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PHA333 > Wk 25 - Pain in Practice > Flashcards

Wk 25 - Pain in Practice Flashcards

1
Q

Give examples of observational changes for pain

A
  • Pallor, tremor, tachycardia
  • Grimacing, brow raising
  • Altered gait, pacing
  • Grunting, groaning
  • Altered sleep
  • Confusion, crying
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2
Q

What are the basic principles of prescribing analgesia?

A
  • By mouth
  • By clock
  • By ladder
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3
Q

Outline the WHO analgesic ladder

A
  • Step 1: non-opioid eg. paracetamol
  • Step 2: weak opioid eg. codeine
  • Step 3: Strong opioid: morphine
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4
Q

Give examples of mild to moderate pain analgesic options

A
  • Paracetamol - inhibition of COX enzymes
  • NSAIDs eg. ibuprofen + naproxen - non selective COX inhibitor
  • Coxibs eg. celecoxib + etoricoxib - selective COX2 inhibitors
  • Aspirin - blocks thromboxane production
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5
Q

Give examples of weak opioids to treat mild-to-moderate pain

A
  • Codeine
  • Dihydrocodeine
  • Tramadol (inhibits NA + serotonin)
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6
Q

What is the choice of analgesic for under 16?

A
  • 1st line (>3 months): paracetamol or ibuprofen
  • 2nd line: Paracetamol + ibuprofen
  • 3rd line: specialist advice
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7
Q

What is the choice of analgesics for adults?

A
  • 1st line: Paracetamol 1g QDS or ibuprofen 400mg TDS (max 2.4g)
  • 2nd line: paracetamol + ibuprofen
  • 3rd line: Naproxen 250-500mg BD
  • 4th line: weak opioid eg. codeine 60mg QDS w/ paracetamol + NSAIDs
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8
Q

What are things to consider when giving NSAIDs?

A
  • Consider topical NSAIDs before oral for OA
  • Think about CV, GI + renal issues
  • Use lowest dose for shortest period
  • Co-prescribe PPI
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9
Q

What is the dose for codeine?

A
  • 30-60mg every 4hrs

- Max 240mg in 24hrs

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10
Q

What is the dose for dihydrocodeine?

A
  • 30mg every 4-6hrs

- Max 240mg in 24hrs

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11
Q

What is the dose for tramadol?

A
  • 50-100mg every 4hrs

- Max 400mg in 24 hrs

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12
Q

When should the dose be lowered when giving weak opioids?

A
  • Elder
  • CKD
  • Hypothyroidism
  • Adrenocortical insufficiency
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13
Q

What are the adverse effects of weak opioids?

A
  • CNS depression (sedation)
  • GI: nausea, vom + constipation
  • Dependence: limit 3 days, caution w/ suspected dependence + w/drawal symptoms
  • Tramadol: seizures, hallucinations, hyponatremia, hypoglycaemia
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14
Q

Give examples of drug interactions of weak opioids

A
  • Caution w/ CNS depressants + alcohol
  • MAOI - avoid during use + 2 weeks after stopping
  • Tramadol: drugs that lower seizure threshold (TCA + carbamazepine), warfarin (raised INR) + SSRIs (inc seizure risk)
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15
Q

Give examples of strong opioids

A
  • Morphine oral: IR + MR
  • Morphine parenteral
  • Diamorphine parenteral
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16
Q

Give examples of immediate release oral morphine

A
  • Oramorph morphine sulphate oral solution (10mg/5ml)
  • Oramorph conc morphine sulphate oral solution (20mg/ml)
  • Sevredol tabs (10/20/50mg)
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17
Q

Give examples of 12hr MR oral morphine

A
  • MST continus tabs

- Zomorph caps

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18
Q

Give an example of a 24hr MR oral morphine

A

MXL capsules

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19
Q

Outline the initiation for chronic pain

A
  • 5-10mg every 4hrs of IR morphine

- Adjust: 1/3 to 1/2 of total daily dose every 24hrs

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20
Q

How do you convert to MR preparation?

A
  • Calculate total daily dose
  • Same total daily dose as MR product
  • Calculate breakthrough
  • Start 10-20mg BD + titrate whilst continuing IR when required
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21
Q

How do you calculate breakthrough dose?

A

1/6th - 1/10th of total daily dose

22
Q

Outline the parenteral administration of opioids

A
  • Patient unable to swallow
  • DI dysfunction
  • Morphine IM/SC every 4hrs
23
Q

What happens if you convert morphine IR to SC/IM?

A

Give 50% of dose same feq.

24
Q

What happens if you convert morphine MR to SC/IM?

A

Give 50% of total daily dose - divide + administer every 4hrs

25
Q

What are the adverse effects of opioid analgesia?

