses factors like vocalizations, facial expressions, change in body language, behavioural change, physiological change and physical change is again something which I think is got the real potential to help us guide our assessment in these groups where it's just

More tricky to make a pain assessment, but it's just as important to make sure that we do it. Nice. Thanks Rob. I think that's really, really nice, valuable overview of how to assess pain. And so I suppose that takes us on to the management of pain and

I guess uh whilst the thought of pain relief probably makes us jump immediately to think about which medicines to use, we definitely shouldn't overlook the impact and the importance of non pharmacological options. 'Cause these often require sort of minimal or no resources and importantly they can be implemented quickly and easily, even in busy emergency departments or in the pre hospital setting.

And actually many of them are also proven to be effective in mitigating patients' anxiety, stress and pain levels. So I think the first thing to think about is the impact of the way in which we communicate with our patients. just simply being calm, reassuring, and for the right patience. It's been shown that actually sharing information with them about the procedure they're going to go through or the sensory experience they might undergo positively affects.

affects their outcomes and leads to reductions in the reported pain and pain medication requirements. And as an example, I think that's something I definitely use and find useful when using ketamine, and particularly when undertaking a procedural sedation. And I guess we can take that idea further really if we want and actually employ relaxation techniques like breathing exercises or visualizations.

Again, I use that a lot with sedations, but I can see that it might have fairly limited utility in emergency care, but it is another tool to think about for the right patient. Now one intervention that does have some good evidence behind it is the use of distraction techniques, particularly in children.

Now the method you use has got to be age appropriate, so if we just think about Simon, I think he'd really enjoy having some bubbles blown for him and and then you won't and he w he won't feel you straightening his femur at all. Um whereas Rob's probably gonna need an episode of Pepper Pig uh on his phone. I think Simon looks a bit like Daddy Pig actually from uh that series. Thank you. That's really kind.

And and I talked about that being uh being supported by the evidence. Well, a recent systematic review and meta-analysis found that these passive distraction techniques. are good, but they might not be quite as effective as active distraction methods. So that's things like engaging them in a video game. But again, I think we've just got to target our choice of distraction to the patient in front of us.

Now there's relatively limited evidence of how effective distraction can be in adults, although I actually think we all do it without thinking,'cause I think we all try and engage our patients in conversation to try and distract them from thinking about either the situation they're in or the injury they've sustained.

And then just thinking about more physical interventions, I mean I think we're all happy with the idea that traction or splinting can be an excellent adjunct to some of the pharmacological interventions. And likewise with burns, you know, cooling them and covering them with cling film can significantly reduce the pain associated with them.

So there are a number of options that are non pharmacological that are available to us, but I think the key message is to remember again and again that we need to manage the pain holistically and just don't forget to integrate those non-pharmacological methods into your multimodal approach to managing the patient's pain experience. Oh thank you, James.

Daddy pig here. Um Right. I'm just gonna stop blowing bubbles and I'm gonna talk about the pharmacological structures. Anyway, so he's lost his mind. Yeah, I I mean th there are some really, really important techniques there and and definitely I think some shortcuts that we take to not concentrate on those as well as we should do. I think it wouldn't be a proper pain episode, would it, without talking about the pharmacological strategies we can use to achieve good analgesia for our patients.

And we've got a huge number of options when it comes to both what we can give our patients and also the route by which we can give them that analgesia. Rob's already mentioned the analgesic ladder, which has got those five key principles which we'll be considering.

The first of which was trying to use oral administration of analgesia whenever possible. But emergency care is really complicated in terms of scenes and location, so we probably need to consider a few other things when it comes to that route. So the analgesic ladder and how we can best deliver the appropriate level of analgesia. Things like access to the patient and the situation and that is specifically thinking about pre hospital situations.

the availability of intravenous access, things like how rapidly we need the analgesia to start and the duration of analgesia required. So think about those predicted clinical courses. Totally different when you're thinking about relocating joints where it might be maximally painful for a short period of time versus a presentation where that pain and the analgesic need is going to be ongoing. And importantly, what the patient wants.

or what might distress them and thinking really about kids in this area here. And I think it's also worth mentioning that we need to be really aware of our biases here and how we might perceive the efficacy of different treatment routes. And we'll talk about that a little bit more with things like paracetamol and whether that be oral or IV.

