NERVOUS SYSTEM - PAIN MANAGEMENT Flashcards
1
Q
What is pain?
A
Unpleasant sensation in body
2
Q
What are the 3 types of pain?
A
- Nociceptive
- neuropathic
- Nociplastic
3
Q
What is an example of nociceptive pain?
A
Tissue damage
4
Q
What is an example of neuropathic pain?
A
Nerve damage
5
Q
What is an example of Nociplastic pain?
A
Sensation - change in pain pathway.
E.G. something that did not hurt before, can hurt now.
6
Q
How many weeks of pain makes it chronic?
A
More than 12 weeks
7
Q
What is cause of pain divided into?
A
Primary
Secondary
8
Q
What is primary pain?
A
There is no cause of pain
9
Q
What is secondary pain?
A
Pain caused by underlying condition.
e.g. cancer, neuropathic, surgery/trauma, headache
10
Q
Describe pain ladder?
A
3 steps.
1- Mild pain (non opioids)
- Mild-mod pain (weak opioids)
- mod- severe pain (strong opiods)
11
Q
Give 2 examples of non opioids for pain management?
A
paracetamol , NSAIDs (aspirin).
12
Q
Give 3 examples of weak opioids for pain management?
A
Codeine, hydrocodeine, tramadol (moderate pain)
13
Q
Give 5 examples of strong opioids for pain management?
A
Morphine, diamorphine, oxycodone, transdermal patches, buprenorphine, fentanyl
14
Q
What 2 TCAs are used for neuropathic pain?
A
Amitriptyline
Nortiptyline
15
Q
What 2 Anti-epileptic meds are used for neuropathic pain?
A
Gabapentin
Pregabalin
16
Q
What is the risk of using pregabalin during pregnancy?
A
Can slightly increase risk of major congenital malformations.
Use effective contraception - avoid pregabalin use in pregnancy unless necessary.
17
Q
What corticosteroid is used for treating nerve blocks?
A
Dexamethasone
18
Q
What drug is used to help with bone metastases?
A
Bisphosphonates
19
Q
What drug is used to treat muscle spasms?
A
Benzos
20
Q
What schedule is codeine?
A
Schedule 5
21
Q
What schedule is codeine via injection?
A
CD2
22
Q
What schedule is tramadol
A
Drug schedule CD3
23
Q
What schedule is diamorphine?
A
Schedule 2
24
Q
What schedule is oral morphine <13mg/5ml?
A
Schedule CD5
25
Oxycodone drug schedule?
CD2
26
How is buphrenoprhine taken + what is schedule
sublingual
CD3
27
What is pethidine used for + schedule?
CD2 - used in labour
28
What does buildup of pethidine cause?
Convulsions
29
What schedule is tapentadol?
CD2- less N + V and constipation
30
What schedule is alfentanil + use?
CD2- used for intra operative analgesia
31
What is nefopam?
Non opiod
32
What schedule + opioid type is dihydrocodeine?
CD5- weak opioid
33
What is use of paracetamol?
Mild- moderate pain + fever - no anti-inflammatory effect
34
What is minimum age limit for codeine?
use in over 12 years old
35
Codeine is not recommended for adolescents (12-18) with what condition?
Breathing problems
36
What condition is codeine contra-indicated in all children (under 18 years) ?
For removal of tonsils or adenoids for the treatment of obstructive sleep apnoea
Can cause more breathing issues
37
Why is codeine avoided in ultra-rapid metabolisers?
Increase risk of toxicity
38
Should women breastfeeding take codeine?
No- codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk.
39
Why is codeine not allowed in use for under12 years?
Risk of respiratory SE
40
What are the 6 codeine SEs?
Dry mouth
constipation
CNS depression
Nausea + vomitting
hypotension
pupil constriction (mioisis)
41
What does codeine target?
mu opioid receptors
42
What is used as antidote for opioid overdose?
Naloxone
43
What does prolonged codeine/ opioid use cause? (3)
Hypogonadism
Adrenal insufficiency
hyperalgesia
44
What is hyperalgia?
Opioid overuse causing sensations to hurt more.
45
What 3 conditions should opioids be avoided in?
paralytic ileus
Head injury
respiratory disease
46
What is breakthrough pain?
1/6 to 1/10 of total dose every 2-4 hours
47
How to increase opioid doses per day?
