Analgesia

Question 1

What are the steps in the WHO pain ladder for prescribing pain relief?

Answer 1

1) Non opiates e.g. paracetamol and NSAIDs plus adjuvants
2) Weak opiates e.g. codeine and tramadol plus non-opiates and adjuvants
3) Strong opiates e.g. morphine and fentanyl plus non opiates and adjuvants

Should increase up the pain ladder if previous step is not working

Question 2

What are the different types of adjuvants?

Answer 2

Medications that primary purposes are not for analgesia

Gabapentin
Pregabalin
Amitriptyline 
Duloxetine
Anti- spasmodics 

Only give them if needed

Question 3

What are the indications for paracetamol and the cautions?

Answer 3

Indicated in mild to moderate pain and fever
Give 0.5-1g every 4-6hrs with maximum 4g in 24 hrs
With IV give the same dose over 15mins
Caution in the elderly, breastfeeding and CKD

Question 4

What is the dosing for NSAIDs?

Answer 4

300-400mg with maximum 1.2g in a day (can go up to 2.4g in certain situations)
Should c-prescribe PPI in vulnerable patients or if long term use

Question 5

What are the side effects of NSAIDs?

Answer 5

Dysphagia
Gastric ulcer
Decreased platelet production
Renal Impairment
Bronchospasm

Question 6

When are NSAIDs contraindicated?

Answer 6

Absolute contraindication in severe heart failure or previous GI bleed or ulcer

Caution in asthma and elderly

Question 7

What are side effects of opioids?

Answer 7

Resp depression
N&V
Constipation
Sedation
Decrease in cough reflex

Question 8

When are opioids absolutely contraindicated?

Answer 8

Acute resp depression
Acute alcoholism
Patients at risk of paralytic ileus
Raised ICP

Question 9

What is the dosing of opioids?

Answer 9

Initially start on 5mg IV morphine and increase as appropriate
If frail then start on 2mg
Should give 1/6 of total daily dose as breakthrough dose that can be given every 2-4 hours (put on prn part of prescription chart)

Should give metroclopramide and senna/lactulose if long term use

Question 10

How is opioid overdose managed?

Answer 10

In hospital setting

• 400mcg IV naloxone
• if no response after 1min then give another 800mcg
• if no response after another 1min then give another 800mcg
• no response- get help and rethink diagnosis

In community

• 1.8g intra nasal naloxone
• can repeat dose 2-3 mins later

Question 11

What is PCA?

Answer 11

Patient controlled analgesia
Allows patient to self administer breakthrough pain via a pump
Often used post operatively or in oncology

Question 12

What are examples of non drug analgesia?

Answer 12

Splints
Cold therapy
Acupuncture
CBT