A Patient's Guide to Pain Relief Following Your Operation (18+) - adults only

If you are worried about the painkillers, you have been given or any other medicines you have been asked to take, please contact your GP or community pharmacist.

You can also phone the hospital pharmacy on 020 3947 0037

It is important to recognise that pain is a normal response to surgery, and it will more than likely get better in time. Painkillers will help control the pain but will often not remove it completely. Take each day as it comes as you recover. Knowing this fact, will help you to manage your pain.

Your muscles and joints weaken and stiffen without movement. It is therefore very important to keep mobilising as per your physiotherapist’s instructions to quicken your recovery.

This may be more painful in the short term but will benefit you a lot in the medium/long term

These include:

• Ice

• Compression bandages

• Distraction techniques

• Elevation

• Breathing exercises

You will be given a pack of medicine(s) on discharge that contain some or all of the following pain killers, unless you already have access to them at home, from your chemist or GP, and depending on your pain relief requirements:

• Paracetamol

• Non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen

• Weak opioids such as dihydrocodeine or tramadol

• Strong opioids such as morphine or oxycodone. These painkillers are usually used on a short-term basis. It is thus very likely that you will only be given a limited supply, if at all, when you leave hospital. This can then be reviewed by your GP.

• Gabapentin such as gabapentin or pregabalin

This is the foundation of most pain relief. You can take up to 2 tablets every 4 hours (each tablet contains 500mg) but do not take more than 8 tablets in any 24-hour period. Paracetamol is safe in normal doses. It is important that you do not take more than is prescribed.

It does not have any common side effects. You can buy paracetamol over the counter from your local pharmacy or supermarket. Please make sure that you do not take more than one paracetamol containing product at the same time. Some pain killers like co-codamol also contains paracetamol. If in doubt consult your GP or pharmacy.

These are anti-inflammatory drugs used for moderate pain.

Ibuprofen. You can take 200-400mg up to three times a day.

Naproxen. You can take one 250mg or 500mg tablet every 12 hours.

Anti-inflammatory drugs can sometimes cause stomach irritation. In rare cases this can be more severe with ulcers or stomach bleeding. These tablets should therefore be taken with or after a meal or snack. You may be prescribed a medicine to protect your stomach such as lansoprazole or ranitidine.

Anti-inflammatory drugs can make asthma worse, but most people with asthma are not affected. Please highlight any such worsening you may have experienced in the past to your doctors and pharmacist so the appropriate measures can be taken.

Anti-inflammatory drugs may also need to be avoided in the elderly or those with a history of kidney disease. Your doctor in hospital will decide whether it is appropriate for you to be taking them.

Dihydrocodeine

This is for the relief of moderate to severe pain. You can take one tablet (30mg) every 4 hours.

Dihydrocodeine can make you feel dizzy, light-headed, drowsy and nauseous. Do not drive or operate machinery while taking any of these if you are affected.

Dihydrocodeine may be constipating, so it is advisable to eat a healthy diet including plenty of fruit and vegetables and drink plenty of fluids.

You may also be prescribed laxatives such as docusate, senna or movicol with this medication to help relieve any constipation.

Although known as “weak opioids” these medicines may still lead to dependence and other side-effects seen with stronger opioid medications. Care should be taken with prolonged use.

If you have more severe pain after your operation, you will be prescribed stronger painkillers such as morphine or oxycodone.

There are 3 different types of preparations of each of these medications.

One is a slow-release preparation which is taken every 12 hours. Another is an immediate release preparation which can be taken when required every 2-4 hours for severe or breakthrough pain in between your regular doses of painkillers. The third is patient controlled analgesia (PCA) which is delivered via a pump into your vein that you can activate when in pain. It has safety measures to prevent you from having too much and will only be given for a short period after your surgery, and only for severe pain (please refer to ‘patient-controlled analgesia’ leaflet).

