Pain Flashcards by Molly Moss

What pain is nociceptive pain?

MSK - NSAIDs
Dental pain - NSAIDs
Moderate to severe visceral pain - opioids
Period pain - oral contraceptives, antispasmodics, non-opioids

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What is used for neuropathic pain?

TCAs - amitriptyline, nortriptyline

Antiepileptics - gabapentin, pregabalin

Nerve compression by tumour - dexamethasone

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What is the pain ladder?

Non-opioids - +/- adjuvant

Weak opioids - +/- non-opioid or adjuvant

Strong opioids - +/- non-opioid or adjuvant

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What are the adjuvants used with the pain ladder?

Neuropathic pain - amitriptyline, nortriptyline, gabapentin, pregabalin

Bone metastases - bisphosphonates, strontium ranelate

Nerve compression by tumour - dexamethasone

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What is paracetamol used for?

Mild-moderate pain and fever

Preferred in elderly

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What is the adult dose of paracetamol?

0.5-1g every 4-6 hours as required. Max. 4g/day

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What is the cautionary labels of paracetamol?

Do not take more than 2 at any one time. Do not take more than 8 in 24 hours

Contains paracetamol. Do not take anything else containing paracetamol while taking this medicine. Talk to a doctor at once if you take too much of this medicine, even if you feel well

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What does paracetamol overdose cause?

Liver damage

Greater risk if < 50kg

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What is used to treat paracetamol poisoning?

Acetylcysteine

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What are the overdose symptoms of paracetamol?

Nausea, vomiting, right subcostal pain/tenderness

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What is aspirin used for?

Antiplatelet

Fever and pain

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What is the dose of aspirin for ACS, TIA?

300mg dispersible tablets

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What is the dose for secondary prevention of thrombotic arterial events?

75mg OD for life

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What is the dose of aspirin for fever and pain?

300-900mg every 4-6 hours as required

Maximum 4g per day

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What is the cautionary label for aspirin?

Take with or just after food or a meal

Contains aspirin. Do not take anything else containing aspirin while taking this medicine

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What are the side effects of aspirin?

GI irritation

Tinnitus in high doses

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What are the contraindications of aspirin?

< 16 years as causes Reye’s syndrome
Unless Kawasaki or as an antiplatelet

Salicylate or NSAID hypersensitivity

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What are the interactions of aspirin?

Increased risk of bleeding - antiplatelet or anticoagulants e.g. warfarin

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How do the opioids work?

Acts in various opioid receptors located in the brain, spinal cord and other nervous tissue to relieve pain

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What are the weak opioids?

Codeine - CD5, injections = CD2

Dihydrocodeine - CD5

Meptazinol - POM

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What are the moderate opioids?

Tramadol - CD3, exempt from safe custody

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What are the strong opioids?

Morphine - CD2, oral solution 13/5 or less CD5
Oxycodone - CD2
Diamorphine - CD2
Buprenorphine - CD3
Fentanyl - CD2
Methadone - CD2
Hydromorphone - CD2

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What are the other opioids and their uses?

Alfentanil - CD2 intraoperative analgesia
Remifentanil - CD2 intraoperative
Pethidine- CD2 labour
Dipipanone - CD2 
Papaveretum - CD2
Pentacozine - CD3
Sufentanil - CD2
Tapentadol - CD2 less nausea and vomiting

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What is the rescue dose for breakthrough pain?

1/10 - 1/6 total daily dose every 2-4 hours as required

Immediate release preparations

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What is used for an opioid overdose?

Naloxone

What are the symptoms of opioid overdose?

Coma Pinpoint pupils Respiratory depression

How does naloxone work?

Opioid receptor antagonist Reverses respiratory depression Can be supplied without prescription

What are the side effects of opioids?

``` Dry mouth Nausea and vomiting Constipation Sedation Reduced concentration and confusion Euphoria and hallucinations Dependence and tolerance Respiratory depression Hypogonadism Adrenal insufficiency Hyperalgesia ```

What is the mnemonic of opioid side effects?

MORPHINE ``` Miosis Out of it Respiratory depression Postural hypotension Hyperalgesia Infrequency Nausea and vomiting Euphoria ```

What are the contraindications of opioids?

Comatose patients Risk of paralytic ileus Respiratory depression Head injury or raised intracranial pressure

What are the interactions of opioids that cause increased sedation?

