Pain

Question 1

Mild pain we would use….

Answer 1

Non opiates: paracetamol, NSAIDs,aspirin

Question 2

Mid to moderate pain we would use… what is a major caution for the third option

Answer 2

codeine, dihydrocodeine - more moderate - tramadol (lower seizure threshold,serotonin syndrome,increased bleeding risk, psychiatric disorder)

Question 3

Moderate pain we would use… and what are main side effects for one of them

Answer 3

morphine, oxycodone , methadone, buprenorphine and fentanyl (morphine side effects : dependence so daily dose increases, hitting max based in weight)

Question 4

Weak opiates: what are the age limits and what age is not licensed? What other groups of people is it contraindicated in? Descent and medical procedures?

Answer 4

codeine: used in patients over the age of 18 - over age of 12 (unlicensed) and those who have had tonsils removed due to sleep apnoea. Avoid in patients who have high metabolism (Afro Caribbean) due to toxicity) + avoid in breast feeding patients

Question 5

What pathway do opiates act one? Considering that, what side effects do we expect?

Answer 5

Acts on the mu- pathway so causes dry mouth, constipation, cons depression, nausea and vomiting, myosis(pupil constriction )

Question 6

Strong opiates prolonged use can lead to what regarding sensitivity and payments suffering from what do we avoid them in? in?

Answer 6

Prolonged use leads to - hyperalgesia(increased sensitivity to pain) - smaller sensation - more pain so more opiates. Avoid in paralytic ileum, respiratory disease and head injury

Question 7

Break through pain

Answer 7

1/6th or 1/10th of total dose every 2-4 hours needed

Question 8

Increase doses of opiates

Answer 8

by 1/2 to 1/3 each day

Question 9

Reduce by morphine dose by what? Each day to prevent what?

Answer 9

by 1/2 to 1/3 each day when switching to prevent overdose

Question 10

Max Breakthrough dose - which is the most potent and appropriate in patients who can’t consume a lot because of nausea???

Answer 10

MAX Breakthrough doe (1/6 to 1/10) every 2 hours so 12x a day max
- Oxycodone more potent and more appropriate in pts who can’t consume a lot due to nausea

Question 11

Analgesics examples? What are they useful in? Where would we opt for opioids instead?

Answer 11

• Nsaids, Aspirin and paracetamol useful in muscoskeletal pain
  
  • Opioids useful in visceral[ trunk,heart,abdominal and pelvic organs] pain and moderate to severe pain

Question 12

Sickle cell disease can be treated using what? What do we use for a severe crisis? What do we want to avoid

Answer 12

• Paracetamol and NSAIDs, codeine and dihyrocodiene
  
  • Severe crisis - morphine or diamorphine may be needed
  • Avoid pethidine- can cause seizures

Question 13

Paracetamol is indicated with what kind of pain?

Answer 13

Mild to moderate pain, pain and inflammation of soft tissue injuries, Pyrexia with discomfort

Question 14

Dental and Orodacial Pain:
First line can be treated using what? What can we combine? What is final line and what properties does it have that will help this? And we can only prescribe for how long?

Answer 14

• NSAIDs(ibuprofen,diclofenac,aspirin). Paracetamol can be used temporarily.
  
  • Benzydamine mouthwash/spray can be used
  • Paracetamol,ibuprofen, aspirin are adequate for dental pain
  • Combining a non-opioid with an opioid analgaesic provides more relief than either on its own.
  • Diazepam- has muscle relaxant and anxiolytic properties (only prescribe short term)

Question 15

Dysmenorrhoea(period pain) what can we use to treat the pain? What do we use to test the vomiting? What else can be prescribed to aid with this whole cycle?

Answer 15

• Antiemetics can be used to prevent vomiting
  
  • Paracetamol and NSAIDs used for relief
  • Oral contraceptives can be used to prevent pain associated with ovulatory cycles

Question 16

Non - opioid analgaesics: examples and agar can they each cause what can they cause???what can be used in pain not responding to non opioid analgesics

Answer 16

• Aspirin - indicated for headaches, musculoskeletal pain, dysmenorrhoea and pyrexia
  
  • GI problems, minimised by taking dose after food. Enteric coating preps have a slow onset of action and therefore unsuitable
  • Aspirin interacts with other drugs especially warfarin which is a special hazard
  • Paracetamol, generally safer and more preferred for elderly- overdose can cause hepatic damage
  • Nefopam can be used for pain not responding to non - opioid analgaesics it has more side effects

Question 17

NSAIDs can be used for what kind of diseases? It is a short term treatment for what? What would we rather go for in elderly patients?what types of NSAID are preferred with risk of gi effects

Answer 17

• Chronic disease accompanied by pain and inflammation
  
  • Short term treatment of mild to moderate pain(musculoskeletal)but paracetamol now preferred especially in elderly
  • Suitable for dysmenorrhoea
  • Pain caused by secondary bone tumours
  • Selective inhibitors or cyclo-oxygenate-2 preferred over NSAIDs for patients with high risk of gi side effects
  • Used for post operative analgesia

Question 18

Compound analgesic preparations- examples? What is a weak stimulant the enhances analgesic effect? Example of combo prep that is no longer licensed

Answer 18

• Compound preparations eg. Co-codamol are commonly used but advantages have not been proven because we can’t titrate doses
  
  • Caffeine is a weak stimulant and enhances analgesic effect
  • Co- proxamol tablets- no longer licensed because of safety concerns

Question 19

Opioid analgesic & dependence:
What are they used to treat? What can repeated doses lead to? When would we caution?

