New pain management

Question 1

RAT system

Answer 1

Recognise

Assess

Treat

Question 2

Inflammatory pain presentation

Answer 2

Throbbing, aching, localised to affected area

Question 3

Inflammatory pain treatment

Answer 3

NSAIDs

Paracetamol

Question 4

Nociceptive- somatic pain presentation

Answer 4

Sharp pain and localised to affected area

Question 5

Nociceptive- somatic pain treatment

Answer 5

NSAIDs

Paracetamol

Opioids

Question 6

Nociceptive- visceral pain presentation

Answer 6

Deep, aching, poorly localised, cramping

Question 7

Nociceptive- visceral pain treatment

Answer 7

NSAIDs

Paracetamol

Opioids

Neuropathic agents

Question 8

Neuropathic pain presentation

Answer 8

Shooting, burning, hypersensitive, tingling, numbing

Question 9

Neuropathic pain treatment

Answer 9

Neuropathic agents

Question 10

Acute pain

Answer 10

Warning sign of injury
- following injury to body

Well defined onset
- no longer than 6 months

Responds well to treatment
- should be treated promptly and stepped up readily

Generally produces anxiety

Often associated with physical signs
- tachypnoea, tachycardia, decreased immunity, well-being

Question 11

Chronic pain

Answer 11

Persists behond expected healing time

May or may not have defined onset

Often difficult to treat

Can have physiological element

Pain signals active in nervous system for weeks, months or years

Progressive physical deterioration

Question 12

Acute pain management

Answer 12

Responds well to conventional analgesics
- paracetamol, NSAIDs, opioids

Non-pharmacological treatments

Question 13

Chronic pain management

Answer 13

Neuropathic agents

Doesn’t respond well to opioids

Psychological therapies

Pain education

Question 14

Classification of analgesics

Answer 14

Simple

Opioids

Neuropathic agents

Miscellaneous

Question 15

Simple analgesics

Answer 15

NSAIDs

Question 16

Opioid analgesics

Answer 16

Weak/ strong opioids

Question 17

Neuropathic agents

Answer 17

Anticonvulsants
- gabapentin, pregabalin, carbamazepine

Antidepressants
- amitriptyline, duloxetine

Question 18

Miscellaneous analgesics

Answer 18

Triptans

Anaesthetic agent

Question 19

Paracetamol

Answer 19

1g QDS PO/IV

If <50kg 500mg QDS

Question 20

NSAIDs

Answer 20

Ibuprofen 400mg TDS PO

Naproxen 250-500mg BD PO

Question 21

Adverse effects of NSAIDs

Answer 21

Renal- prostanoid inhibition

Reduced/ increase platelet aggregation

Reyes syndrome in children

GI side effects

Drug interactions

Hypersensitivity and cross reactivity

Question 22

Renal protanoid inhibition

Answer 22

Decreased renal blood flow, imbalance in vasodilation mechanism leading to ischaemia

Water/ sodium retention

Question 23

Reduced/ increase platelet aggregation

Answer 23

Aspirin antiplatelet

NSAIDs and COX-2 thromboembolic

Question 24

Reyes syndrome

Answer 24

Encephalopathy in children

Question 25

GI side effects of NSAIDs

Answer 25

Due to inhibition of COX1 of prostaglandins Decreased blood flow, decreased mucous production, increase acid production Duration of therapy not good predictor

Question 26

Weak opioids

Answer 26

Used for: moderate pain and anti-diarrhoeal properties Dihydrocodeine first line weak opioid- metabolite likely to accumulate

Question 27

Strong opioids

Answer 27

Used for: effective for moderate to severe acute pain Usual suspects: morphine, oxycodone, fentanyl

Question 28

Opioid prescribing

Answer 28

No variable doses or routes of administration on the regular side of the drug chart No weak opioids plus strong opioids No systemic opioids with PCA/ epidurals

Question 29

Adverse effects of opioids

Answer 29

Respiratory depression - caution elderly patients, COPD, always prescribe prn naloxone 100mcg iv/im Constipation - inhibition of peristalsis, increae tone of anal sphincter and reduces the reflex relaxation response to rectal distension - stimulant laxatives e.g. senna Nausea and vomiting Sedation Pruritis

Question 30

Nefopam

Answer 30

Non opioid and non NSAID Mechanism not fully understood, thought to affect serotonin, dopamine and noradrenaline reuptake and glutamine release Side effects: nausea, dizziness, urinary retention, dry mouth Can turn urine pink Contra-indicated in convulsive disorders

Question 31

Gabapentin

Answer 31

Neuropathic analgesic, used 'off-label' in acute post operative pain Mechanism of action for pain not fully understood Acts on voltage gated Ca2+ channels, blocking neuronal Ca2+ influx and decreasing glutamate release Opioid sparing- reduces problematic side effects of opioids (nausea and constipation)