Great. Well let's start with paracetamol then. Uh and actually there is more than uh more than one reason to uh to pick up with paracetamol other than Simon leading me in nicely. Um I mean, yes, it's commonly used for treating mild to moderate acute pain, but More than that, it's frequently the absolute foundation of this multimodal analgesia concept that we're going to start talking about.

And it features in almost every guideline for almost every type of acute pain and that's because it's not only a good analgesic on its own, it's also got excellent opiate sparing actions and a longer duration of action than opiates. And some studies have shown that it can decrease opioid requirements by up to twenty percent. And that's really important because that reduces the chances of side effects of opius like nausea and vomiting.

Now, as Sim has mentioned, in emergency care paracetinol is often given either orally or intravenously. Now if we take it orally then pain relief begins within about half an hour, then if it's given IV, then that's only about eight minutes to an onset of analgesic action. And we'd expect a duration of action either way to be about four hours, which is when we can readminister another dose.

And one of the great things about paracetamol, very, very minimal side effects. And really the only downside is that it's got no anti inflammatory effect, and that's only a downside if you want it. So the age old debate IV versus oral. What should we do? Well, a best bet from twenty twenty three concluded that the IV form may have some benefit in pain reduction over oral, but realistically the results are pretty mixed from the trials that are out there.

And I think you just need to choose the right option for your patient. And when we do that, we need to accept that some patients might not be able to take oral medications. The IV route has got a faster onset time, but the IV option costs twenty-three times more than the oral option, and apparently, didn't know this until the other day, it releases eight times more CO2 into the atmosphere. I've no idea how that works. But there we go. You've got the facts now.

I think it's really interesting this paracetamol debate and i it's interesting when people talk about this rapidity of onset of action, you know, it being beneficial for that. It goes back a little bit. You can work out which side of the fence that I lie on. It goes back a bit to the system, doesn't it? And the time that it takes to me for IV paracesimal, you know, firstly to get access, then to get it run through, then to hook it up to your patient.

You know, I think that takes quite a few minutes. And takes multiple people to do it. And I think, you know, y I think with anything like this, if you're spending a bit more money, if you're having to put an IV line in when they didn't need to have it, it's really useful, isn't it, to know the evidence base and to know that actually it doesn't seem to make a massive amount of difference, does it? No, it doesn't. You're absolutely right. And I think that's a really valuable kind of uh

Holistic way to look at it. So if we stick with those simple oral analgesic options, then uh the NSAIDs uh are another option available to us, those are the non steroidal anti inflammatories, things like ibuprofen, diclofenac, and neproxin. Um and they're often used, aren't they, in mild to moderate pain and I think that's particularly useful when there's an inflammatory component to the pain.

Interestingly though, definitely worth realising that recent guidelines for the management of sprains and fractures have suggested not using NSAIDs within the first three days after injury to avoid potential delays to the healing process. But on the positive side, NSAIDs also have an opiate sparing effect and they can work synergistically with paracetamol to increase the overall efficacy of the analgesia offered.

Just to jump in there slightly, with regard to the not taking NSAS for the first three days, that is based on in vitro studies, so There will be a group of people out there who definitely do not think that evidence applies directly to the human population. So there is some theoretical lab based benefits to avoiding NSAIDs in the first couple of days. But I've read those bits of evidence and from my perspective

I would take paracetamol and if required I would use some NSAIDs, uh not necessarily avoid them altogether. Uh just to prefix that slightly in case there's anyone listening who might have very strong feeling. I I I love the fact that you said that there may be some people where there are probably a multitude behind a microphone right at this moment. But very very diplomatically put, Rob. Uh thanks, Rob. Thank you for your uh research insights there. Um

So um when we think about the ingestion of these medicines, uh when they're taken orally the onset time is about half an hour and the duration of effect is longer than paracesomol. It's about six hours for the NSAT. Now, unlike paracetamol, we do have to be a bit more cautious with it though, because it's contraindicated with GI issues such as bleeding and ulcers, and we've got to be a bit cautious as well in the elderly patients and those with renal impairment.

Now, changing tack ever so slightly. Let's well, quite a lot actually. Let's think about the inhaled analgesics. And here I'm talking entinox and methoxify fluorine, although before Rob jumps in, I am aware that Entinox is falling out of favour in many circles because of uh nitrous oxide's effect as a greenhouse gas. These inhaled analgesics have got two really key benefits. They're patient delivered and they've got rapid onset. I'm talking six inhalations before we start to see an effect.

