Pain Management

Question 1

How long does chronic pain last?

Answer 1

More than 12 weeks

Question 2

What is primary chronic pain?

Answer 2

Pain with no clear underlying conditions

Question 3

What is chronic secondary pain

Answer 3

Has underlying conditions eg.osetoarthritis

Question 4

What is a common comorbidity with chronic pain?

Answer 4

Depression, can be treated by non opioid and adjuvant analgesics eg. Antidepressants, anti epileptics,benzos and other muscle relaxants, corticosteroid, lidocaine, rubefacients and topical capsaicin

Question 5

The pain ladder

Answer 5

1) Mild pain - non opioid = paracetamol, aspirin and NSAIDs (+/- adjuvant)
2) Mild to moderate pain weak opioid = (codeine, tramadol or low dose morphine)
3) Moderate to severe pain - strong opioids - morphine,fentanyl,oxycodone and buprenorphine

Question 6

Analgesics

Answer 6

NSAIDs, aspirin and paracetamol - useful in muscoskeletal pain

Opioids useful in visceral (trunk,heart,abdominal and pelvic pain) and moderate to severe pain

Question 7

Sickle cell disease

Answer 7

Paracetamol and NSAIDs, codeine and dihydrocodeine
Severe crisis - morphine or diamorphine may be needed
- avoid pethidine - can cause seizures

Question 8

Please learn doses of paracetamol and ibuprofen doses

Question 9

Dental pain

Answer 9

NSAIDS (ibuprofen,aspirin and diclofenac) paracetamol is used temporarily

Benzydamine mouthwash/spray can be used

Paracetamol,ibuprofen and aspirin are adequate for dental pain

Diazepam - has muscle relaxants and anxiolytic properties (only prescribe short term)

Question 10

Dysmenorrhea

Answer 10

Antiemetics can be used to prevent vomitting
Paracetamol or NSAIDS used to provide relief
Oral contraceptives can be used to prevent pain associated with ovulatory cycles

Question 11

Non opioid analgesics

Answer 11

Aspirin - indicated for headache,pain,dysmenorrhea and pyrexia
Gi- minimised by taking dose after food, enteric coated preps have slow onset of action and therefore unsuitable

Aspirin interacts with other drugs especially warfarin which is a special hazard

Paracetamol, generally safer and more preferred especially for elderly. Overdose can cause hepatic damage
- nefopam can be used for pain not responding to non - opioid analgesics but more side effects

Question 12

Compound analgesic preps

Answer 12

Single ingredient analgesics is preferred to allow for independent titration of each drug

Caffeine is a weak stimulant and enhances analgesic effect

Co proxamol tablets. -no longer licensed because of safety issues

Question 13

Opioid and analgesic dependence

Answer 13

Used to relief moderate to severe pain, particularly visceral origin eg. Heart

Repeated use may cause dependence and tolerance

Caution in impaired respiratory function (avoid in COPD),asthma,hypotension, Mg shock and convulsive disorder

Question 14

NSAIDs

Answer 14

Chronic disease accompanied by pain and inflammation

Short term treatment of mild to moderate pain (muscoskeletal) but paracetamol now preferred especiallly in elderly

Suitable for dysmenorrhea

Pain caused by secondary bone tumours

Selective inhibition of cyclo - oxygenate-2 preferred over NSAIDs FOR PATIENTS WITH HIGH risk of Gi side effects but risk of cardiac side effects

• used as post operative analgesics

Question 15

What are common side effects of opioids

Answer 15

• respiratory depression - treated by artificial ventilation or reversed by naloxone
• dependence and withdrawal - tolerance can develop during long term use
• overdose - causes comas, respiratory depression and pinpoint pupils

N/v

Constipation

Dry mouth

Billary spasm

Larger doses = muscle rigidity,hypotension,respiratory depression

Long term use - hypogonadism and adrenal insufficiency

Drowsiness

Question 16

Important things to remember about opioids

Answer 16

Pregnancy - respiratory depression and withdrawal symptoms reported

Hepatic impairment may precipitate coma

Treatment cessation - avoid abrupt withdrawal after long term treatment

Patient and carer advice = drowsiness (may affect driving or skilled tasks)

Question 17

Strong opioid Morphine

Answer 17

Most valuable opioid analgesics for sever pain (gold standard) despite causing n/v

Confers euphoria and state of detachment in addition to pain relief

Given every 4 hours (every 12 to 24 hrs as modified release preps)

Question 18

Buprenorphine

Answer 18

• has both opioid agonist and antagonist properties
• may precipitate withdrawal symptoms
• abuse potential and may cause dependence
• longer duration of action than morphine
• effective sublingual for 6-8 hours
• compared to other opioids, its effects only partially revered by naloxone

Question 19

Patient and carer advice on using patches

Answer 19

Apply to no dry, non irritated , non hairy skin on upper torso or outer arm

Heat or fever can increase absorption, avoid heat from sauna

Remove after 72/96 or 7 days

Avoid same are for at least 3 weeks (7 days for prenotrix,hapoctasin,bupeaze,buplast and relevtec) 6 days for transtec

Remove it if: breathlessness, difficulty to breathe , drowsiness, confusion and dizziness

Question 20

Conversion of Buprenorphine to fentanyl

Answer 20

Convert first to morphine then to fentanyl
Page 29 of the BNF!!

