Oral analgesics

Question 1

Non-opioids

Answer 1

1. acetaminophen
2. NSAIDs
3. selective COX-2 inhibitors

Question 2

Opioids

Answer 2

1. oxycodone
2. hydromorphone
3. tramadol

Question 3

Combined analgescis

Answer 3

1. hydrocodone-acetaminophen
2. hydrocodone-ibuprofen
3. oxycodone-acetaminophen

Question 4

acetaminophen

Answer 4

contraindicated in liver failure or active hepatic disease

Question 5

NSAIDS

Answer 5

aspirin, ibuprofen, diclofenac, naproxen, indomethacin,, meloxicam.

1st line for mild/moderate
use with caution if PUD (peptic ulcer disease) and renal disease

contraindicated in recent MI, peri-op of CABG

avoid NSAID in bleeding disorders

Question 6

Celecoxib

Answer 6

2nd line for mild/moderate pain. preferred over NSAID if peptic ulcer disease. use with caution in patients with renal or cardiovascular disease

Question 7

opioids

Answer 7

oxycodene
hydromorphone
tramadol

combine with non-opioids to minimize the dose needed for analgesia

monitor for respiratory depressoin.

oxycodone contraindicated in periop or post op in opioid naive patients. tramadol not recommended in epilepsy

other contraindications: asthma, bowel obstructoin, pancreatits, biliary colic, head injury

Question 8

combination analgesics

Answer 8

hydrocodone-acetampinophen
hydrocodone ibuprofen
oxycodone actampinophen

consider combo in management of moderate/mod-severe pain

follow same precuations as opioid and NSAIDs

Question 9

parenteral analgesics

Answer 9

NSAIDs- ketoroloc, diclofenac, ibuprofen.

Opioids- tramadol, morphine, hydromorphone, fentanyl, buprenoprhine, meperidine
*contraindicated in bowel obsturction

Question 10

analgesic suppositories (into rectum or vagina)

Answer 10

acetaminophen
indomethacin
aspirin

Question 11

topical analgesics

Answer 11

lidocaine:

• patch: postherpetic neuralgia
• jelly: painful urethritis
• ointment: minor burns, sunburn, abrasion of the skin, insect bite

diclofenac:

• patch: acute pain, minor strains, sprains, contusions
• diclofenac: topical solution or gel, chronic pain in osteoarthritis

Question 12

adjuvant analgesics (improves the reponse of)

Answer 12

1. anticonvulsants
2. muscle relaxants
3. antidepressants

Question 13

adjuvant anticonvulsant analgesi

Answer 13

nueropathic pain
chronic pain

• gabapentin
• pregabalin
• carbamezepine

Question 14

muscle relaxants

Answer 14

pain associated wtih muscle spasictiy

cyclobenzaprine
methocarbamol
baclofen

Question 15

antidepressants (adjuvant analgesia)

Answer 15

TCA can be helpful for chronic pain syndrome and neuropathic pain.

TCA: amitriptyline, doxepin, clomipramine.

SNRI: duloxetine, venlafaxine.

Question 16

patient controlled analgesia

Answer 16

infusion pump to release additional IV meds in response to patient’s request.

indicated in severe pain that is difficult to manage and expected to be limited in duration

manage side effects with laxatives, anti emetics and PPI’s

Question 17

an additional method of pain management

Answer 17

regional analgesia
physical therapy- massage, thermotherapy (heat to joints, muscles, soft tissue), desensitization techniques, osteopathic manipulation

acupuncture
behavioural therapy
CBT
patient education

Question 18

examples of opioids

Answer 18

strong opioids- morphine, diamorphine, fentanyl

mild opioids- codeine, dihydrocodeine, co-codamol.

non opioids- paracetemol +/- NSAID

Question 19

NSAID

Answer 19

non-steroidal anti-inflammatory drugs
mild to moderate pain and antipyretics

examples: ibuprofen, paracetemol, diclofenac

PGE are cell signalling molecules synthesised from arachadonic acid by the enzyems COX-1 and 2 so NSAIDs inhibit that enzyme and therefore reduce inflammatory response and sensation of pain

side effects: gastric ulcers, reduced renal perfusion in those with cardiac, renal and liver problems, hypersensitivtiy, bleeding

give PPI (lansoprazol 30mg OD) if regular use

Question 20

Paracetemol

Answer 20

slightly different to NSAIDs so can be used in combination as it has no anti-inflammatory properties. Acts weakly on COX enzymes.

Question 21

Opioid MOA

Answer 21

work on 3 receptor types- u, kappa and delta. then subdivided into type 1 and 2.
type 1 reduces the sensation of pain (inhibits transmission of pain signals along ascending nerves to the spinal cord). type 2 produces the unpleasant side effects such as constipation, drowsiness, nausea, vomiting and respiratory depression.

reversal for OD- naloxone, naltrexone

Question 22

example of perscribing opioid

Answer 22

1. mild/moderate- non opioid e.g. paracetemol 1g QDS and ibuprofen 400mg TDS
   watch liver functoin, avoid NSAID in GI ulcers, give PPI, add adjuvant such as antidepressant or anticonvulsant
2. add weak opioid (conitnue step 1 agents) codeine phosphate 30-60mg QDS as required. consider laxative (sodium docusate 200mg BD) and antiemetic (metoclopramide 10mg TDS)
3. strong opioid. morphine 2.5-5mg orally every 2 hours as required. signs of overdose give naloxone. stop codeine.