An opioid may be considered starting with codeine related drugs and allowing for the inevitable constipation. In more severe cases the judicious use of morphine, in particular for severe night pain, can be helpful, with care not to use doses that cause confusion. Usually 2.5mgm to 10mgm will be enough. Morphine for ischaemic pain One of the great challenges in the control of severe pain seen in nursing homes is the pain associated with ischaemia. Morphine is of some but limited use for severe ischaemic pain.
Peripheral vasodilators are also of some use.
An old drug well known to anaesthetists is ketamine. Ketamine activates the limbic system and depresses the cerebral cortex producing profound analgesia, slight respiratory depression, cardiovascular stimulation and amnesia. The protective reflexes are maintained. When simple touch leads to intense and prolonged pain resistant to other analgesics, ketamine may be considered. Use of ketamine will be discussed in a later article.