Answer 19

• Used to relief moderate to severe pain particularly of visceral origin
  
  • Repeated use may cause dependence and tolerance
  • Caution in impaired respiratory function(avoid in cold),asthma,hypotension,MG,shock,cons=vulsive disorders

Question 20

Common opioid side effects:
3

Answer 20

1) Respiratory depression: treated by artificial ventilation or reversed by naloxone
2) Dependence and withdrawal :tolerance can develop during long term use
3) Overdose:Cause coma,respiratory,depression and pinpoint pupils

Question 21

Other side effects of opioids include?

Answer 21

• Nausea and vomiting
  
  • Constipation
  • Dry mouth
  • Hillary spasm
  • Larger doses- muscle rigidity,hypertension,respiratory depression
  • Long term use-hypogonadism and adrenal insufficiency
  • Drowsiness

Question 22

Pregnancy: nsaids which trimester are the contraindicated in? What is there an increased risk of?

Answer 22

NSAIDs are contraindicated in the third trimester of pregnancy. This means they should not be used from week 28 of pregnancy. This is due to the increased risks of constriction of the ductus arteriosus and renal dysfunction, which are greater in the last trimester

Question 23

Strong opioids:
MORPHINE is the most…. According to which standards? How often is it given?

Answer 23

• Most valuable opioid analgesic for severe pain(gold standard) despite causing nausea and vomiting
  
  • Confers euphoria and state of detachment in addition to pain relief
  • Given every 4 hours (every 12 to 24 hours as modified release preps)

Question 24

STRONG OPIODS - Buprenorphine has both? But it may precipitate? What can abuse cause? What does it have a longer duration of action tha? How effective are sublingual? What can the effects be partially reversed by?

Answer 24

• Has both agonist and antagonist properties(both = bu)
  
  • May precipitate withdrawal symptoms
  • Abuse potential+ may cause dependence
  • Longer duration of action than morphine
  • Effective sublingual for 6-8 hours
    Compared to other opioids, effects are only partially reversed by naloxone

Question 25

Patient carer advice:
How to apply the patch -
Usually avoid suing the area for how long and for which specific patches is it for 3 weeks? And which is for 6 days. Remove is there are?

Answer 25

• Apply to a dry,non irritated, non hairy skin on the upper torso or outer arm
  
  • Heat or fever can increase absorption so avoid head and saunas
  • Remove after 72 hours/96 hours/7 days
  • Avoid same area for at least 3 weeks (7 days for Prenotrix,hapoctasin,bupeaze,buplast and relevtec) 6 days for transtec
  • Remove if: breathing difficulties, drowsiness,confusion,dizziness

Question 26

Methadone

Is less sedating than what? When should it not be administered? What happens to patients that miss 3 days of treatment and what would we consider doing for them?

Answer 26

• Less sedating than morphine
  
  • Shouldn’t be administered more than twice daily -risk of accumulation and opioid overdosage
  • Patients who miss 3 days of treatment are at risk of overdose because of tolerance .consider reducing dose with these patients

Question 27

Oxycodone is similar to what? What are its main uses which group of people?

Answer 27

• Similar to morphine
  
  • Main use - pain control in palliative care

Question 28

Pethidine is prompt but ? What is it less constipating than?

Answer 28

• Prompt but short lasting analgesia
  
  • Less constipating than morphine

Question 29

Tramadol is an example of analgesia by what effect and what pathways does it enhance?

Answer 29

• Analgesia by opioid effect and enhancement of seratogenic and adrenergic pathways

Question 30

Neuropathic pain is when there is what to neural tissue? What can be used to treat is tabs,plasters and cream - what occurred along initial treatment with the cream?

Answer 30

• Damage to neural tissue(phantom limb pain, trauma,central pain, compression neuropathies)
  
  • -Amitriptyline, nortriptyline,pregabalin and tramadol can be used
  • Lidocaine plasters can be used
  • Capsaicin cream - burning sensation can occur during initial treatment and limit use

Question 31

Non-opioid analgesics examples and what kind of pain are they suitable for?

Answer 31

(paracetamol, aspirin, NSAIDs) suitable for
musculoskeletal pain

Question 32

Opioids are more suitable for what kind of pain?

Answer 32

are more suitable for moderate severe pain or visceral pain

Question 33

Benzydamine used to relive the what?

Answer 33

used to relive pain of oral mucosa

Question 34

All NSAIDs are associated with serious gastro-intestinal toxicity;

Answer 34

the risk is higher in the elderly. Evidence on the relative safety of non-selective NSAIDs indicates differences in the risks of serious upper gastro-intestinal side-effects—piroxicam, ketoprofen, and ketorolac trometamol are associated with the highest risk; indometacin, diclofenac, and naproxen are associated with intermediate risk, and ibuprofen with the lowest risk (although high doses of ibuprofen have been associated with intermediate risk).