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Prescribing > Analgesia > Flashcards

Analgesia Flashcards

1
Q

Which type of fibres transmit dull, poorly localised pain?

A

C fibres

they are unmyelinated

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2
Q

Which type of fibres transmit sharp, well localised pain?

A

A-delta fibres

they are myelinated

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3
Q

What is chronic pain?

A

Pain that has persisted for over 3 months

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4
Q

Give some ways to assess pain?

A
  • History and examination (rating the pain out of 10)
  • Visual analogue scale (mark on a line from no pain to pain as severe as it could possibly be)
  • McGill pain questionnaire (assesses sensory, affective and evaluative aspects of pain)
  • Wrong-baker faces pain rating scale (shows 6-8 facial expressions showing a range of emotions)
  • Modifiable behavioural pain scale or CRIES scale (objectively assess facial expressions, crying and body movements in children under 3)
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5
Q

Give some examples of Non-pharmacological analgesia

A
  • Sweet solutions/ breast milk can be given to infants under 12 months
  • TENS machines in adults for chronic pain
  • Reassurance, reduces anxiety which reduces pain
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6
Q

Describe the WHO Pain ladder

A
  1. Paracetamol
  2. Weak opioid (codeine, dihydrocodeine, tramadol, buprenorphine)
  3. Strong opioid (morphine, diamorphine, oxycodone, hydromorphone, fentanyl)

Each step is +/- adjuvant

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7
Q

Give the dose of Paracetamol and routes it can be given

A

Dose in adults is 1g QDS (max 4g/24hrs)

if the adult is less than 50kg it is best to use the 500mg dose

can be given PO or IV - IV has a higher analgesic effect

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8
Q

What is the next step if paracetamol is ineffective?

A

Usually Co-codamol 30/500mg PO
Dose in adults is 30-60mg QDS (max 240mg/24hr)

Tramadol is an alternative to codeine
Dose in adults 50-100mg QDS (max 400mg/ 24hr)

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9
Q

How much codeine/ dihydrocodeine/ tramadol is equivalent to 10mg oral morphine?

A

100mg

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10
Q

What is the max dose for strong opioids?

A

There is none, only side effects prevent escalation in dose

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11
Q

Give some examples of NSAIDs (including doses)

A

Ibuprofen 400mg QDS (max 2.4g/24hr)
Naproxen 250mg TDS (max 1.5g/ 24hr)
Diclofenac 25-50mg TDS (max 150mg/24hr)

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12
Q

Give some examples of adjuvant analgesics

A
  • NSAIDs, bisphosphonates and steroids for bone pain
  • Anti-depressants (amitriptyline) and anti-convulsants (gabapentin, pregabalin, valproate, carbamazepine) for neuropathic pain
  • Steroids and NSAIDs for enlarging tumours (including raised ICP)
  • Smooth muscle relaxants (hyoscine, glycopyrronium) for colic
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13
Q

How would you manage acute pain?

A

Pre-hospital can include Entonox (self administered using a demand valve to prevent overuse. it may take about 4 minutes to take effect)

Morphine 5mg IV every 4 hours at a rate of 1-2mg/ minute, stopping when there is a response
in elderly consider lower doses

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14
Q

How would you start a patient on morphine for chronic pain?

A

Start on 5-10mg immediate release morphine (e.g. oromorph liquid, sevredol tablets) 4 hourly (6 times daily)

Review this daily and increase 30-50% daily until pain is controlled

When pain is controlled switch the patient to 12 hourly modified release morphine (e.g. Zomorph capsules and MST). This should be half the dose of the total dose of immediate release morphine used in 24 hours.

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15
Q

What do you give for breakthrough pain?

A

1/6th of total daily morphine as immediate release morphine (either oral or transmucosal)

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16
Q

What alternatives can be used to morphine if it isn’t tolerated? (include dose conversions)

A
  • Subcut diamorphine (3mg oral = 1mg SC)
  • Oxycodone (10mg oral = 5mg oxycodone)
  • Hydromorphine (10mg oral = 1.3mg hydromorphine)
17
Q

How much morphine is a 25microgram fentanyl patch equivalent to?

A

60mg morphine over 24 hours

18
Q

How much codeine is a 24mg butrans patch equivalent to?

A

240mg codeine over 24 hours

19
Q

Give the side effects of opioids

A
  • Constipation
  • Nausea and vomiting
  • Sedation and confusion
  • Dry mouth
  • visual hallucinations, mood changes, euphoria and dysphoria
  • Itching
20
Q

What are the signs of opioid toxicity?

A
  • Intractable nausea
  • Hallucinations
  • Drowsiness
  • Myoclonic jerks
  • Pinpoint pupils
  • Respiratory depression
21
Q

What are the contra-indications to using opioids?

A
  • Acute respiratory depression
  • Comatose patients
  • Raised ICP (as if they have this it prevents accurate assessment of pupils)
22
Q

What medication(s) should you prescribe alongside morphine and in what circumstances?

A

An anti-emetic in opiate naive patients (you develop tolerance of the ematogenic effects after a week on morphine)

Cyclizine 50mg TDS PRN is best

Always prescribe a laxative alongside opioid analgesics and continue it for the duration of treatment

23
Q

Describe somatic pain

A

Somatic pain is aching and often constant and it may be dull or sharp. Often it is worse on movement.

24
Q

In cancer, what usually causes somatic pain?

A

Bone mets

25
Q

How is somatic pain best treated?

A

Often treated with NSAIDs

but opioids can help too

26
Q

Describe visceral pain

A

Visceral pain is either constant or cramping. It is poorly localised and can be referred to other areas of the body

27
Q

In cancer, what usually causes visceral pain?

A

Infiltration of abdominal organs causing liver stretch, bowel obstruction etc.

28
Q

How is visceral pain best treated?

A

Often responds well to steroids, however colic will often need adjuvant smooth muscle relaxants (e.g. hyoscine butyl bromide)

29
Q

What is given to reduce tumour oedema?

A

Dexamethasone 4-8mg

30
Q

What kind of things cause steady dysaesthetic neuropathic pain (causing burning, tingling, constant, aching, itching sensations)?

A

Diabetic neuropathy

Post-herpetic neuropathy

31
Q

What kind of things cause paroxysmal neuralgic neuropathic pain (causing stabbing, shock-like, electric, shooting sensations)?

A

Trigeminal neuralgia

Nerve root compression

32
Q

How is neuropathic pain best treated?

A

Adjuvants such as TCAs, gabapentin, steroids, ketamine, methadone and nerve blocks in extreme cases.

Neuropathic pain is partially responsive to opioids and NSAIDs

33
Q

What is the WHO guidance for analgesia in children?

A

A two step approach:

  1. Mild pain
    - Children under 3 months paracetamol
    - Children over 3 months paracetamol and ibuprofen
  2. Moderate to severe pain
    - Opioids (morphine 1st line)
34
Q

What routes are preferred for giving morphine in children?

A

Oral or intranasal

35
Q

Which anti-emetic should be given with morphine in children?

A

Ondansetron

36
Q

If the child’s weight is unknown how do we estimate it in order to calculate drug doses?

A

Luscombe formula:
(for children 1-10)

Weight (kg) = (3x age in years) +7

Prescribing (4 decks)

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