Pain Management

Dr Doron Sher
Knee, Elbow, Shoulder Surgery


Pain is a very individual experience. What one person might experience as mild discomfort another might feel as severe pain.  It is best to take the recommended pain killers well before the pain becomes severe and to “stay on top of the situation”. It is much harder to get pain back under control once it becomes severe. 

Pain killers are designed to reduce the pain to a tolerable level, not to eliminate it completely.   

Factors that may make your pain perception worse include:   

  • Anxiety,
  • Uncertainty, 
  • Other emotions – sadness, anger, tiredness, 
  • Previous experiences with pain.     

When you are discharged from hospital you will receive either a script or the pain medication itself to take at home.  My anaesthetist and I have tried to take into consideration many of these factors when prescribing a pain killing medication for you however, because each patient is different, there is no guarantee that the medication will always be the perfect one for you.  This is why you should not wait too long before contacting me (or your family doctor if I am operating at the time) if you have significant continuing pain. Generally speaking placing ice on the area that has been operated on will also help reduce pain. Ask me if you are uncertain whether this is safe for you.

There are different types of pain killers that vary in potency and also the type of pain they treat. They are classed into:   – 

  • Simple analgesics  – like Panadol  
  • Anti-inflammatories – like Voltaren, Indocid, Naprosyn, Nurofen, Celebrex, Mobic etc – 
  • Narcotic Analgesics – like Codeine, Endone or Tramadol (although this is actually a slightly different drug)    

Often a combination of the medications is more effective than using them on their own, however they should not be combined without checking with me first. Generally speaking it is safe to take both an anti-inflammatory and a narcotic analgesic at the same time. Sometimes I will ask you to use a simple analgesic first and then only add a stronger pain killer if you are still in pain. 

The common pain killers that you may be prescribed are described below. It is worth while keeping a note of the time, medication and dosage you are using to avoid under or over dosing, particularly if the drugs make you feel drowsy.

PARACETAMOL 

Plain Paracetamol (Panadol, Dymadon, Febridol, Panamax, Parahexal, Paralgin, Tylenol) is probably the safest pain killer to use providing no more than eight tablets (of 500mg) are taken in 24 hours. It is very effective as a pain killer and is often underrated as to how effective it can be.  It may well be worth trying two Paracetamol tablets first to see if they provide adequate pain relief before adding a stronger pain killer like Tramadol or Endone. If there is no result within 30 minutes, a stronger pain killer should be taken as well. (Do not take Panadeine Forte within 4 hours of taking Panadol). It is  important to realise that there are many other types of preparations that may also contain Paracetamol such as cold and flu tablets and these should therefore not be taken in combination with the Panadol.

TRAMAL or TRAMADOL 

This is my preferred medication for most patients. It is a very effective drug and for most people has fewer side effects than Codeine. Tramal has a weak Morphine-like action in the brain, combined with an effect on certain brain chemicals that add to your pain control. The maximum dose is 8 capsules of 50mg per 24 hours for long term usage but for the first 2 days after surgery it can be taken every four hours.  Unless you have liver problems you should take 2 panadol (1000mg of paracetamol), each time you take the tramadol. The combination of the 2 medications is more effective than taking each of them alone. Tramadol may interact with other medications such as St John’s Wort and anti-depressants. Signs of this occurring may consist of agitation, muscle spasm, sweating, shivering, tremor, diarrhoea, lack of coordination and fever. Tramadol can also cause side effects, which may consist of nausea, dizziness, rash, tremor, headache or a ‘spaced out’ type feeling. Alcohol is not recommended while you are taking this medication. It is important to realise that there are many other types of preparations that may also contain Paracetamol such as cold and flu tablets and these should therefore not be taken in combination with the 2 Panadol.

PANADEINE FORTE 

This medication contains Paracetamol together with a strong dose of Codeine. Codeine is a medicine that can cause constipation in susceptible people.  Increasing fluid and fibre intake can help reduce the likelihood of this happening. Codeine acts in the brain (to reduce pain) so it may also cause drowsiness and affect your concentration.  Alcohol may make these effects worse and should be avoided.  It may also cause nausea.  The maximum number of Panadeine Forte that you can take in 24 hours is 8 tablets (It is OK to take 10 tablets per day for the first 2 days after surgery). It is important to realise that there are many other types of preparations that may also contain Paracetamol such as cold and flu tablets and these should therefore not be taken in combination with Panadeine Forte.

