Analgesics Flashcards
Which drugs are particularly suitable for treating pain in MSK conditions? (2)
Paracetamol
Aspirin and other NSAIDs
Opioid analgesics are ideal for treating which type of pain?
Moderate to severe pain associated with viscera
Which drugs are used to manage pain in mild sickle-cell crises? (4)
- Paracetamol
- NSAIDs
- Codeine phosphate
- Dihydrocodeine tartrate
Which drugs are used to manage pain in severe sickle-cell crises? (2)
- Morphine OR
- Diamorphine
+concomitant use of an NSAID to potentiate analgesia and allow lower doses of opioids to be used
Which analgesic should be avoided in sickle cell crises?
Pethidine
May cause neurotoxic accumulation of metabolites and precipitate seizures; short half-life necessitates frequent injections
Analgesics provide temporary relief in cases of dental pain (usually for about ___________) until the causative factors have been brought under control.
1 to 7 days
In the case of pulpitis, intra-osseous infection or abscess, reliance on analgesics alone is usually ____________
inappropriate
The pain and discomfort associated with acute problems of the oral mucosa (e.g. acute herpetic gingivostomatitis, erythema multiforme) may be relieved by ______________ mouthwash or spray until the cause of the mucosal disorder has been dealt with
benzydamine hydrochloride
In cases of orofacial pain where the patient is febrile, ___________ or ____________ are often helpful
Paracetamol
Ibuprofen
The choice of an analgesic for dental purposes should be based on its suitability for the patient. Most dental pain is relieved effectively by _____________.
non-steroidal anti-inflammatory drugs (NSAIDs)
Which NSAIDs are used to treat dental pain? (3)
Ibuprofen
Diclofenac
Aspirin
Paracetamol has __________ and ___________ effects but no ______________ effect
analgesic
antipyretic
anti-inflammatory
Opioid analgesics such as dihydrocodeine tartrate act on the ______________ and are traditionally used for ______________ pain
central nervous system
moderate to severe
Are opioid analgesics useful for treating dental pain?
Relatively ineffective in treating dental pain and their side-effects can be unpleasant
Paracetamol, ibuprofen, or aspirin are usually adequate and opioids are rarely required
However, opioid analgesics are relatively ___________ in dental pain
ineffective
What is the advantage of combining non-opioid and opioid analgesics?
Combining a non-opioid with an opioid analgesic can provide greater relief of pain than either analgesic given alone.
*however this applies only when an adequate dose of each is used (most combination analgesic preparations have NOT been shown to provide greater relief of pain than an adequate dose of the non-opioid component given alone)
What are the disadvantages of using combination analgesic preparations? (2)
- Most combination analgesic preparations have not been shown to provide greater relief of pain than an adequate dose of the non-opioid component given alone
- Combination preparations have an increased number of side-effects
Any analgesic given before a dental procedure should have a low risk of increasing ______________.
postoperative bleeding
In the case of pain after the dental procedure, taking an analgesic _____________________ can improve control.
before the effect of the local anaesthetic has worn off
Postoperative analgesia with ibuprofen or aspirin following dental procedures is usually continued for about ____________.
24 to 72 hours
Postoperative analgesia with ___________ or __________ following dental procedures is usually continued for about 24 to 72 hours.
ibuprofen
aspirin
Temporomandibular dysfunction can be related to __________ in some patients who may clench or grind their teeth (bruxism) during the day or night.
anxiety
Temporomandibular dysfunction can be related to anxiety in some patients who may clench or grind their teeth (___________) during the day or night.
bruxism
What is considered to be the main source of pain in TMJD?
Muscle spasm
What is the empirical treatment of TMJD?
Overlay appliance (provides a free-sliding occlusion on the molar and may also interfere with grinding)
In addition to empirical treatment with overlay, _____________ may be helpful in the short-term treatment of TMJD. Analgesics such as _____________ or ____________ may also be required
diazepam (muscle relaxant and anxiolytics properties)
Aspirin
Ibuprofen
Use of a(n) ______________ prevents the pain of dysmenorrhoea which is generally associated with ovulatory cycles.
oral contraceptive
If treatment is necessary paracetamol or a NSAID will generally provide adequate relief of pain.