A
  • Euphoria
  • Drowsiness
  • Nausea + vom
  • Constipation
  • Tolerance
  • Addiction
  • Respiratory depression
26
Q

Oxycodone

A
  • Semi-synthetic analogue of morphine
  • Partly metabolised to oxymorphone
  • Caution in hepatic impairment
  • Renal impairment: Clearance of drug + metabolites red
  • 2nd line, difficult pain, mild renal impairment
27
Q

Fentanyl patch

A
  • Semi-synthetic analogue of morphine
  • Norfentanyl (inactive) metabolite
  • Safe for renal impairment
  • 2nd line, stable pain, concordance, constipation, renal impairment
28
Q

Outline how to apply fentanyl patches

A
  • Apply to non-hairy, non-irritated skin of torso or upper arm
  • Skin cleaned w/ water only + skin dry
  • Patch cut or damaged should not be used
  • Applied for 72hrs + new patch applied to diff. skin
  • Same brand
29
Q

What are things to remember when giving fentanyl patches?

A
  • Evaluation of analgesic effect shouldn’t be made before system has been worn for 24hrs
  • Previous analgesic therapy phased out gradually
  • Close monitoring
  • Dose adjusted 48-72 hrs intervals in steps of 12-25mcg/hr
30
Q

How is the breakthrough dose usually given when using fentanyl patches?

A

Morphine sol or oxycodone sol

31
Q

Alfentanil

A
  • Synthetic derivative of fentanyl (more rapid onset + shorter duration of action)
  • 1/4 potency of fentanyl
  • 10x more potent than SC diamorphine
  • Injection
  • 2nd line, renal failure
32
Q

Buprenorphine patch

A
  • Semi-synthetic analogue of morphine
  • Metabolites: norbuprenorphine
  • Potency: transect (low dose strong opioid) + buTrans (weak opioid)
  • Duration: transect 4 days + butrans 7 days
  • 2nd line, stable pain, concordance + low dose
33
Q

Hydromorphone

A
  • Semi-synthetic analogue of morphine
  • Metabolites: H3G
  • Renal impairment: clearance unchanged but metabolite accumulate
  • 2nd line, mild-mod renal impairment
34
Q

What should you remember when increasing opioid dose?

A

Not >50% higher than previous dose

35
Q

What is neuropathic pain?

A

Characterised by aetiologies affecting NS

Nerve lesion related to:

  • CNS (traumatic spinal cord injury, central post stroke pain)
  • PNS (diabetic polyneuropathy, carpal tunnel syndrome + HIV sensory neuropathy)
36
Q

How does neuropathic pain present as?

A
  • Burning constant pain w/ stabbing paroxysmal attacks

- Hypersensitivity on clinical examination

37
Q

How does neuropathic pain respond to opioids + anti-inflammatory?

A

Poorly responsive

38
Q

What is the neuropathic pain oral analgesic ladder?

A
  • 1st line: tricyclic antidepressants or anti epileptics (1 drug)
  • 2nd line: tricyclic antidepressants + antiepileptics (combination)
  • 3rd line: strong opioids + invasive procedure
39
Q

Amitriptyline

A
  • Analgesic
  • 3-7 days til effect
  • S/e: antimuscarinic
  • Dose: 10mg nocte, upto 75mg nocte
  • Alts: imipramine + nortriptyline
40
Q

What is the mechanism of action of gabapentin + pregablin?

A
  • Chemical analogue of GABA
  • Binds to CNS, interact w/ alpha 2 delta calcium channels in CNS
  • Anticonvulsants for neuropathic pain
  • Caution in renal impairment
  • S/e: drowsy/dizzy
41
Q

Gabapentin pharmacokinetics

A

Requires slow individual titration (100mg nocte, max 3.6g daily)

42
Q

Pregabalin pharmacokinetics

A
  • Linear pharmacokinetic profile
  • 90% bioavailability
  • Onset of pain-relief = quicker
43
Q

Duloxetine

A
  • Selective inhibitor of serotonin + NA
  • Central pain inhibitory actions
  • Act in synergistic manner to red transmission of pain signals from periphery to CNS
  • For diabetic neuropathy: 60mg daily upto 120mg
  • S/e: nausea, dry mouth, insomnia, constipation
44
Q

What is the NICE recommendations on initial pharmacotherapy for neuropathic pain?

A
  • Offer: amitriptyline, duloxetine, gabapentin or pregabalin
  • Tramadol for acute rescue
  • Capsaicin cream if oral agent unsuitable
45
Q

What is used for trigeminal neuralgia?

A

Carbamazepine

46
Q

What are the other options for neuropathic pain?

A
  • Ketamine

- Methadone

47
Q

Ketamine

A
  • Most potent NMDA receptor channel blocker
  • Indication: dissociative anaesthetic
  • S.e: HT, tachycardia, hallucinations, urological complications
  • Red dose if opioid co-prescribed
48
Q

Methadone

A
  • Mu + delta agonist
  • NMDA receptor channel blocker
  • Accumulates in tissue
  • Safe in renal + hepatic impairment
  • Stop other opioids
49
Q

Give examples of other adjuvant therapies

A
  • Corticosteroids: inflammatory conditions, cancer pain
  • Bone pain: bisphosphonates, calcitonin, radiopharmaceuticals
  • Musculoskeletal: muscle relaxants + benzodiazepines
  • Bowel obstructions: octreotide + hyoscine
50
Q

Give examples of non-drug pain relief

A
  • Apply heat + cold
  • Massage
  • TENS
  • Radiotherapy
  • Acupuncture
  • Psychological therapies

PHA333 (35 decks)

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