Only increase by 1/2 or 1/3 a day
48
How to switch between opioids?
Reduce dose by 1/2 to 1/3 a day = prevent overdose
49
What is more potent; oxycodone or morphine?
Oxycodone - used in patients who cannot swallow large amounts of morphine
50
What 3 counselling points to tell patient using opioid patches?
Rotate sites
Avoid heat exposure
Apply to clean dry hairless skin
51
What to do if fentanyl patch toxicity suspected?
Remove ASAP
52
What 2 drugs are used topically for neuropathic pain?
Lidocaine
Capsaicin
53
What is paracetamol dose?
0-5 to 1g every 4-6 hrs PRN
54
What is max paracetamol dose?
maximum 4g per day
55
What 2 labels are on paracetamol box?
Do NOT take more than 2 at any 1 time. Do not take more than 8 in 24 hrs.
Contains paracetamol. Do not take anything else containing paracetamol whilst taking this med
56
What can overdose of paracetamol cause?
Liver damage - higher risk in less than 50kg patients
57
What is antidote for paracetamol overdose?
Acetylcysteine
58
What is aspirin indication?
Mild- mod pain + fever
Anti-platelet - medical emergency + secondary prevention
59
What is aspirin daily dose?
300 to 900 mg every 4-6 hrs
60
What is maximum aspirin dose?
4g per day
2.4g without doctor's advice
61
What 2 labels are on aspirin box?
Do not take anything else containing aspirin while taking meds
Take with or just after food or meal - contains aspirin
62
What are 2 SEs of apsirin?
GI irritation
Tinnitus
63
What to give to avoid GI irritation with aspirin?
Give Enteric coated version
64
What is minimum age for aspirin?
16
65
Why cannot aspirin be given to under 16?
Can cause reyes syndrome
66
What disease is exception to give aspirin to under 16 years?
In case of kawasaki disease or antiplatelet
67
What are 4 signs of NSAID hypersensitivity?
Bronchospasm
Asthma attack
rhinitis
urticaria - hives/itching
68
MOA of opioid analgesics?
Acts on opioid mew receptors in CNS
69
What is indication of opioid analgesics?
Acute pain
Palliative care
Chronic malignant pain - short term
70
What type of pain are opioids used short term for?
Chronic malignant pain
71
What are 8 SEs of using opioids ?
1.Miosis (pinpoint pupils), muscle rigidity, mouth dry
2. Out of it (sedation)
3. RESPIRATORY DEPRESSION
4. Postural hypotension
5. Hyperalgesia, hallucination
6.Infrequency (urinary retention, constipation)
7.Nausea + vomiting
8. Euporia
72
What drug to treat vomiting caused by opioids?
Metoclopramide
73
What is antidote for respiratory depression?
Naloxone
74
What is a contraindication of opioids as one of the SE is pupil constriction?
not for patients with head injury - increased intracranial pressure
75
What is a SE of opioids in high doses?
Hypotension
76
What is a caution for opioids as they cause dependence?
May not be suited for patients with substance use, mental health disorder
77
What is tolerance?
Higher doses are needed to reach same level of analgesia
78
What is physical withdrawal?
Appears on abrupt withdrawal of opioids , physical symptoms show
79
What is an MHRA warning related to addiction + dependence with prolonged use in non-malignant pain?
Withdrawal plan in place
regular monitoring needed.
Hyperalgesia if increased pain sensitivity
Give MHRA leaflet
80
How to counsel patients on opioid use and reducing tolerance?
Report signs of overdose
81
What are the 3 symptoms of opioid overdose?
Respiratory depression
Pinpoint pupils
coma
82
What is a MHRA warning regarding benzodiazepines + opioids?
CNS depressant effects- monitor at start , if new dose + for any interactions
83
When should methadone be monitored due to respiratory depression effect?
Methadone within 2 weeks of initiation
84
What 2 laxative types are given to combat opioid use and constipation?
Osmotic + stimulant laxative
85
What is a CI in using opioids due to constipation?
risk of paralytic ileus - caution in pts with IBD
86
What to do if patient has hyperalgesia?
reduce opioid dose or switch
87
What is hypogonadism?
Reduced fertility - no bleeding or ED
88
What 4 main drug classes interact with opioids to cause CNS depression?
Alcohol*
Benzos*
Z drug*
Irreversible MAOIs*
Antihistamines, antipsychotics, barbiturates-
89
What are 2 other indications of codeine?
