Pain Management
AKT High-Yield Breakdown
Pain management in primary care spans acute pain, chronic primary pain, neuropathic pain, and palliative analgesia. The AKT tests the analgesic ladder, opioid equivalence and safe prescribing, NICE guidance on neuropathic pain, and the pharmacology of common analgesics including their key contraindications and interactions.
What You'll Learn
Master the WHO analgesic ladder, opioid morphine equivalence calculations, neuropathic pain drug choices and dosing, NICE NG193 on chronic primary pain (and what NOT to prescribe), palliative syringe driver drugs, and the key risks of long-term opioid prescribing in primary care.
Practise Pain Management MCQs
From opioid morphine equivalence calculations and NICE NG193 chronic pain guidance to neuropathic pain drug choices, syringe driver conversions, and medication overuse headache — tackle focused MCQs across the full Pain Management curriculum.
WHO Analgesic Ladder
The WHO analgesic ladder provides a structured approach to pain management, originally developed for cancer pain but applicable more broadly. The AKT tests appropriate step selection and adjuvant use.
- Step 1 — Mild pain: non-opioid analgesics — paracetamol (1 g QDS), NSAIDs (ibuprofen 400 mg TDS, naproxen 500 mg BD); +/− adjuvants
- Step 2 — Moderate pain: weak opioids — codeine (30–60 mg QDS), dihydrocodeine (30 mg QDS), tramadol (50–100 mg QDS); combined with paracetamol (e.g. co-codamol); +/− adjuvants
- Step 3 — Severe pain: strong opioids — morphine (IR: 5–10 mg every 4 hours; SR: Zomorph/MST 12-hourly); titrate to effect; oxycodone, fentanyl, hydromorphone as alternatives; +/− adjuvants
- Adjuvant analgesics: antidepressants, anticonvulsants, corticosteroids, muscle relaxants, topical agents — used at any step for specific pain types
- Regular + PRN: regular dosing provides baseline analgesia; PRN (pro re nata) doses for breakthrough pain = 1/6th of total daily dose
The WHO ladder is a "step-up" approach for cancer/acute pain. For chronic primary pain, NICE NG193 recommends a different evidence-based approach — this distinction is important and the AKT exploits it.
NSAIDs: Safe Prescribing
- Contraindications: eGFR <30 (use with caution if eGFR 30–60); active peptic ulcer disease; heart failure; third trimester pregnancy; anticoagulation (increased bleeding risk); avoid in elderly (risk of GI bleeding, fluid retention, renal impairment)
- NSAID + PPI: prescribe a PPI (omeprazole or lansoprazole) for all patients on regular NSAIDs who are ≥65, or have a history of peptic ulcer/GI bleed, or on corticosteroids/anticoagulants
- COX-2 inhibitors (celecoxib, etoricoxib): GI side-effects lower but cardiovascular risk equivalent to non-selective NSAIDs; avoid in established CVD; renal risks same as non-selective NSAIDs
- Aspirin interaction: ibuprofen (but not naproxen or diclofenac) can block aspirin's antiplatelet effect if taken within 2 hours — take aspirin at least 2 hours before ibuprofen
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