And this makes them a fantastic option to give to patients while you're finding splints, sorting out IV access, or establishing kit to undertake a sedation as examples. But they've also got a short duration of action, maybe up to about twenty minutes. So they're great options for mild to moderate pain that might get better after a procedure such as splinting. So start the patient on the inhaled analgesic

Give some IV morphine if analgesia isn't sufficient with that inhalation option alone. And we're going to come to morphine in a minute. Then, after the splinting is done, we can stop the inhaled option, we can give some oral paracetamol. And that is an awesome example of a multimodal approach to managing your patient. Even if you do say so yourself. Um however

Um all of these analgesics are great, but they're not perfect. Both of them have got contraindications, and one of the biggest drawbacks of methoxy fluorine is that it's not licensed for children and for both agents. Patients have got to be able to understand instructions and hold the mouthpiece to their faces and have enough breath to be able to breathe in.

Uh so there are some drawbacks to them, there are some things you need to think about, but I think they're really great options for the right patients. It's getting very boring that term, isn't it? But that's what this is all about. So that's a simple analgesics, paracetamol and NSAIDs, although they aren't really simple. I think they should probably be called essential given how many patients can benefit from them as part of our multimodal approach.

And then you've got those inhalational analgesics which are great for fast short term pain relief.

So now we need to move on to consider how we're going to manage slightly more severe pain, that sort of moderate to severe categories, which is expected to be of a longer duration rather than just during a procedure. Yeah, absolutely. It's time to cover those opioids, isn't it? Something that we see used all the time and we need to be absolutely expert in understanding which ones to pick.

and thinking about their benefits and their side effects. Because whilst they all act, as you might be expecting on the opioid receptors, they've got a range of potency. And I guess the thing that we see commonly in practice is that opioids, especially in those that are naive to them, can induce some nausea, some vomiting, some sedation and some respiratory depression. So Just like anything that's really effective, we need to consider the pros and the cons of using it.

Now Tramadol and Codeine, probably things that we're again pretty familiar with, have similar potency, but Tramadol, although not used hugely in the emergency department, has the ability to be administered through other routes, not just orally. In terms of IV though, I guess you've got morphine or fentanyl. And I think it'd be fair to say that morphine's used a lot more in the emergency setting than fentanyl.

Now the main differences are gonna be duration of action and rapidity of onset. So the duration of action of morphine is longer than fentanyl and morphine takes longer to start to work. So many people will say that morphine is actually more difficult to titrate acutely than fentanyl for our patients, but it's going to last longer. So again, it's about thinking about that patient, thinking about what's going on with them and their expected clinical course.

Now fentanyl won't be available to everybody. It's not available to paramedics in the UK, so you're going to be using morphine if you're thinking about considering those two different things. But fentanyl can also be used intranasally in a really useful way, especially in pediatrics. and in burns when IV access might have specific challenges. So neither is right or wrong, but thinking about what those agents can do with moderate to severe pain is really important.

Now, we couldn't talk about morphine and acute pain without mentioning ketamine and we recently covered the Pac Man trial in our papers of the month. Go and have a listen to that if you haven't already. But ketamine's a fast-acting analgesic with some side effects, but they're different to morphine. So ketamine might make you a bit tachycardic and hypertensive and can give you some behavioural disturbances as well.

in a different way to that side effect profile of morphine, which, as we know, can make you nauseous, can make you hypotensive, but won't give you that behavioural disturbance. Essentially with Pac Man, that concluded that neither was more efficacious. And I think What we're looking at here is that ketamine, certainly in the UK, is a less familiar agent to use with those moderate to severe pains, but when used in a safe and effective way, will deliver analgesia in a similarly effective way

but might want to be picked out for those patients where you're really trying to avoid those side effects that you get with morphine.

Awesome. And I just want to jump in, I guess, with one other thing that we need to touch on here, and that is regional analgesia or regional anesthesia, depending on which terminology you use most. And I think in emergency care setting, you know, the increase in the attention around this as an option has just been absolutely fantastic in the past five to ten years. You know, the idea of providing nerve blocks which specifically relieved the pain.

for the patient's specific condition. Now that is incredible, thinking back to them aims that we were looking at earlier. And of course, you know, there are different drugs that you can utilize there, each with different pharmacodynamics and pharmacokinetics. So things like lignocaine, bupivacaine, levobubivacaine, you'll need to go and have a read around that and the exact dosing for them.