If treatment is necessary for dysmenorrhea, ______________ or a(n) ____________ will generally provide adequate relief of pain.
paracetamol
NSAID
The vomiting and severe pain associated with dysmenorrhoea in women with endometriosis may call for an _____________ (in addition to an analgesic).
antiemetic
Are antispasmodics effective in treating pain associated with dysmenorrhea?
Do not generally provide significant relief; OCPs, paracetamol, and/or NSAIDs are preferred
What are the analgesic indications of aspirin? (4)
- Headache
- Transient MSK pain
- Dysmenorrhea
- Pyrexia
In inflammatory conditions, most physicians prefer anti-inflammatory treatment with another NSAID which may be better tolerated and more convenient for the patient. Aspirin is used increasingly for its antiplatelet properties.
Is aspirin the analgesic of choice for inflammatory conditions?
Most physicians prefer another NSAID which may be better-tolerated and more convenient for the patient
Gastric irritation caused by aspirin and other NSAIDs can be minimized by…?
Taking the dose after food
What are the advantages and disadvantages of enteric-coated preparations of NSAIDs and aspirin?
Advantages:
- minimize gastric irritation
- prolonged action may be useful for treating night pain
Disadvantages:
- unsuitable for single-dose analgesia due to slow-onset of action
Aspirin interacts significantly with a number of other drugs and its interaction with _____________ is a special hazard
warfarin sodium
Paracetamol is similar in efficacy to aspirin, but has no demonstrable ________________ activity; it is _____________ (more/less) irritant to the stomach
anti-inflammatory
Less (and for that reason is now generally preferred to aspirin, particularly in the elderly)
Overdosage with paracetamol is particularly dangerous as it may cause hepatic damage which is sometimes not apparent for _____________.
4 to 6 days
Nefopam hydrochloride may have a place in the relief of persistent pain unresponsive to other non-opioid analgesics. It causes little or no _______________ but ____________ and ____________ side-effects may be troublesome
respiratory depression
sympathomimetic
antimuscarinic
What drug class does Nefopam belong to?
Centrally-acting non-opioid, non-steroidal analgesic
Non-steroidal anti-inflammatory analgesics (NSAIDs) are particularly useful for the treatment of patients with ___________ disease accompanied by pain and inflammation.
chronic
In addition to their use in chronic disease, NSAIDs are also used in the short-term treatment of mild to moderate pain including transient musculoskeletal pain but ____________ is now often preferred, particularly in the elderly
paracetamol
______________ are suitable for the relief of pain in dysmenorrhoea and to treat pain caused by secondary bone tumours, many of which produce lysis of bone and release prostaglandins.
NSAIDs
Selective inhibitors of ____________ may be used in preference to non-selective NSAIDs for patients at high risk of developing serious gastro-intestinal side-effects.
cyclo-oxygenase-2
Selective inhibitors of cyclo-oxygenase-2 may be used in preference to non-selective NSAIDs for patients at high risk of developing _______________.
serious gastro-intestinal side-effects
Several NSAIDs are also used for post-__________ analgesia.
operative
Ziconotide is a non-opioid analgesic administered by ____________ infusion that is licensed for the treatment of chronic severe pain; can be used by a hospital specialist as an adjunct to opioid analgesics
Intrathecal
Compound analgesic preparations that contain a simple analgesic (such as __________ or __________) with a(n) ____________ component reduce the scope for effective titration of the individual components in the management of pain of varying intensity.
aspirin
paracetamol
opioid
Compound analgesic preparations containing paracetamol or aspirin with a low dose of an opioid analgesic (e.g. _____________) are commonly used
codeine phosphate
Are opioid side effects seen with administration of low dose opioid analgesics like codeine?
Yes, particularly constipation
A low dose compound analgesic preparation may contain around _________ of codeine per tablet, whereas a full dose compound preparation may contain closer to ________ per tablet
8 mg
60 mg
A full dose of the opioid component in compound analgesic preparations effectively augments the analgesic activity but is associated with the full range of opioid side-effects including…? (5)
- nausea, vomiting
- severe constipation
- drowsiness
- respiratory depression
- risk of dependence on long-term administration
Important: the elderly are particularly susceptible to opioid side-effects and should receive lower doses.
__________ are particularly susceptible to opioid side-effects and should receive lower doses.
The elderly
In general, when assessing pain, it is necessary to weigh up carefully whether there is a need for ____________ and __________ analgesics to be taken simultaneously.
non-opioid
opioid
____________ is a weak stimulant that is often included, in small doses, in analgesic preparations
Caffeine
It is claimed that the addition of caffeine may enhance the analgesic effect, but the alerting effect, mild habit-forming effect and possible provocation of headache may not always be desirable.