``` Antidepressants Antihistamines Alcohol Z-drugs Antipsychotics Antiepileptics Benzodiazepines ```

What opioid interaction can cause CNS excitation or depression?

MAOIs

What are the cautionary labels for opioids?

This medicine may make you sleepy If this happens do not drive or use tools or machines Do not drink alcohol

What is oral morphine used for?

Severe pain in palliative care and coughs

What are the main side effects of morphine?

Causes most euphoria, nausea, vomiting

What is the dose of oral morphine?

Every 4 hours for immediate release 12-24 hourly MR

What is the maximum dose increments for oral morphine?

1/3 or 1/2 of total daily dose per 24 hours

What is the equivalent parenteral dose of oral morphine?

Half the oral dose

What is the schedule of morphine?

CD5 for solutions but if over 13mg/5ml then CD2

What is a morphine alternative?

Oxycodone

Why is diamorphine preferred when administering parenterally?

More soluble and smaller volumes can be injected in emaciated patients in palliative care

What is the diamorphine equivalent dose compared to oral morphine?

1/3 oral morphine

Does diamorphine have more or less nausea and hypotension than morphine?

Less

100 mg codeine PO is equivalent to how much morphine PO?

10mg PO morphine

3mg diamorphine IM is equivalent to what dose of tramadol PO?

100mg tramadol

100mg dihydrocodeine PO is equivalent to how much tramadol PO?

100mg tramadol

How much oxycodone PO is equivalent to 5mg morphine IM?

6.6 mg

How much hydromorphone PO is equivalent to morphine IM 5mg?

2mg hydromorphone

What is buprenorphine?

Partial agonist - precipitates withdrawal symptoms Effects are only partially reversed by naloxone Sublingual for opioid dependence

What is the risk with fentanyl patches?

Risk of fatal respiratory depression in opioid naive patients

What are the counselling points for fentanyl patches?

Immediately remove patch in case of breathing difficulties, marked drowsiness, confusion, dizziness, impaired speech. Seek prompt medical attention

What do you reduce the new opioid dose by due to hyperalgesia in fentanyl use?

1/4 to 1/2

Are fentanyl patches suitable or unsuitable in acute pain or rapidly changing pain?

Unsuitable It is given when dose and pain level is stable

What do you need to avoid when using fentanyl patches?

Exposure to external heat as increases absorption Avoid hot baths/sauna. Monitor if fever present

How do you apply transdermal opioid patches?

Apply to dry, non-irritated and non-hairy skin on upper torso or upper arm Rotate patch site after each use

What is the equivalent dose of morphine salt to a fentanyl 100 patch?

240mg

What is the equivalent dose of morphine salt to a fentanyl 75 patch?

180mg

What is the equivalent dose of morphine salt to a fentanyl 50 patch?

120mg

What is the equivalent dose of morphine salt to a fentanyl 25 patch?

60mg

What is the equivalent dose of morphine salt to a fentanyl 12 patch?

30mg

What is the equivalent dose of morphine salt to a buprenorphine 5 patch?

12mg

What is the equivalent dose of morphine salt to a buprenorphine 10 patch?

24mg

What is the equivalent dose of morphine salt to a buprenorphine 15 patch?

36mg

What is the equivalent dose of morphine salt to a buprenorphine 20 patch?

48mg

What is the equivalent dose of morphine salt to a buprenorphine 35 patch?

84mg

What is the equivalent dose of morphine salt to a buprenorphine 52.5 patch?

126mg

What is the equivalent dose of morphine salt to a buprenorphine 70 patch?

168mg

What is codeine used for?

Mild to moderate pain 30-60mg every 4 hours Codeine linctus in dry or painful cough Acute diarrhoea

What is the MHRA advice for codeine?