And if you think about the most simple version of this type of anesthesia or analgesia, just think about a ring block. where you administer a small amount of local anesthetic to block a digital nerve just so that you can do something that's painful to that digit, either suture it up or reduce a joint dislocation. Absolutely perfect. Absolutely incredible.

And now of course it's being used more frequently for things like rib fractures, so the serratus anterior block. But currently I think when we look at emergency care and we think of nerve blocks, probably the most common one we see

in practice is of course the fascia iliaca compartment block, which is, you know, highly effective in reducing pain for hip fractures. So just as an aside note for anyone that doesn't do these It doesn't make the pain go away completely, it does reduce that pain considerably though, and studies have demonstrated it improves pain scores by an average of three point five points on a numerical rating scale.

And these beneficial effects are reported at up to forty-eight hours post the injury. So this is really useful as it's long lasting analgesia or anesthesia. and it avoids the systemic side effects of other drugs like opiates, which in the elderly population can of course be really, really significant. I think that's one of the big things, isn't it, with regional analgesia or anesthesia is that avoidance of Systemic treatment.

of a problem which is only localized to one area. Yeah. Um so I think if you can use these regional techniques, it's fantastic because you know I think your second point that you came up with way back when when we were talking about the uh the sort of the primary aims of uh of pain relief. was that we wanted to to reduce the pain but with limited side effects. You know, this is is gleaming out as an answer to to how you achieve that, isn't it?

Yeah, absolutely. And I I completely agree. And like I say, I think it's been fantastic to see more of it being utilized in emergency care setting. But coming back to it, there are some barriers and we've already talked about the barriers, but for specifically for things like blocks, well firstly, you know So the the barriers there are training. So you know this does require either ultrasound or landmarking skills and importantly it requires skills maintenance.

Now if you work in an emergency department, fractured hips are an incredibly common presentation, so it's not too tricky. But I guess that, you know, it could be significantly less in terms of if you look at other groups that might be able to provide this like paramedics. So

I guess the potential for getting blocks to become part of that role really would have to be quite focused and specific roles relating to groups of patients. So I don't know, James, what your thoughts are, but you know, potentially those full specialist paramedics or similar.

Well s I mean, since you did it to me, Rob, I'll just tell you that there's definitely research out there that says this is absolutely achievable in the pre hospital setting by paramedics. Um so uh yeah, a hundred percent, but I do agree with you. It's probably got to be in a small group of targeted clinicians who are seeing this regularly so they can maintain their skills. But absolutely this is totally feasible in the pre-hospital setting.

Brilliant. And I think, you know, anything that's got an evidence base behind it that can improve patient care through the provision of better analgesia or anesthesia is absolutely warranted, but it's about how you deliver that safely, isn't it? So

You know, for me, I personally feel, you know, in practice, any time you have the option to provide regional anesthesia, I think it has a huge amount of benefits for that patient and should not be scoffed at. It should be one of the first line things that we're looking to provide.

Would completely agree with that. And the other thing is by leaving it late, you often end up giving a lot of those opioids, don't you? And we're talking about things like respiratory depression and what you don't want to do is end up giving an absolute shed load of opioids. then doing a really great block and then then being opioid toxic. So trying to get this in early on is really important. I I think the other thing that we should probably mention

Because we were asked this online when we put out those messages on our X, we really opened ourselves up for questions that we have absolutely no idea about. And we got one of those, which was About the use of IV lignocaine or lidocaine, depending on where you're from, and how efficacious it is. And

I must admit this is something I've never seen in the UK and the question came from down under. So did a bit of a search and there is a great systematic review and meta-analysis published from Intensive Care and Anesthesiology by Zong a couple of years ago in twenty twenty two. And that looked at twelve RCTs on the use of lidocaine, over three hundred patients, and it essentially compared IV lignocaine to standard analgesia, so NCEDs and opioids.

And I was surprised'cause Ivy lignicane sounds like a pretty aggressive approach. But they found no significant difference in pain scores between IV lignocaine and the other analgesic strategies. They found a need for rescue analgesia was actually higher in the IV lignocaine group. And the meta analysis showed no statistically significant difference in side effects.