Although it may enhance analgesic effects, caffeine may not always be desirable due to its ___________, __________, and _________ effects
Alerting
Mild habit-forming
Headache-provoking
What is co-proxamol?
Dextropropoxyphene + paracetamol
No longer licensed because of safety concerns, particularly toxicity in overdose
Opioid analgesics are usually used to relieve moderate to severe pain particularly of ____________ origin
visceral
Repeated administration may cause ____________ and _____________, but this is no deterrent in the control of pain in terminal illness.
dependence
tolerance
Regular use of a potent opioid may be appropriate for certain cases of chronic non-____________ pain.
malignant
____________ remains the most valuable opioid analgesic for severe pain although it frequently causes nausea and vomiting
Morphine
____________ is the standard against which other opioid analgesics are compared.
Morphine
In addition to relief of pain, morphine also confers a _____________ and ____________
state of euphoria
mental detachment
What are the strong opioids? (13)
- Morphine
- Buprenorphine
- Dipipanone
- Diamorphine
- Alfentanil
- Fentanyl
- Remifentanil
- Methadone
- Oxycodone
- Pentazocine
- Pethidine
- Tapentadol
- Tramadol
What are the weak opioids? (3)
- Codeine
- Dihydrocodeine
- Meptazinol
______________ is the opioid of choice for the oral treatment of severe pain in palliative care
Morphine; it is given regularly every 4 hours (or every 12 or 24 hours as modified-release preparations).
Buprenorphine has both opioid _________ and ___________ properties and may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids
agonist
antagonist
Buprenorphine has both opioid agonist and antagonist properties and may precipitate ________________ symptoms in patients dependent on other opioids
withdrawal
Can buprenorphine cause dependence?
Yes, despite having both agonist and antagonist properties, it has abuse potential and may itself cause dependence
Buprenorphine has a much ___________ (shorter/longer) duration of action than morphine and sublingually is an effective analgesic for 6 to 8 hours.
Longer
Buprenorphine has a much longer duration of action than morphine and sublingually is an effective analgesic for _____________
6 to 8 hours
Unlike most opioid analgesics, the effects of ______________ are only partially reversed by naloxone hydrochloride.
buprenorphine
Unlike most opioid analgesics, the effects of buprenorphine are only partially reversed by ________________
naloxone hydrochloride.
Dipipanone hydrochloride used alone is ___________ (more/less) sedating than morphine but the only preparation available contains an antiemetic and is therefore not suitable for regular regimens in palliative care.
Less
Dipipanone hydrochloride used alone is less sedating than morphine but the only preparation available contains a(n) _____________ and is therefore not suitable for regular regimens in palliative care.
antiemetic
Diamorphine hydrochloride (__________) is a powerful opioid analgesic
heroin
Diamorphine may cause _________ (less/more) nausea and hypotension than morphine
Less
In palliative care the ______________ of diamorphine hydrochloride allows effective doses to be injected in smaller volumes and this is important in the emaciated patient
greater solubility
In palliative care the greater solubility of diamorphine hydrochloride allows effective doses to be injected in smaller volumes and this is important in the ______________ patient
emaciated
Alfentanil, fentanyl and remifentanil are used by ____________ for intra-operative analgesia
injection
____________, ____________, and __________ are used by injection for intra-operative analgesia
Alfentanil
fentanyl
remifentanil
Alfentanil, fentanyl and remifentanil are used by injection for _____________ analgesia
intra-operative
Fentanyl is also available in a ____________ drug delivery system
transdermal (in addition to injection preparations)
Methadone hydrochloride is _________ (more/less) sedating than morphine and acts for _________ (longer/shorter) periods
Less
Longer
In prolonged use, methadone hydrochloride should not be administered more often than __________ to avoid the risk of accumulation and opioid overdosage
twice daily
_____________ may be used instead of morphine in the occasional patient who experiences excitation (or exacerbation of pain) with morphine.
