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Nervous system 2 > Pain > Flashcards

Pain Flashcards

1
Q

Drug of choice for musculoskeletal pain and dental pain ?

A

NSAIDs

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2
Q

Drug of choice for moderate-severe visceral pain?

A

opioids

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3
Q

Drugs of choice for period pain ?

A

oral contraceptives, antispasmodics or non opioids

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4
Q

Drug of choice for nerve compression by tumour ?

A

dexamethasone

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5
Q

What drugs are available to treat neuropathic pain ?

A

Amitriptyline, nortriptyline

Gabapentin, pregabalin

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6
Q

Describe pain ladder step 1 ?

A

step 1: mild pain

Non-opioids: paracetamol, aspirin, NSAIDs

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7
Q

Describe the pain ladder step 2 ?

A

step 2: mild to moderate pain

weak opioids: codeine, dihydrocodeine, tramadol ( moderate)

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8
Q

Describe the pain ladder step 3 ?

A

step 3: moderate to severe pain
strong opioids: moprhine, diamorphine, oxycodone, hydromorphine, methadone
transdermal patches: buprenorphine, fentanyl

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9
Q

Drug for pain due to bone metastases ?

A

bisphosphonates and strontium ranelate

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10
Q

How to treat paracetamol poisoning ?

A

acetylcysteine

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11
Q

Which patient group has higher risk of hepatoxicity while taking paracetamol ?

A

those who weigh under 50 kg

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12
Q

if aspirin is taken in high doses what side effect can occur ?

A

tinnitus

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13
Q

How does opioid analgesics work ?

A

acts on various opioid receptors located in the brain, spinal chord and other nervous tissue to relieve pain

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14
Q

Name weak opioid drugs ?

A

codeine (CD5; injections CD2)
dihydrocodeine (CD5)
meptazinol (POM)

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15
Q

Name moderate opioid drug ?

A

tramadol ( CD3, exempt from safe custody )

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16
Q

Name strong opioids ?

A

morphine ( CD2, oral morphine solution 13mg/5ml or less is a CD5)
oxycodone ( CD2= alternative to oral morphine, similar efficacy and side effect profile )
diamorphine ( CD2, given IV also known as heroin)
buprenorphine ( CD3 )
fentanyl ( CD2)
methadone ( CD2)
hydromoprhone (CD2)

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17
Q

What are other opioids available ?

A

alfentanil, remifentanil =CD2
pethidine CD2=used in labour, if accumulates can cause convulsions
Dipipanone CD2
tapentadol CD2 ( less nausea and vomiting and comstipation than other strong opioids )
papaveretum CD2
pentazocine CD2
Sufentanil CD2

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18
Q

What is a rescue dose of strong opioid for breakthrough pain ?

A

1/10 or 1/6 of total daily dose of strong opioid, every two to four hours as required
Recue preparation is usually immediate release

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19
Q

What happens in opioid overdose ?

A

coma, pinpoint pupils, respiratory depression

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20
Q

Whats is naloxone and what does it do ?

A

naloxone is an opioid receptor antagonist. Reverses respiratory depression

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21
Q

Which opioid is only partially reversed by naloxone ?

A

buprenorphine

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22
Q

What are the side effects of opioids ?

A 
dry mouth, nausea and vomiting ( frequently with morphine ) 
constipation ( lactulose + Senna )
sedation 
reduced concentration and confusion 
euphoria and hallucinations ( euphoria can be common with morphine )
miosis ( pin point pupils )
postural hypotension 
urinary retention
23
Q

What happens when large doses of opioids are given ?

A

respiratory depression, hypotension, pupil constriction, muscle rigidity

24
Q

What happens in long term use of opioids ?

