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Oncology: Pharmacology, Anaesthetics, Analgesia > Analgesia > Flashcards

Analgesia Flashcards

1
Q

Pain definition

A

An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage or both

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2
Q

Inadequate pain relief

A

Global concern for pts and practitioners

Pain not always cured and requires continuous medical management, the same as any other disease process

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3
Q

How many people in the UK suffer from persistent pain?

A

About 40%

Around 28 million people

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4
Q

Pain pathway - why we feel pain (injury)

A

Normal –> protective
–> acute –> reflexes
–>prolonged –> inflammation and repair
(acute can –> prolonged)

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5
Q

Congenital insensitivity to pain

A

SCN9A gene mutation in humans

-Nav1.7 voltage-gated sodium channel mutations in a-subunit cause loss of function

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6
Q

Sources of pain

A

Injury

Disease

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7
Q

Fracture types

A

Oblique: diagonal break across bone
Comminuted: break in three or more pieces and fragments are present at same fracture site
Spiral: break spirals around bone (common in twisting injury)
Compound: broken bone pierces skin, causing risk of infection

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8
Q

Sensory pathways

A

Transduction: conversion of a sensory stimulus from one form to another e.g. nerve endings in skin?
Transmission: thalamus, spinal cord, sensory fibres (touch, pain)
Somatosensory cortex: perception
Limbic (amygdala): perception/ learning

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9
Q

Pain modulation

A

Emotion and attention profoundly modulate nociception
Amount of pain experienced does not necessarily relate to severity of tissue damage
Anxiety > pain transmission
Complex cultural and contextual influences

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10
Q

Chronic

A

Abnormal –> non-protective –> chronic (pain as disease)

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11
Q

Therapeutic goal for chronic and prolonged pain

A

Return sensitivity to normal thresholds without loss of protective function

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12
Q

NSAIDS and opioids problematic

A

??

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13
Q

Dental pain

A

Infection - acute inflammation
Exposed nerve endings: neurogenic pain
Swelling in confined space: pressure effects
Fear and anxiety

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14
Q

Treatment of pain

A 
< tissue damage
-NSAIDS (non steroidal anti inflammatory drugs)
-steroids
-cooling
Nerve block: LA
Spinal cord: opioids
CNS: opioids, psychological factors
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15
Q

WHO cancer pain relief steps

A 
Believe the pt
History of symptoms
Assessment of severity
Physical examination
Appropriate pain management
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16
Q

WHO analgesic ladder

A

Step 1: mild to moderate pain
-non-opioids e.g. paracetamol +/- NSAID
Moderate
-weak opioids e.g. tramadol, dihydrocodeine +/- non-opioids e.g. paracetamol +/- NSAID
Step 3: severe pain
-strong opioids e.g. morphine, diamorphine, fentanyl patch +/- non-opioids e.g. paracetamol and/ or NSAID
Co-analgesics: other drugs, nerve blocks, surgery, radiotherapy, complementary therapies, addressing psychosocial issues

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17
Q

Analgesic ladder assumptions

A

Synergism
Overall philosophy assessing severity, starting at lowest level and increasing if necessary
Joint Royal Colleges Report (1988) quality of analgesia in hospital practice is inadequate

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18
Q

Placebo effect

A

Placebo is anything administered which is pharmacologically and physiologically inert
Not ineffective therapeutically
-can have measurable effect
Reassurance and confidence in one’s therapy may also have an effect

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19
Q

WHO analgesic ladder: paracetamol

  • mechanism
  • effect
  • route
  • dose
A

Mechanism of action unknown - inhibitor of the synthesis of prostaglandins
Analgesic, antipyretic, not much anti-inflammatory effect
Oral, soluble potions, IV, rectal
1g 4-6 hourly adult dose
-4g in 24hr

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20
Q

Paracetamol: adverse effects

A

Uncommon
Hepatotoxicity if overdose
-early treatment with N-acetyl-cysteine
-not absolutely contraindicated in liver disease

21
Q

WHO analgesic ladder: NSAIDs

  • examples
  • mechanism
  • effect
A

Aspirin, ibuprofen, naproxen, indomethacin
Irreversible inhibitor of cyclo oxygenase (COX1 and/ or COX2) enzyme
COX generates inflammatory mediators: prostaglandins and thromboxanes
COX widely distributed, different isotypes
COX inhibitors effective at < acute inflammation

22
Q

NSAIDs adverse effects

A

Due to extension of therapeutic effects
GI tract:
-occult GI blood loss from minor breaches in mucosa (loss of PGE)
-peptic ulceration
-general GI upset, indigestion
Renal function: < in intrarenal blood flow can cause renal failure
Platelets: COX inhibition, bleeding tendency
CV: as result of altered renal function, fluid retention ca precipitate heart failure
Respiratory: some ‘aspirin sensitive’ asthmatics