Methadone hydrochloride
Methadone hydrochloride may be used instead of morphine in the occasional patient who experiences ________________ with morphine.
excitation (or exacerbation of pain)
________________ has an efficacy and side-effect profile similar to that of morphine.
Oxycodone hydrochloride
Oxycodone hydrochloride has an efficacy and side-effect profile similar to that of ___________.
morphine
_______________ is commonly used as a second-line drug if morphine is not tolerated or does not control the pain
Oxycodone
Pentazocine has both ____________ and ___________ properties and precipitates withdrawal symptoms, including pain in patients dependent on other opioids
agonist
antagonist
(Like buprenorphine)
Which two opioids have both agonist and antagonist effects and can therefore precipitate withdrawal in patients with opioid dependence?
Buprenorphine
Pentazocine
By injection, pentazocine is _________ (more/less) potent than dihydrocodeine or codeine
More
____________ and ___________ may occur with injection of pentazocine
Hallucinations
Thought disturbances
______________ is not recommended and, in particular, should be avoided after myocardial infarction as it may increase pulmonary and aortic blood pressure as well as cardiac work.
Pentazocine
Pentazocine is not recommended and, in particular, should be avoided after ____________ as it may increase ______________ as well as _____________.
myocardial infarction
pulmonary and aortic blood pressure
cardiac work
Pethidine hydrochloride produces ____________ but _________-lasting analgesia
prompt
short
Pethidine is _________ (more/less) constipating than morphine
Less
In high doses, pethidine is ___________ (more/less) potent than morphine
Less
Pethidine __________ (is/is not) suitable for severe continuing pain
Is not; even in high doses, it is a less potent analgesic than morphine
Pethidine is used for analgesia in __________; however, other opioids such as morphine or diamorphine are often preferred for ___________ pain
Labor
Obstetric
What are the two main mechanisms by which tapentadol produces analgesia?
- Opioid receptor agonist
2. Inhibition of noradrenaline reuptake
Nausea, vomiting, and constipation are ___________ (more/less) likely to occur with tapentadol than with other strong opioid analgesics
Less
What are the two mechanisms by which tramadol produces analgesia?
- Opioid agonist effects
2. Serotonergic and adrenergic enhancement
Compared to other opioids, tramadol has __________ (greater/fewer) side-effects
Fewer; notably less respiratory depression, less constipation, and less addiction potential
Although fewer typical opioid side-effects are associated with tramadol, __________ have been reported
Psychiatric reactions
_______________ can be used for the relief of mild to moderate pain where other painkillers such as paracetamol or ibuprofen have proved ineffective.
Codeine phosphate
Dihydrocodeine tartrate has an analgesic efficacy similar to that of ______________
codeine phosphate
Higher doses of dihydrocodeine may provide some additional pain relief but this may be at the cost of more ____________ and ____________.
nausea
vomiting
Meptazinol is claimed to have a low incidence of _______________
repiratory depression
Meptazinol has a reported length of action of _______________ with onset within ______________.
2 to 7 hours
15 minutes
What is the ideal approach to managing postoperative pain?
Multimodal approach ie combination analgesics from different classes
The use of intra-operative __________ affects the prescribing of postoperative __________.
opioids
analgesics
A postoperative __________ analgesic should be given with care since it may potentiate any residual respiratory depression.
opioid
A postoperative opioid analgesic should be given with care since it may potentiate any residual ______________
respiratory depression.
_____________ is used most widely as postoperative analgesia
Morphine
_________________ is not as effective in severe pain as other opioid analgesics
Tramadol
In post-operative pain management, _____________ may antagonize the analgesic effect of previously administered opioids and is generally not recommended
Buprenorphine
___________________ is generally not recommended for postoperative pain because it is metabolized to ____________ which may accumulate, particularly in renal impairment
Pethidine
Norpethidine
*norpethidine stimulates the CNS and may cause convulsions
Norpethidine stimulates the _____________ and may cause __________
central nervous system
convulsions
Opioids are also given _____________ [unlicensed route] in the postoperative period but are associated with side-effects such as pruritus, urinary retention, nausea and vomiting; respiratory depression can be delayed, particularly with morphine.
epidurally
Opioids are also given epidurally [unlicensed route] in the postoperative period but are associated with side-effects such as ____________, _____________, and ______________; respiratory depression can be delayed, particularly with morphine.
pruritus
Urinary retention
nausea and vomiting
Patients who are dependent on opioids or have a history of drug dependence __________ (may/may not) be treated with opioid analgesics
May; caution is necessary, but opioid analgesics may be used when there is a clinical need
Treatment with opioid analgesics in this patient group should normally be carried out with the advice of specialists.