Question 21

WHICH bp PATCHES ARE APPLIED WEEKLY

Answer 21

Bupramyl
Butec
Butrans
Reletrans
Sevodyne
Panitaz

Question 22

Bp patches 4 days - 96hrs

Answer 22

Bupeaze
Buplast
Relevtec
Transtec

Question 23

Bp 3 days - 72 hrs

Answer 23

Hapoctasin
Prenotrix

Question 24

General tip for buprenorphine

Answer 24

5mcg = 7 days
35mcg =4 days

Question 25

Methadone

Answer 25

Less sedating than morphine Shouldn’t be administered more than twice daily - risk of accumulation and opioid overdose Patients who miss 3 or more days of treatment are at a risk of overdose because of tolerance. Consider reducing dose in these patients Driving counselling

Question 26

Strong opioids

Answer 26

Oxycodone: - similar to morphine - main use - pain in palliative care Pethadine: - prompt but short lasting analgesia - less constipating than morphine Tramadol: - analgesia by opioid effect and enhancement of seratogenic and adrenogenic pathways

Question 27

Neuropathic pain

Answer 27

Damage to neural tissue (phantom limb pain, central pain,compression and neuropathies) Amitriptyline, noritriptyline, pregablin, gabapentin and tramadol can be used Lidocaine plasters can be used Capsaicin - burning sensation can occur during initial treatment and limit use

Question 28

Migraine

Answer 28

Treatment of acute migraine Treatment guided by response to be previous treatment and severity of attacks Aspirin, paracetamol (soluable) effective Offer 5HT1 receptor agonist (triptans) if above meds if adequate Antiemetics - may be required Excess use of migraine medications can cause overuse headaches

Question 29

Migraines - 5ht receptor antagonists

Answer 29

Act on the 5HT(Serotonin) receptors Preferred treatment for those who fail to respond to conventional analgesics Not indicated for the treatment of (hemiplegic,basilar and opthalmolplegic migraines) Examples for migraine: almotriptan,eletriptan,frovatriptan,naratriptan,rizatriptan,sumatriptan and zolmitriptan) If patient doesn’t respond to one, another can be tried - sumatriptan and zolmitripan can be used for cluster headaches

Question 30

Strong opioid

Answer 30

Oxycodone - similar to morphine - main use - pain control in palliative care Pethidine - prompt but short lasting analgesia - less constipation than morphine Tramadol - analgesia by opioid effects and enhancement of seratogenic and andrenergic pathways

Question 31

Analgesics

Answer 31

Most migraines respond to aspirin and paracetamol Soluable preps preferred (improve absorption) Tofenamic acid (licensed specifically for migraine attacks) Other nsaids (diclofenac potassium, flubiprofen and ibuprofen also licensed

Question 32

Migraine - ergot alkaloids

Answer 32

Ergotamine tarate - limited sued due to: Difficulties in absorption Side effects (n/v, abdo pain and muscular cramps) Do not exceed recommended doses Do not repeat treatment at intervals of more than 4 days Do not use more than twice a month (prevents habituation) Should not be prescribed prophylactically (but in management of cluster headache,low douses can be given 1-2 weeks)

Question 33

Migraine antiemetics

Answer 33

- antiemetics such as metoclopramide,domperidone,phenothiazines or antihistamines relieve nausea associated with migraine attacks - give antiemetics IM or rectally if vomitting is the problem - metoclopramide and domperiodone also promote gastric emptying

Question 34

Migraine prophylaxis

Answer 34

Can be brought on by many factors - irregular lifestyle,stress, the pill etc. Preventative treatment only considered for patients that suffer: - two or more attacks a month - suffer increasing frequency of headaches - suffer significant disability despite suitable treatment from migraine attacks - cannot take suitable treatment for migraine attacks

Question 35

Examples of meds used in migraine prophylaxis

Answer 35

1) beta blockers = propranolol - most commonly used,atenolol,metoprolol,nadolol, timiolol - all are effective 2) TCAs 3) Gabapentin 4)Topiraamate 5)Sodium Valporate 6)pizotifen (limited value and ma \y cause weight gain) 7) Botulinum toxin type A (for chronic migraines in adults)

Question 36

Cluster headaches and trigeminal autonomic cephalagias

Answer 36

- rarely respond to standard analgesics - sumatriptan by subcutaneous injection - drug of choice in the treatment of cluster headaches - sumatriptan nasal spray or zplmitripan can be used (unlicensed) if injections are not suitable - alternatively 100% oxygen at the rate of 10-15 ml/min for 10-20 mins are useful in aborting an attack

Question 37

Cluster headache prophylaxis

Answer 37

Consider if: Attacks are more frequent - last more than 3 weeks - can not be treated effectively Medication - verapamil or lithium(unlicensed used) Prednisolone (short term) Ergotamine tartar (short term)