INDOCID (Examples of other medications in this class are Nurofen, Brufen, Voltaren, Naprosyn, Orudis, Mobic, Celebrex etc).

 These medications have anti-inflammatory as well as pain killing effects and are all of similar potency (although some patients may respond better to some than others).  They may sometimes cause a small rise in blood pressure, fluid retention, headaches, dizziness, gut irritation and may affect kidney function (amongst other side effects).  For these reasons intermittent use is encouraged – that is, take them only when you need them.  These medications may be taken as a breakthrough medication whilst on other regular pain killers. There is no problem combining them with Panadol and Tramadol! If they cause any discomfort in the stomach they should not be taken. Patients with asthma should avoid this drug as it may induce an asthma attack. Take these with food where possible.   

Do not take anti-inflammatory medications for one week before or after your surgery unless I have specifically said that it is OK to do so. 

OXYCODONE (Endone, Oxynorm) 

Oxycodone is an opioid (morphine-like) pain killer used for severe pain. This should always be taken in combination with Paracetamol to make both medications more effective. The type and severity of adverse effects depends on the dosage and duration of therapy. Oxycodone may cause nausea, drowsiness, dizziness and constipation, especially if used for more than a few days. Increased fluid intake, maintaining your mobility and taking a laxative if necessary helps prevent constipation.  Concentration and coordination may be affected and this is much more likely if alcohol is consumed.  Driving, operating machinery or computers may be affected. You may need to take more of this drug in the first day or two after surgery and then taper back to the recommended daily dose once the acute pain has settled. 

CAPADEX (also known as Digesic) 

This medication is a combination of products containing Paracetamol and Dextropropoxyphene.  Dextropropropoxyphene acts in the brain and may therefore cause dizziness, nausea, confusion, drowsiness and affect your concentration and coordination.  This is more likely if Capadex/Digesic is taken by the elderly and for longer periods of time (that is, more than 7 – 10 days).  This is because Dextropropropoxyphene lasts for much longer in the body than Paracetamol and may accumulate when taken every four to six hours.  When used occasionally for acute pain, it is no more potent than Paracetamol and generally is not used unless you are allergic to other pain killers.  Alcohol should be avoided while taking this medication.

Constipation: 

Many of the drugs listed above can cause constipation. This is particularly bad with Endone and Panadeine Forte. I suggest you adjust your diet to include items such as prunes or actually take medication to soften your bowel motions to avoid constipation. This includes movicol, normacol, coloxyl or many others which can be recommended by your pharmacist. My personal preference is 2 teaspoons of normacol twice a day until your bowel motions become soft again.

Summary:

  • Different medications will work for different people.
  • The idea of the medication is to reduce the pain to a tolerable level, not to eliminate it completely.
  • There will always be more pain when moving around than when you are keeping still.
  • Combining the medications as listed above will give better pain control than using them individually.
  • Avoid constipation. 
  • Please contact me if you have any concerns about your medications.   

Example of medication usage for severe pain: 

    • 7am –  2 panadol (2x500mg) 
    • 720am – still in pain – 2 tramadol (2x50mg) 
    • 740am – still in pain – 1 Endone (5mg)   
    • 11am – 2 panadol (2×500)mg 
    • Further doses depend on the degree of pain. 
    • Nil or mild pain – no further medications Moderate to severe pain – see above.
  • 3pm –  2 panadol (2×500)mg Tramadol or Endone as needed   
  • 7pm – 2 panadol (2×500)mg Tramadol or Endone as needed   
  • 11pm – 2 panadol (2×500)mg Tramadol or Endone as needed 

After the first 2 days you must reduce the panadol to a maximum of 8 tablets per day.

Dr Doron Sher

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Low Back PainNeuromaOsteotomy

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