Do doctors require a special license to prescribe opioid analgesics to patients with opioid dependence?
No
Opioids cause a dose-dependent increased risk of ____________, consider total opioid dose reduction
central sleep apnoea
Manufacturer advises extreme caution when using _____________ for postoperative pain relief in children—reports of rare, but life threatening adverse events after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea; if used, monitor closely for symptoms of opioid toxicity.
tramadol
Manufacturer advises extreme caution when using tramadol for postoperative pain relief in _____________—reports of rare, but life threatening adverse events after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea; if used, monitor closely for symptoms of opioid toxicity.
children
Long term use of opioids in non-malignant pain (longer than ___________) carries an increased risk of dependence and addiction, even at therapeutic doses. At the end of treatment the dosage should be tapered slowly to reduce the risk of withdrawal effects; tapering from a high dose may take ____________
3 months
weeks or months
Paracetamol is not licensed for use in children under ____________ by mouth OR under ___________ by rectum
2 mo
3 mo
Intravenous infusion of paracetamol not licensed in children and neonates with body-weight under____ kg.
10
__________ damage and less frequently _________ damage can occur following paracetamol overdose.
Liver
Renal
___________ and ___________, the only early features of paracetamol poisoning, usually settle within __________. Persistence beyond this time, often associated with the onset of right subcostal pain and tenderness, usually indicates development of hepatic necrosis.
Nausea
vomiting
24 hours
Nausea and vomiting, the only early features of paracetamol poisoning, usually settle within 24 hours. Persistence beyond this time, often associated with the onset of ___________ and ____________, usually indicates development of ____________
right subcostal pain
tenderness
hepatic necrosis.
What is the typical dose of aspirin prescribed for secondary prevention of CVD?
75 mg daily PO
What is the dose of aspirin prescribed for suspected TIA and, acute ischemic stroke, and NSTEMI/STEMI?
300 mg PO
What are the contraindications to prescribing aspirin? (7)
- Active peptic ulcer
- Bleeding disorders
- Children under 16 yo (Reye’s syndrome UNLESS specifically indicated ie Kawasaki)
- Hemophilia
- Previous peptic ulceration
- Severe cardiac failure
- History of hypersensitivity to aspirin or any other NSAID
What are the potential side effects of aspirin? (5)
- Asthmatic attach, bronchospasm, dyspnea
- Dyspepsia, hemorrhage
- Skin reactions
- Hearing loss, tinnitus, vertigo
- Renal impairment, hyperuricemia, sodium retention
What are the symptoms of aspirin overdose? (6)
- Hyperventilation
- Tinnitus
- Deafness
- Vasodilation
- Sweating
- Coma in very severe poisoning
Is aspirin safe to use in pregnancy?
- Use antiplatelet doses with caution during third trimester; impaired platelet function and risk of haemorrhage;
- delayed onset and increased duration of labour with increased blood loss;
- high doses may be related to intrauterine growth restriction, teratogenic effects, closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of newborn
- kernicterus may occur in jaundiced neonates
Is aspirin safe to use in breastfeeding?
Avoid due to possible risk of Reye’s syndrome and hypoprothrombinemia in infants if neonatal vit K stores are low
Is aspirin safe to use in patients with hepatic and/or renal impairment?
Caution in mild to moderate impairment of both
Avoid in severe hepatic and renal impairment
Which drug interactions should be avoided when prescribing aspirin? (5)
- Coprescription with other NSAIDs increases bleeding risk
- Coprescription with warfarin, anticoagulants, antiplatelets, and fibrinolytics increases bleeding risk
- Coprescription with biologics increases bleeding risk
- Coprescription with diuretics increases risk of renal failure
- Coprescription with SSRIs increases bleeding risk
Is diclofenac safe to use in pregnancy and breastfeeding?
Avoid unless essential
What are the contraindications to using Celecoxib? (6)
- Active GI bleed or ulcer
- Cerebrovascular disease
- IBD
- IHD
- Mild to severe HF
- PAD
Celecoxib is a selective _____________ inhibitor
COX-2
Avoids GI erosion but tips scales in favor of pro-thrombotic state unfavorable for patients with CVD
Caution—long-term use of some NSAIDs is associated with reduced __________, which _______ (is/is not) reversible on stopping treatment.
female fertility
Is