Diarrhoea
Dry cough (18+)
90
Codeine is used to treat ------ in over 18s?
Dry cough
91
What route is codeine NEVER given via?
IV - dangerous hypotensive effect
92
What is maximum duration of treatment using codeine for moderate pain?
3 days
93
What is maximum codeine dose in children aged 12-18?
Max daily dose of codeine should NOT pass 240 mg.
Taken up to four times a day at intervals of no less than 6 hours
94
What is use of tramadol?
For mild to moderate pain
95
What are 2 SEs of tramadol?
psychiatric reactions
Reduces seizure threshold
96
What type of drugs interact with tramadol to increase serotonin syndrome?
Serotonergic drugs
97
List common serotonergic drugs which can interact with tramadol to cause serotonin syndrome?
Antidepressants (SSRI, TCA, MAOIs), Lithium, methadone, MAO-B inhibitors, sumatriptan, ondansetron, st John's wort
98
What is morphine used for in palliative care aside from severe pain?
Dyspnoea in palliative care
99
What is an alternative drug to oral morphine?
Oxycodone
100
How often is immediate release oral morphine given?
4 hourly
101
How often is MR oral morphine given?
12 or 24 hourly
102
How is the dose of parenteral morphine compared to oral?
Parenteral dose is 1/2 of oral dose
103
What are 2 SEs common in morphine?
N+ V
increased euphoria
104
What is more potent; diamorphine or morphine?
Diamorphine - 2-3 times stronger
105
Why is diamorphine better than morphine?
Less side effect of nausea + hypotension
106
List parenteral strong opioid?
Diamorphine
107
What is breakthrough pain dose?
1/6 to 1/10th of total daily dose every 2 to 4 hours
108
What type of opioid preparation is used for breakthrough pain?
Immediate release
109
How long is buprenorphine patches used for in pain management?
3 days, 4 days + 7 days
110
Which drug is partially reversed by naloxone?
Buprenorphine
111
What is 2 main SEs of Buprenorphine + Fentanyl?
withdrawal + respiratory depression
112
What 3 counselling points apply to administration of Buprenorphine patches?
1. avoid heat exposure (hot baths/saunas).
2. apply to dry, non irritated, non hairy skin
3. rotate patch site
113
What are the common SE of Buprenorphine patches?
Appetite decreased (in adults); asthenia (in adults); dyspnoea (in adults); gastrointestinal discomfort (in adults); muscle weakness (in adults); oedema (in adults); sleep disorders (in adults)
114
What duration is fentanyl patches commonly seen in?
72 hrs
115
What is an MHRA warning for fentanyl patches regarding use in non cancer pain?
Do NOT use in opioid-naive patients - try other analgesics for non-malignant pain before this.
116
How can we prevent fentanyl toxicity? (5 things)
not exceeding the prescribed dose
following the correct frequency of patch application, avoiding touching the adhesive side of patches, and washing hands after application
not cutting patches +avoiding exposure of patches to heat including via hot water;
ensuring that old patches are removed before applying a new one.
following instructions for safe storage and properly disposing of used patches or those which are not needed.
117
Can we cut fentanyl patches?
NO
118
When should a fentanyl patch be removed instantly?
When signs of breathing difficulties -drowsiness, confusion, dizziness, or impaired speech
119
What is used for management of dysmenorrhoea?
Oral contraceptives
Paracetamol/NSAID if needed
120
What is used to manage pain of mild sickle-cell crisis?
Paracetamol, NSAID, codeine or dihydrocodeine.
121
Why to AVOID pethidine in sick cell management?
Can build up + toxic metabolite can increase risk of seizures.
122
What has codeine linctus been reclassified as?
POM
123
What is the ONLY use of codeine linctus?
dry cough, + only considered to be effective for chronic coughs lasting over 8 weeks
124
What 3 cases are codeine CI in?
children younger than 12 years old
patients of any age known to be CYP2D6 ultra-rapid metabolisers
breastfeeding mothers
125
Codeine effective in treating chronic coughs lasting over --- weeks?
8 weeks
126
What drug is given for Trigeminal neuralgia?
Anti epileptics - carbamazepine
127
What cream is given as symptomatic relief for postherpetic neuralgia?
Capsaicin 0.075% cream is licensed for the symptomatic relief of postherpetic neuralgia.