A
  • HYPOGONADISM: REDUCED FERTILITY, AMENORRHEA, ERECTILE DYSFUNCTION
  • ADRENAL INSUFFICIENCY
  • HYPERALGESIA: REDUCE DOSE OR SWITCH TO A DIFFERENT TREATMENT
25
What are opioids contraindications ?
-comatose patients ( opioids cause neurological depression and sedation ) -risk of paralytic ileus ( opioids reduce gastro-intestinal motility ) -respiratory depression ( opioids reduce respiratory drive ) -head injury or raise intracranial pressure ( opioids interfere with pupillary responses vital for neurological assessment )
26
What are the cautions for opioids ?
inflammatory bowel disease | respiratory diseases: avoid in asthma attacks and COPD
27
What are opioid interactions ?
1. increased sedation with antihistamines, antidepressants, alcohol z- drugs, antipsychotics, anti epileptics, benzodiazepines 2. Possible CNS excitation or depression: (hypertension hypotension ) MAOIs
28
What is morphine dose for immediate release preparations ?
dose is every four hours
29
How often MR morphine dose is given ?
12 hourly or 24 hourly
30
What are maximum morphine dose increments ?
1/3 or 1/2 of total daily dose per 24 hours. only change dose every 24 hours
31
What is the equivalent parental morphine dose to oral morphine dose ?
half oral dose
32
Should morphine be avoided in renal impairment ?
yes, alternative would be oxycodone
33
Why diamorphine is preferred over morphine for parenteral administration ?
diamoprhine is more soluble and smaller volumes can be injected. better for emaciated patients, since you don't to overload the with fluids
34
If patients needs to be switched from morphine to diamorphine, what is the equivalent dose of diamorphine?
1/3 of oral morphine dose
35
Morphine or diamorphine has less nausea and hypotension ?
diamorphine
36
What is the risk when using fentanyl patches in opioid naive patients ? fentanyl long acting 72 hours
risk of fatal respiratory depression, thus only used if opioid tolerant
37
What counselling should patients be given when fentanyl patches are dispensed ?
immediately remove patch in case of breathing difficulties, marked drowsiness, confusion, dizziness, or impaired speech. Call 999 for opioid overdose.
38
What other counselling patients should be given when dispensing opioid transdermal patches ?
avoid exposure to external heat: increased absorption. Avoid hot baths/sauna. Monitor if fever present
39
How should opioid patches be applied ?
apply to dry, non-irritated and non-hairy skin on upper torso or upper arm. rotate patch site after each use.
40
What is the dose of codeine in mild to moderate pain ?
30-60 mg every four hours
41
What is the maximum dose of codeine in children aged 12-18 years ?
maximum 240 mg daily for three days. Dosage: up to four times a day with no less than 6 hour intervals.
42
What was MHRA warning regarding using codeine in children ?
for acute moderate pain in children above 12 years only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone.
43
Codeine is not recommended in which children group ?
in children with compromised breathing: severe cardiac or respiratory conditions/infections neuromuscular disorders multiple trauma and extensive surgical procedures
44
Codeine contraindications ?
- ultra rapid metabolisers (CYP2D6- morphine toxicity ) | - children under 18 who had their tonsils or adenoids removed for treatment of obstructive sleep apnoea.
45
Patient counselling when dispensing codeine ?
stop and seek medical attention if: reduced consciousness, lack of appetite, somnolence, respiratory depression, constipation, pin point pupils, nausea and vomiting
46
Why codeine and dihydrocodeine can never be given intravenously ?
severe reaction similar to anaphylaxis
47
How does tramadol work ?
affects serotonergic and noradrenergic pathways, acting as a NA and 5 HT reuptake inhibitor.
48
What are the side effects of tramadol ?
increased risk of bleeding lowers seizure threshold psychiatric reactions
49
What interaction occurs if tramadol is given with SSRIs, TCA's, 5-HT1 agonists, MAOIS ( serotonergic drugs ? )
risk of serotonin syndrome
50
What interaction occurs if tramadol is given with SSRIs, TCA's, anti epileptics ?
lowers seizure threshold
51
What interaction occurs if tramadol is given with warfarin ?
increased risk of bleeding, tramadol enhances anticoaugalant effect of coumarins
52
For 16+ patients, outline stepwise strategy in managing mild-to-moderate pain?
Step 1: paracetamol Step 2: paracetamol should be substituted with ibuprofen or if ibuprofen is unsuitable, weak opioid Step 3: paracetamol added to ibuprofen or the weak opioid Step 4: paracetamol continued, ibuprofen replaced with alternative NSAID Step 5: weak opioid should be started in addition to paracetamol or NSAID.
53
For 16+ patients, outline stepwise strategy in managing mild-to-moderate pain?
Managing mild-to-moderate pain in adults-Step 1 — paracetamol. This is a suitable first-line choice for most people with mild-to-moderate pain; increase to maximum dose before switching to or combining with another analgesic; Step 2 — substitute the paracetamol with low-dose ibuprofen (400 mg three times a day). If necessary, increase the maximum dose of ibuprofen to 2.4 grammes daily unless contra-indicated; if unable to take NSAIDs; use full therapeutic dose of a weak opioid e.g. codeine 60 mg every 4 to 6 hours; maximum 240 mg daily; Step 3 — add paracetamol (1 gram four times a day) to low-dose ibuprofen (400 mg three times a day). If necessary,increase the dose of ibuprofen to a maximum of 2.4 grams daily.If the person is unable to tolerate an NSAID, add paracetamol to a weak opioid; Step 4 — continue with paracetamol 1 gram four times a day. Replace the ibuprofen with an alternative NSAID (such as naproxen 250 to 500 mg twice a day); Step 5 — start a full therapeutic dose of a weak opioid (such as codeine 60 mg up to four times a day; maximum 240 mg daily) in addition to full-dose paracetamol (1 gram four times a day) and/or an NSAID.

Nervous system 2 (8 decks)

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