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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
Q

What are opioids contraindications ?

A

-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
Q

What are the cautions for opioids ?

A

inflammatory bowel disease

respiratory diseases: avoid in asthma attacks and COPD

27
Q

What are opioid interactions ?

A
  1. increased sedation with antihistamines, antidepressants, alcohol z- drugs, antipsychotics, anti epileptics, benzodiazepines
  2. Possible CNS excitation or depression: (hypertension hypotension ) MAOIs
28
Q

What is morphine dose for immediate release preparations ?

A

dose is every four hours

29
Q

How often MR morphine dose is given ?

A

12 hourly or 24 hourly

30
Q

What are maximum morphine dose increments ?

A

1/3 or 1/2 of total daily dose per 24 hours. only change dose every 24 hours

31
Q

What is the equivalent parental morphine dose to oral morphine dose ?

A

half oral dose

32
Q

Should morphine be avoided in renal impairment ?

A

yes, alternative would be oxycodone

33
Q

Why diamorphine is preferred over morphine for parenteral administration ?

A

diamoprhine is more soluble and smaller volumes can be injected. better for emaciated patients, since you don’t to overload the with fluids

34
Q

If patients needs to be switched from morphine to diamorphine, what is the equivalent dose of diamorphine?

A

1/3 of oral morphine dose

35
Q

Morphine or diamorphine has less nausea and hypotension ?

A

diamorphine

36
Q

What is the risk when using fentanyl patches in opioid naive patients ? fentanyl long acting 72 hours

A

risk of fatal respiratory depression, thus only used if opioid tolerant

37
Q

What counselling should patients be given when fentanyl patches are dispensed ?

A

immediately remove patch in case of breathing difficulties, marked drowsiness, confusion, dizziness, or impaired speech. Call 999 for opioid overdose.

38
Q

What other counselling patients should be given when dispensing opioid transdermal patches ?

A

avoid exposure to external heat: increased absorption. Avoid hot baths/sauna. Monitor if fever present

39
Q

How should opioid patches be applied ?

A

apply to dry, non-irritated and non-hairy skin on upper torso or upper arm.
rotate patch site after each use.

40
Q

What is the dose of codeine in mild to moderate pain ?

A

30-60 mg every four hours

41
Q

What is the maximum dose of codeine in children aged 12-18 years ?

A

maximum 240 mg daily for three days. Dosage: up to four times a day with no less than 6 hour intervals.

42
Q

What was MHRA warning regarding using codeine in children ?

A

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
Q

Codeine is not recommended in which children group ?

A

in children with compromised breathing:
severe cardiac or respiratory conditions/infections
neuromuscular disorders
multiple trauma and extensive surgical procedures

44
Q

Codeine contraindications ?

A
  • ultra rapid metabolisers (CYP2D6- morphine toxicity )

- children under 18 who had their tonsils or adenoids removed for treatment of obstructive sleep apnoea.

45
Q

Patient counselling when dispensing codeine ?

A

stop and seek medical attention if: reduced consciousness, lack of appetite, somnolence, respiratory depression, constipation, pin point pupils, nausea and vomiting

46
Q

Why codeine and dihydrocodeine can never be given intravenously ?

A

severe reaction similar to anaphylaxis

47
Q

How does tramadol work ?

A

affects serotonergic and noradrenergic pathways, acting as a NA and 5 HT reuptake inhibitor.

48
Q

What are the side effects of tramadol ?

A

increased risk of bleeding
lowers seizure threshold
psychiatric reactions

49
Q

What interaction occurs if tramadol is given with SSRIs, TCA’s, 5-HT1 agonists, MAOIS ( serotonergic drugs ? )

A

risk of serotonin syndrome

50
Q

What interaction occurs if tramadol is given with SSRIs, TCA’s, anti epileptics ?

A

lowers seizure threshold

51
Q

What interaction occurs if tramadol is given with warfarin ?

A

increased risk of bleeding, tramadol enhances anticoaugalant effect of coumarins

52
Q

For 16+ patients, outline stepwise strategy in managing mild-to-moderate pain?

A

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
Q

For 16+ patients, outline stepwise strategy in managing mild-to-moderate pain?

A

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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