So yeah, something that I was ignorant about. I'd now like to retrospectively say I was ignorant about it because I knew the evidence base didn't support its use terribly. But yeah, really interesting to have a look at it. And I'll put the hyperlink to that paper in the show notes.

Excellent stuff. Okay then chaps. Well that brings us nicely to the end of that section on management, doesn't it? But let's summarise it all just so that we can be sure on the same page. Let me take you back firstly to that section on the principles of acute pain management where we said that the primary aim is the reduction in pain with minimal side effects.

and that allows the maintenance of function. So with that in mind, I think we have the option to do this by combining pharmacological and non pharmacological approaches For example, definitely give that paracetamol, but also consider the splinting and the distraction techniques to help with that situation. But we also want to avoid polypharmacy, so we want to tailor our treatments to that patient's needs.

rather than just throwing everything at every patient that we come into contact with Yeah, there's an awful lot to consider here and there's a lot of ways that we can be a lot much better in our practice at managing pain in our patients and it would be amiss not to think about a couple of special areas here, and one that is talked about is clearly drug seeking behaviour. And this is a massive can of worms.

And when I was thinking about this, a real opportunity actually to reflect on our own inherent biases because there are patients. That either are or we just deem them to be seeking opioids with their presentation to acute care and a few different things to think about. So firstly, apioid addictions are really unlikely to start in the emergency department. But, as Arkham mentioned in their documents, we can if we're not careful, cultivate that addiction and make it worse.

So we really do need to be aware that some patients might be there because they have a need for opioids, but we do need to make a really good assessment of our patients and listen to what they're describing and what we should be doing for them.

Some of the literature on this topic is pretty difficult to read and actually to know how accurate it is. And the worst thing I think that I read preparing for this podcast is Drug seeking behaviour groups often present with conditions that might be easily feigned and are difficult to evaluate. Such as headaches and Back pain and dental pain.

And in that publication they also say that drug seeking patients are common in the emergency department, accounting for as many as twenty percent of all emergency department visits. And when we go back to the beginning of the podcast and think about how people express pain, what they're experiencing.

There is a huge amount of judgment in this on this topic and I think we can probably all identify times where we've just come to a very, very early decision that the patient in front of us isn't presenting like someone that's in pain and they are there seeking drugs.

So what do we do to get this right? And I guess where I ended up landing is that we need to strike a balance between ensuring we do a really fair assessment and treatment of patients who are in pain And probably asking a patient what their expectations, their hopes and what they want should be part of your assessment. And when things don't add up so when signs don't match symptoms, having an honest but definitely not rude an honest conversation with the patient can really help.

And having an opportunity then to talk about why we wouldn't prescribe opioids is really important. I've described that as I've got some sort of halo round my head and don't worry, you don't ever have to be judgmental, you won't ever get into an awkward situation and and I'm certainly not trying to describe that. But I do think that honesty in the consultation, giving patients time is really important and can make things an awful lot easier.

The other thing to remember is that there are other non-opioid options, so there are things like ketamine, inhaled analgesia that we've spoken about, and nerve blocks. Yeah, thanks Simon. I think that's a really important point and it was something that came up uh several times, wasn't it, on X and the social media interactions was around this idea of opiates or drug seeking behaviour and

I guess for me I I do I do worry a little bit and I think my mentality and my approach to these patients and my approach that I recommend for my trainees is that the the biggest danger I think is that we under analgeze our patients, not the fact that we over analge. And I think

You know, when you read statements like drug seeking patients are common in the E D accounting for as many of twenty percent, well, it sort of leads you to this this situation where you're you you sort of distrust patients and you think, Oh, so that means one in five of the patients that I see are drug seeking.

Well, I I I think what you're gonna do if you latch onto it with that is you're gonna do a disservice to the vast, vast majority of the patients that you see. And I think we absolutely have to believe our patients that they are in pain. and we work up that analgesic ladder and we explore other analgesic options if we are suspicious around opiate seeking behaviour.

There aren't many patients that come to me in severe pain and they won't let me administer some paracetamol, some NSADs, and then work up that perspective. So I would be just very cautious about labelling people as having drug seeking behaviour or opiate seeking behaviour without considering whether they are in genuine degrees of pain first because

We've explained the complexities and the barriers here, so I really don't want us to be doing a disservice to our patients or to be putting too much focus on the potential that there might be one or two patients out there that are drug seeking. So yeah, I'm sorry to jump in just to just to prefix that really.