The dose may vary from patient to patient and some patients may require higher or lower doses according to their pain and sensitivity to the opioid medicine. Oxycodone is twice as strong as morphine so doses will be lower.

There is evidence to show that slow-release strong opioids are not very effective in managing acute pain and therefore may not be prescribed for you. Your ward team or acute pain team will decide if this is appropriate for you.

Gabapentinoids can be used to treat post-operative pain or neuropathic pain (pain arising from damage to the nervous system). Gabapentinoids can cause drowsiness and dizziness. The acute pain service will decide if it is appropriate to start this medication.

Tramadol is a controlled drug (CD) used for the relief of moderate to severe pain. You can take one to two capsules (50-100mg) every 4 hours but do not take more than 400mg (or 8 x 50mg capsules) in any 24-hour period.

Tramadol may cause drowsiness. Make sure your reactions are normal before driving, operating machinery or doing any other jobs which could be dangerous if you are not fully alert. Tramadol can also cause hallucinations, especially in the elderly.

The following side effects may occur with opioid medication:

• Increasing the dose without close supervision by your doctor could lead to opioid overdose causing severe sedation, respiratory depression (breathing problems) and possibly death.

• Decreasing or stopping any medication without the close supervision of your doctor can lead to withdrawal. Withdrawal symptoms may include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flushes, abdominal cramps and diarrhea. These symptoms can occur 24 to 48 hours after the last dose and can last up to three weeks.

• You may feel drowsy or confused with a normal dose. Do not drive or operate heavy machinery if this is the case.

• Constipation, nausea, vomiting and drowsiness can occur. Less common side effects are mental slowing, flushing, sweating, itching, urinary difficulties and jerkiness. These side effects may occur at the beginning of treatment or if the dose is increased and often go away within a few days.

• Continued use of strong opioids can lead to tolerance (where the drug becomes less effective leading to the need for higher doses for the same effect) and addiction.

You may be prescribed laxatives (to treat any constipation) and anti-sickness medication to prevent any nausea and vomiting.

Take your painkillers regularly for the first 24-48 hours after your operation. Do not wait for the pain to become severe as mild pain is easier to control. These painkillers will be more effective when taken throughout the day. Assess your pain at least four times per day – for example at breakfast, midday, late afternoon and just before bedtime.

• Step 1 - Ask yourself how bad is your pain? Does your pain increase with movement? Does it wake you up from sleep? Is it mild, moderate or severe?

Assessment of pain:

0 - No pain = “comfortable”
1 - Mild pain = “a bit of a niggle or ache, feels uncomfortable”
2 - Moderate pain = “really quite sore, not sure I want to move about much”
3 - Severe pain = “worst pain I’ve had, stops me coughing and moving completely”

• Step 2 - It is safe to take the 3 types of painkillers, providing you follow the advice given (See below for which combinations of painkillers can be taken together).

• Step 3 - Allow time for the painkillers to work. Keep on assessing your pain regularly, i.e. every four hours and take the painkillers as advised.

The following painkillers can be taken together according to your pain requirements and tolerance of the various painkillers:

Note: Do not take more than one drug from each group of medicine. For example, do not take ibuprofen and naproxen together and do not take codeine and dihydrocodeine together.

Everyone has a different experience of pain; some may have none or very little. If you do not use all your tablets, you should return them to the local chemist for disposal.

Do not put them in your refuse bin or flush them down the toilet.

If you experience a lot of pain, you may need more tablets. You can buy paracetamol, ibuprofen and lower strengths of co-codamol from your pharmacy; however, you will need a prescription from your GP for dihydrocodeine or any of the stronger opioids.

You will need to make an appointment to see your GP who will review your pain and if required give you a new prescription for further pain killers.

If you continue to experience pain or nausea or your pain is unbearable despite taking strong pain killers then please contact your GP, ring 111 or visit your nearest urgent care centre.

24-16 © RNOH

Date of publication: May 2024

Date of next review: May 2026

Author: Pharmacy Department and Acute Pain Service