23
Q

COX2 inhibitiors

A

Newer
Parecoxib celecoxib
< bleeding as GI tract and platelets have mainly COX1
Not less nephrotoxic

24
Q

COX2 and CV disease

A

Absence of antiplatelet effects
Slightly pro thrombotic
> risk of MI and stroke
Contraindicated in CV disease

25
NSAIDs and elective surgery
Need to stop at least 5 days before elective surgery Bleeding at operation: platelet transfusion Consider platelets if emergency surgery
26
Weak opioids: moderate to severe pain - type - mechanism - effect
``` Codeine or di-hydrocodeine Both metabolised to morphine -metabolism varies -some people have minimal enzyme and hence less effective Weak opioid effects ```
27
Weak opioids: moderate to severe pain | -adverse effects
``` CV: < sympathetic outflow, > vagal tone -bradycardia -hypotension -excitation Respiratory: inhibit cough reflex, respiratory depression GI tract: < gastric motility -constipation -nausea -vomiting ```
28
CNS opioid effects
Sedation, euphoria,(dysphoria), excitation
29
Analgesia in SC and brainstem
Spinal cord: < pain fibre transmission, kappa opioid receptors Brainstem: < pain projection to higher centres, Mu opioid receptors
30
CNS opioid adverse effects
Respiratory drepression, < brainstem responseto hypoxia and hypercarbia
31
Reversal of opioid effects
Naloxone 400mg IV - dramatic reversal of Mu receptor opioid effects - far less effective on newer synthetic opioid-like substances as their effects in CNS are less well defined
32
Opioid dependency
Chronic opioid use: < effect as CNS becomes more tolerant | -dose increase
33
Opioid withdrawal
``` Acute withdrawal --> -hypertension -tachycardia -tachypnoea -diarrhoea -sweating -anxiety -hallucinations Any chronic opioid medication will precipitate some withdrawal reaction if stopped suddenly ```
34
Newer oral opioids - types - effectiveness - effects
Tramadol and Nefopam As effective as codeine, much less constipation hence very frequently prescribed 'Oramorph' - lower dose oral morphine Usual opioid effects: sedation, dizziness, nausea Occasional flushing/ sweating with tramadol
35
Tramadol adverse effects
> number of fatalities from OD causing respiratory depression Dependency develops with long term use -difficult to withdraw
36
Tramadol legislation
``` Controlled drug (class 3) Limit to maximum prescription Must be signed for ```
37
Weak opioids/ paracetamol combinations
Co-codamol, co proxamol, various Now less popular than either nefopam or tramadol Need to include paracetamol in total 24hr maximum of 4g Check BNF if an unfamiliar oral analgesic
38
Group cautions prescribing opioids
Dependent on hepatic metabolism and renal excretion of metabolites -some active metabolites Prolonged effect in liver or renal impairment Respiratory disease, sleep apnoea, > sensitivity Aim for minimum duration of prescription
39
WHO analgesic ladder: severe pain - types - dose
Morphine; oral, SC, IV Diamorphine: SC, IV Fentanyl patch (transdermal) Oral dose approx. 3x IV dose for same efficacy
40
Post-op analgesia
If required IV in recovery 2mg increments every 3min until comfortable (10 - 20mg) in recovery setting -must be given by trained staff Ward care: morphine 10mg SC 2 hourly usually co-prescribed antiemetic; Ondansetron or cycizine
41
Morphine pt controlled analgesia
Syringe driver intermittent IV bolus delivery initiated by pt (push button) 1mg minimum frequency every 5 mins Multiple studies show approx. 1/3 dose compared to nurse administered SC morphine
42
Routes of opioids administration
``` Oral IV SC and IM Rectal Intrathecal (spinal canal --> CSF) Epidural Buccal Trans dermal ```
43
Severe pain: chronic pain
``` Oral morphine syrup or tablets Morphine SC infusion Diamorphine SC infusion Fentanyl transdermal patch lasts 5 days Buprenorphine patch ```
44
Gabapentin and pregablin
Effective for chronic neurogenic pain | < central transmission and pain projection
45
Adverse effects of gabapentin
Sedation, dizziness, nausea, occasionally hypotension
46
Antidepressant drugs
Amitryptiline Duloxetine and Citalopram Have useful adjuvant effects in neurogenic pain -also some antidepressant effect can be useful
47
Antidepressant drugs adverse effects
GI and CVS
48
Psychological support
Pain management
49
Pain management
Assessment of severity in context of daily living and functioning Acute pain; large variation in requirements complex -amount of analgesia (i.e. correct dose) required is 'enough to stop pain' Synergism of different drug actions, psychological factors

Oncology: Pharmacology, Anaesthetics, Analgesia (6 decks)

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