That's really fair, isn't it? I mean, ultimately at the end of the day, we need to justify the decisions that we're making and we need to be honest with our patients, don't we? So if we really are thinking that, then we need to be able to have that conversation with our patients and that might put a slightly different

uh enthusiasm on how much we're gonna label people as drug seeking behavior. I think the other group that we need to mention is chronic pain patients and Some papers again describe chronic pain as really frequent, so around sixteen percent of E D presentations, which feels like an awful lot.

But they're in a really complicated position because they're often at their wit's end and not able to cope anymore. And we haven't got enough time to do chronic pain justice. But I think just a a few key points. It's complicated, so things like allydinia, so pain from light touch do exist. But can be really easy for us not to believe or appreciate it. It's really important again to show that you understand the impact that that pain is having on the patient's life.

Even if you can't solve it, just listening and appreciating it has a huge degree of power. We need to make sure in these patient groups that we don't just attribute it to a chronic problem. We need to think about red flags and ruling out new pathology. We need to think about the medications that they're on and make sure they're on appropriate treatment. And even if we can't

help with the problem at that point. Signpost specialist services that can help those patients. So loads to consider there. We must be coming to the end of the episode. So what about those discharge considerations before we wrap it all up?

Yeah, discharge it's a really important element of this whole picture to I think to to pull it together and the evidence out there suggests that around half of those who attend the emergency department will still have moderate to severe pain when they are discharged. So not great reading, but we need to be aware of that and we need to plan for it.

And there are some really good examples where written instructions can be useful here. So think about advice sheets that are given to patients. Just thinking about my department, the guns that I commonly use, things like lower back pain advice or the neck injury advice cards following a road traffic collision.

where they explain the next steps that the patient can expect to go through and uh hopefully you can complement that with some really good verbal instructions as well and I think that explanation works wonders.

Now the evidence also shows that around three quarters of patients who are discharged from the ED with a prescription for medication state that they are happy with pain relief. However Thirteen percent of patients with prescribed analgesia never collect that medication and somewhat unsurprisingly, these patients report the least satisfaction with their pain relief overall.

So, you know, on the idea of discharge, you know, everyone will have their different prescribing thresholds, et cetera, et cetera. But I think communication with the patient is the key here. Explaining why you think Over the counter medications such as paracetamol and ibuprofen should be adequate for the condition that they've got.

Or on the flip side, offering additional analgesia in the form of stronger NSAIDs or codeine and when that might be possible, well that's really the key, and you will get a feel for when that patient thinks they need it in my experience and it isn't always that they want a prescription or that they want medication. What I think that they want is they want communication and an explanation of the strategy that you're initially putting them on and embarking on at the point of discharge.

So for me, you know, those summary sheets That conversation that you have about what analgies you're expecting them to need and about whether or not they want to explore other prescribed options is definitely a conversation that is absolutely time well spent at the closure of that consultation.

Well, that is it for Payne and our roadside to Resus this month. And how do you sum up? A hugely long episode like that. Well I guess the key bits are that pain in the acute and emergency setting is really important and if we're honest with ourselves we're not doing a very good job. That isn't necessarily from a lack of but just systems at the moment. But there are small things that we can do all the way through that patient's journey to try and improve the situation that we're currently in.

The definition of pain is complicated, the perception of pain is complicated, and we need to be really careful and check our biases and make sure that we're doing an excellent assessment of those patients in front of us. and making sure that we're treating patients in the best way possible. That includes the non-pharmacological strategies that we've covered and the pharmacological strategies.

By thinking about the pros and the cons of each approach and titrating our analgesic prescription to not only the pain but to try and minimise the side effects. And make sure that the side effects aren't going to compromise the patients further. We need to think about regional analgesia or anesthesia, and we need to make sure that we're doing really fair and excellent assessments for those patients that are coming in who are possibly seeking drugs or that have got chronic pain.

presentations and make sure again that we are delivering them the best care that we possibly can. So a huge thanks to Zol Medical Corporation for collaborating with us on the podcast. and helping deliver this podcast as free and open access. Make sure you go over to the website and you download your certificate for listening to this afterwards and pop it in your CPD diary.

And we will be back with another Papers of the Month and Roadside to Resus for you next month. So take care of yourselves and we'll speak to you soon.