Restricted use in children due to reports of morphine toxicity For acute moderate pain in children above 12 years only if it cannot be relieved by other pain,illness such as paracetamol or ibuprofen alone Children aged 12-18 years max 240mg daily for 3 days up to 4 times a day with no less than 6 hour intervals Not recommended in children with compromised breathing

What are the contraindications of codeine?

Ultra rapid metabolisers Children under 18 who undergo removal of tonsils or adenoids for treatment of obstructive sleep apnoea

Can you give codeine in breastfeeding mothers?

Do not give codeine to breastfeeding mothers, passes to baby through breast milk

What are the counselling points for codeine?

Recognise signs and symptoms of morphine toxicity Stop and seek medical attention if reduced consciousness, lack of appetite, somnolence, respiratory depression, constipation, pinpoint pupils, nausea and vomiting

What is the MHRA advice for codeine in coughs and colds?

Restricted use in children Not recommended in 12-18 years with breathing problems

What are the contraindications of codeine?

Children under 12 Ultra rapid codeine metabolisers Breast feeding mothers

What is the route if administration of codeine and dihydrocodeine?

Never IV as severe reaction similar to anaphylaxis

What is the MHRA advice for dihydrocodeine?

Prescribe and dispense co-dydramol by strength to minimise risk of medication error and risk of accidental overdose

How does tramadol work?

Moderate opioid NA and 5HT reuptake inhibitor

What are the side effects of tramadol?

Increased risk of bleeding Lowers seizure threshold Psychiatric reactions

What are the interactions with tramadol that lowers seizure threshold?

SSRIs TCA Antiepileptics

What are the tramadol interactions that increase the serotonergic effect and therefore the risk of serotonin syndrome?

SSRIs TCAs 5-HT1 agonists MAOIs

What are the tramadol interactions that increase the risk of bleeding?

Warfarin

What is a migraine?

Moderate/severe headache felt as a throbbing pain on one side of the head

What are the symptoms of migraine?

Intense throbbing headache on one side of the head Nausea and vomiting Sensitivity to light or sound

What is an aura?

Temporary warning symptoms before a migraine Visual disturbances Numbness or pins and needles Dizzy, off balance Difficulty speaking

What is used to treat migraine?

5HT1 receptor agonists (triptans) Sumatriptan Zolmitriptan Ergot alkaloids - ergotamine do not repeat in less than 4 days, limited to use twice a month to avoid habituation NSAID - tolfenamic acid

What is used for prophylaxis of migraine?

Propranolol Anti epileptics - topiramate, valproate, gabapentin TCAs Pizotifen

What is used for acute migraine attacks first line?

Simple analgesic (dispersible)

What is used for acute migraine attacks second line?

5HT1 agonist (sumatriptan) can combine with NSAID Ergotamine rarely used

What antiemetics are used for acute migraine attacks?

Metoclopramide Domperidone Buclizine Prochlorperazine

When is migraine prophylaxis used?

At least 2 attacks a month Increasing frequency of headaches Significant disability despite treatment for migraine attacks Can’t take suitable treatment for migraine attacks

What is the mechanism of action of the triptans?

Act on 5HT1D and 5HT1B present on cranial arteries and veins to cause vasoconstriction

What are triptans used for?

Treatment of acute migraine

What is the dose of triptans?

One dose ASAP after onset, second dose at least 2 hours later if migraine recurs Do not take second dose for same attack

What are the side effects of triptans?

Coronary vasoconstriction or anaphylaxis

What are the contraindications of the triptans?

Ischaemic heart disease MI TIA Not for hemiplegic, basilar or opthalmoplegic migraines

What are the counselling points for triptans?

Stop if intense tingling, heat, heaviness, pressure or tightness in any part of the body

What is used for neuropathic pain?

TCA - amitriptyline Gabapentin Pregabalin Morphine and oxycodone by specialist Tramadol Corticosteroids - compression neuropathy Trigeminal neuralgia - carbamazepine or phenytoin

Pain Flashcards

(97 cards)